Monday, February 22, 2010

Are You Nuts?

The new DSM (Diagnostic and Statistical Manual of Mental Disorders), Fifth Edition (DSM V), is in the final stages of preparation for publication. The DSM is often referred to as the "psychiatrist's bible," which makes sense since psychiatrists rarely consult real Bibles, and "evil" is not a mental disorder to be dealt with. You can't make money by billing Medicare and the insurance companies for treating evil people, only "sick" ones.

One of the best ways to insure that your billing gets paid is to create all new mental disorders, or find arcane ways to define common character flaws as diseases to be treated. Psychiatrists, with the willing assistance of governmental bureaucrats and the public in general, have made a major industry out of mental illness. They alone get to decide what's "normal," and who are you to dispute them? Are you a psychiatrist?

Be sure to note that the operative word is "psychiatrist." Psychologists are another thing entirely. They don't have a big enough union to set national standards. Psychiatrists don't just get paid for talking and listening, and accomplishing nothing. Unlike psychologists, psychiatrists have medical degrees, which allows them to use drugs as part of the talk and listen. And unlike the average psychologist, psychiatrists have actually made some great breakthroughs in treating certain mental diseases with largely organic causes. Schizophrenia comes immediately to mind.

For psychiatrists, asking "And how do you feel about your five year old son acting out?" is not enough. He must follow up with "And how do you feel about my diagnosing Attention Deficit Hyperactivity Disorder and prescribing drugs to 'cure' him?" This was one of the earliest newly-created disorders which took boisterous boys and turned them into mental defectives in need of drugging. Your son's inattentive? He's rambunctious? He doesn't follow orders well? DSM comes to the rescue. Drug the little psycho until he's compliant. Christina Hoff Sommers did a pretty good job of describing how the radical feminists convinced psychiatrists to decide that little boys who don't act like little girls must be mentally ill and in need of drugs in The War Against Boys. Boys who didn't fit the proper mold were being brought into line with drugs as far back as the early 70s. Prior to that, we all just waited for them to grow up and behave. An occasional paddle had also been applied back in the Dark Ages.

The latest "advance" in psychiatry is the proposed addition to the DSM of "psychosis risk syndrome." Some teenagers and young adults do, indeed, show early signs of mental illness, occasionally including mild delusional behavior. We used to call those "phases," and though potentially serious, conscientious parents and friends simply helped wherever possible and waited to see if something actually came of it. By their own admission in the Journal of Clinical Psychiatry in a major study entitled Intervention in Individuals at Ultra-High Risk for Psychosis, the study found that seventy percent of those identified as potential risks never went on to develop the mental illness feared.

In The Wall Street Journal of February 19th, psychiatrist Sally Satel has said that: "Since we don't know who those [30%] will be, otherwise healthy kids will be exposed to potent antipsychotic medications and their side effects, such as diabetes and weight-gain." She goes on to conclude that treatment is not especially effective in forestalling psychotic illness in that minority destined to develop it, and therefore "until the science of prevention becomes more advanced, it is better to keep psychotic risk syndrome out of the main DSM, placing it in an Appendix for Further Research."

Another problem with modifications, additions to and deletions from the DSM is the problem of ever-shifting parameters which are often as sociological as they are medical. Is homosexuality a mental disorder? At one time, the DSM said "yes." Then it said "maybe." Now it says, "probably not." What does any of that have to do with medical treatment? Psychologists, politicians, moralists and theologians can argue over the issue from now until doomsday, but until somebody actually finds that elusive "gay gene," it is not a proper subject for a psychological-medical approach, let alone designation as "abnormal" or "normal." You can't "cure" or palliate a "disease" that has no scientifically-proven organic basis with drugs. So the psychiatrists should simply keep it out of the DSM, however it is described, and leave it to the rest of us to debate simply whether it's "right" or "wrong."

An example of changing the parameters of the ever-increasing diagnosis of autism is another example. That does not necessarily mean that autism itself is any more of a danger than it was 100 years ago, but as the definitions shift, so do the number of positive diagnoses of the disease. There have at least been some serious scientific studies which indicate strongly that some forms of autism are almost purely organic/genetic in nature, and therefore possibly amenable to drugs. There have also been studies that show that drugs can be the very cause of autism. Autism exists, there is science built around it, and therefore belongs in the DSM in some form or another.

