In Better Living Through Chemistry: Part I, I reviewed some history of the Psychiatric profession's attempts to codify diagnosis, starting with the first Diagnostic and Statistical Manual (DSM-I) in 1952 through the paradigm shift of DSM-III in the 1970s.
DSM-I, using the wealth of information about the Psychic apparatus discovered by Freud and the early Psychoanalysts, attempted to explain Psychiatric symptoms as caused by conflicts and deficits within the mind. The DSM-I was akin to the bacteria model of infection. In other words it was an attempt to explain illness by looking at the underlying causes of the illness. Bacteria cause infections and anti-bacterial drugs could therefore cure infections. Conflict within the mind causes neurotic symptoms, resolving such conflict cures the neurosis.
However, just as the bacteria theory of infection has had to be amended to include significant contributions from genetics and the immediate status of the proteome (ie, the dynamic state of the thousands of proteins that control and define the workings of the body's biochemistry, so too the conflict theory of psychiatric illness has shown itself to be inadequate. However, where the Medical Doctors has built their current theories of disease etiology upon the foundation of their older theories, the Psychiatric profession in the 1970s decided to make their diagnostic categories more medically based. (In reality, a convincing case can be made that they merely made diagnoses appear to be more medical, but that is another argument.) The DSM-III, and the current DSM-IVR (revised) made diagnosis contingent on symptoms and symptom clusters. The connection to problems in the mind was severed and replaced by a over-reliance on neurochemistry for etiological explanation. This was a mistake that continues to reverberate for several reasons.
One problem with the current system of Psychiatric diagnosis is that a symptom based etiology depends on subjective reporting of subjective experiences. Under the influence of a compliant culture and mass advertising which pathologizes unhappiness, millions of people now consider themselves depressed when they should more properly be thought of as unhappy. Consider three patients seen for consultation:
Patient A is a 45 year old, overweight woman with diabetes, osteoarthritis, and mild asthma. She has four children, two of whom are teenagers who are impossible for her to control, and a boyfriend, father of her youngest, who is verbally abusive, drinks, rarely works, and sees other women. She has been unhappy ("depressed") for as long as she can remember. She had an unhappy childhood and her father left when she was very young. Her current mental state shows minimal discontinuity with her past functioning; she came in for evaluation because the clinic doctor