But now the new DSM proposes to replace Asberger's Disorder as a separate category, and toss it into the larger category of Autism Spectrum Disorder. Asberger's kids tend to be very bright, overactive, have early language delays followed by the development of perfectly normal or even advanced speech abilities, and they (via their parents, of course) object to being place into the general category of Autism which largely describes children with serious concentration, intelligence and language deficiencies.

And let's not forget the potential Christine Jorgensens of this world. The proposal on the table is to remove the classification of Gender Identity Disorder. That has stirred up a big brouhaha among those who wish to change their sex. The camps are divided into those who believe the disorder should be removed from the DSM because it implies they are mentally ill, and those who wish it to remain in order to have their sex-change procedures covered by insurance and government programs.

The DSM III was the break from the original approach of simply describing Freudian concepts of unconscious conflict and stunted sexual development and leaving it to the individual psychiatrist to determine if his or her patient suffered from it, and whether psycho-medical procedures would alleviate the problem. Published in 1980, The DSM III switched to describing mental illnesses based on symptoms. Add up enough symptoms, and you had the disorder. That had the advantage of allowing two or three separate psychiatrists to interview the same patient, and agree that the patient had a disorder based on the symptoms rather than acute observation by one psychiatrist acting alone. It established a necessary uniformity, but it tended to leave little to individual observation and divergent treatment.

The DSM III carefully warned psychiatrists to be wary of diagnosing a disorder and automatically turning it into a mental disease to be treated with drugs. Depression, a common symptom of humans world-wide, can have so many causes that it is dangerous to assume it is always organic and permanent or even amenable to drug treatment. It can range from a serious but temporary condition caused by a current crisis or tragedy to a lifelong clinical problem which may or may not be amenable to drug treatment. And the treatment is often as dangerous as the condition. Yet by the time of DSM IV, the warnings had essentially been removed, and clinical depression was diagnosed far too often because at the time of the interview, the patient exhibited all the classic symptoms.

As Dr. Satel concludes, "In the preface to DSM III they said 'this symptomatic approach to defining mental disease is only one still frame in the ongoing process of attempting to better understand mental disorders.'" She concludes that "thirty years later, despite undeniable progress in brain science, we are saying much the same thing." Defining mental illness solely by an accumulation of symptoms does both the art and the patient a disservice, which DSM V ought not to be perpetuating. There is a great deal more to a human being than his or her symptoms, and psychiatrists, of all people, should recognize that and use the DSM as a tool, not as a Bible.


Anonymous said...

I don't have much to contribute to this... only that I was seeing shrinks when I was ten years old and we also went for family therapy (my folks, younger brother, and myself). I also saw a shrink when I was 19.

My brother was always acting up and I had what I guess can now be referred to as "social anxiety disorder" a.k.a. shyness (part of me thinks SAD is a crock; the other part of me is more than sympathetic, because I've been there).

But I shudder to think of what the situation would be today, if I were 10 and my brother was 7. Would the shrink have recommended drugs? I doubt our parents would've done that but who knows? I'm totally against the whole "Your kid is acting up so give him this" approach to therapy.

And as for BS disorders, I have a friend from film school who suffers from "seasonal depression" or words to that effect. Is it real? I don't know.

Writer X said...

It's a little scary how much (and how quickly) children are medicated. It seems for too many medication has taken the place of parenting.

StanH said...

Dr. Benjamin Spock’s treatise on child rearing , and his belief in the barbarity that is an occasional spanking IMO led directly to, spanking our children with drugs. By taking thousands of years of civilization and flipping it on it’s head, “spare the rod spoil the child,” …to be stylish was, and is foolish. I don’t mean too sound like a brutish draconian jerk, but many of the psychoses of today were, as you say “phases,” in yesterday. You can be certain they would drug, Mozart, Einstein, etc. people behaving outside the “norm.”

Some psychotropic drugs do indeed work, Manic Depression with Lithium, etc. but drugging kids in most cases IMO, are criminal!

Joel Farnham said...

And how about the boys that become dysfunctional after being drugged at an early age?

More and more we are seeing boys being drugged for no particular reason than he acts up in class. Less and less recess and more and more drugs.

When I was growing up, I would never have seen a cop in my highschool unless it was career day. Now, there is a cop car "stationed" on campus.

I believe that repressing the natural urges of young boys causes far more damage in the long run.

AndrewPrice said...

My problem with all of this is that the psychiatric profession is merely catering to bad parents who want to shift the blame for their bad decisions. They would rather assume their kids are misbehaving or are not-socially adjusted because of some medical condition rather than what they've done, and then "treat" the problem with medication rather than acting like a parent.

And in so doing, the profession merely encourages these people to continue to act irresponsibly, allows children to be medicated who shouldn't be, and makes these conditions into jokes -- which harms the few children who really do have real conditions.

Anonymous said...

ScottDS: In case you haven't guessed, as a child I suffered from ROMS (running off at the mouth syndrome), a primitive form of Tourette's. When the words I wasn't supposed to say came out, the main drug was Palmolive Hand soap, applied to the mouth. I was never cured, but it is under control (most of the time).

Anonymous said...

WriterX: Drugs are so much easier than actually having to deal with an obstreperous or inattentive child, particularly boys. When my older daughter (who should have known better) told me that her first son had been diagnosed with ADHD and they wanted to give him drugs, I told her to tell them to go to hell. I have no degree in psychology or medicine, but I know an overactive kid when I see one. I spoke to my lifelong friend (who is a clinical psychologist) and he recommended a psychiatrist who was more along my line of thinking and uses the DSM only as a guide. The final diagnosis was mild Asberger's, and a very mild matching drug was prescribed, to be used sparingly. He is now in junior high school, no need for drugs, a top athlete and exhibits his grandfather's "won't shut up" syndrome, for which there is no cure. I am proud to say I had made sure they didn't turn a rather wild little kid into a zombie based on "symptoms" rather than genuine observation.

LL said...

When I was a kid and in flights of anger, engaged in ROMS - it was settled with a fist. I learned the discretion is often the better part of valor and never to ROMS unless I was a lot bigger and was absolutely confident I could kick the other kid's butt.

So much of life is dealt with by -- life. I know there are extreme circumstances, but the VAST majority of humans fit comfortably within the lines that bounded normal conduct for the last 10,000 years.

Circumscribing children into a politically correct box does more harm, IMO, than allowing them to develop normally.

Anonymous said...

StanH: I am one of those rare lawyers who stands in awe of good doctors and modern medicine. So I am not automatically dismissive of drugs the way many of my friends and colleagues are. But I can also see how many lawyers do their work by generalizing the charges against their clients--very much like doctors who use symptoms alone with a guidebook (DSM) to diagnose their patients. Doing that with adults is bad. Doing it to children as if they're sheep to be sheared is unforgivable.

You got some of those historical figures absolutely on the money. Napoleon and Mozart most surely would have been declared ADHD by a school psychologist, and Churchill (who was nearly mute as a child, and couldn't seem to learn to read) would have been diagnosed with autism or at least serious Asberger's.

patti said...

are you trying to make me puke this morning?!

as a used to be tutor, i have seen many kids medicated that, in my humble opinion, were just being highly active kiddos. the drugs stripped the kids of their rambunctious and curious personalities and replaced it with the silent stare off into space. viola! easy to handle kids!

i know had i been born later, i too would have been a candidate for drugs. *that girl be crazy-wild. to the meds!* what a shame for us. or perhaps, shame on us.

Anonymous said...

Joel: Even when I was raising my own kids, I could tell my son was different from my daughters. Of course, I knew from personal experience that he was a boy, of all things. So in my world, boys who acted like girls were the ones with the problem. Bad behavior had to be punished, but if he hadn't been more aggressive and tougher to deal with, that would have worried me. The girls were no slouches (we didn't believe that girls had to do only "girly" things, either). Today, he would have been drugged for being "too defiant and inattentive to those around him." It all stems from the idiotic idea that since boys and girls are "equal," they must automatically be the "same." Nature hasn't changed in a million years, and the DSM and radical feminist psychology can't change that, no matter how hard they try. But they can certainly take a non-problem and turn it into one. It's the best example of taking all "patients" as a group, looking at the symptoms (boys are louder and more troublesome) and drugging those who have the "symptoms."

I got into a few schoolyard fights, and was always in trouble for interrupting the teachers. A trip to the principal's office was the worst that ever happened, and nobody ever even considered drugs as the remedy for the "disease" of being a boy. The most radical treatment necessary was a warning that they were going to tell my parents. Now that was a very calming "drug" for me.

Anonymous said...

Andrew: You are so right. "Spare the rod, spoil the child." We don't have to take that literally of course (I think I did a mild spanking twice while raising the kids, and one was actually an accident where I had to give my son a spank on the bottom when he was very little. He kept standing up in the bathtub, and I didn't want him to slip and hurt himself. I connected slightly harder than I intended, and with the water and his white bottom, I left a superficial handprint. I felt guilty about that for years to come).

As you've aptly pointed out, drugs aren't the solution. Parents who parent, and teachers who teach is the solution. For those who act up, punishment of some sort is necessary and proper. Drugs (except in those very rare cases that we've discussed) are a disease unto themselves.

Anonymous said...

LL: That sounds very familiar. I was slightly bigger than the other boys in my class until about sixth grade. Then, they all started to get bigger at a rapid rate, while my rate was a little slower. So I just learned how to fight dirty. LOL

None of us were drugged, and by far the vast majority of us turned out just fine. Not a single zombie in any of my schools. Another side effect was that the girls preferred the boys who could "take care of themselves," and defend the girls' honor.

Anonymous said...

Patti: Ain't it the truth? It's not bad enough that they give kids drugs just to shut them up, but it creates in their young minds the idea that any "problem" can be solved by the ingestion of another drug. You don't feel happy? Take a drug. You're anxious? Take a drug. You're not feeling strong enough today? Take a drug. Along with the "therapy" culture, we've created the whole sub-culture of "take a drug." It's not your fault. You have a chemical imbalance. Take a drug.

Anonymous said...

I should add that much of my son's inattentiveness and minor speech defect was indeed a medical problem in his early years. But the doctors didn't even consider drugs. They just kept working at it. And then they discovered he had a hearing problem, not a behavior problem. They put those "tubes" in his ears, and the inattentiveness and speech defect went away practically overnight. But he was still boisterous, and somewhat stubborn. God love him, that has served him very well over the years.

StanH said...

Aldous Huxley’s “Brave New World.” Where the state administers Soma , to maintain bliss. Frightening prophetic book published in 1932, so here we are...

Anonymous said...

StanH: I feel very good about Huxley and Brave New World. Of course that might stem from the fact that I take my daily Soma, so I feel good about pretty much everything. LOL

HamiltonsGhost said...

Lawhawk--I see the logic behind symptoms as a "guide" to problems, but never as a final diagnosis simply because two or three psychiatrists observed the same symptoms and will therefore automatically make the same diagnosis. Drugs have become the first line of offense rather than the last line of defense. Too easy, and not helpful.

Anonymous said...

HamiltonsGhost: There is no substitute for careful, personal observation by one caring professional who is reluctant to use drugs just because the DSM says his patient has the requisite symptoms.

Since I've never been "treated" by a psychiatrist, and have been declared merely slightly off-kilter by my ex-wife and lifelong best friend (psychologists both), my experience with that lone doctor who cares was strictly medical. Some time back, before I had my current coverage and the truly great doctors I have seen over the past fifteen years, I had a recurring and debilitating knot in my stomach. No acid stomach. No "acid reflux." Just bend-over and hope for the best pain. I described my symptoms, and was referred to several different specialists. The cardiac doctor found my heart was just fine. The internists looked for gastro-enteritis and diverticulosis. After an unpleasant visit with a TV camera in places I would prefer not to have a camera, I didn't have either of those. The pain was in the right place, and the symptoms were classics for what the specialists looked for.

The pain finally went away for awhile, and when it returned, I now had a good family doctor who knows how to listen and look before diagnosing. The symptoms didn't fit the classic symptoms. He decided that it was most likely an ulcer (which is rampant on my mother's side of the family, but he was the first to ask). I replied that my stomach didn't "burn," and I took lots of ulcer OTC medications which did nothing. His reply, "sometimes the symptoms don't fit." After the tests, it was by God, an ulcer. Easily cured, and it never returned. One caring doctor who knew what the word "asymptomatic" means.

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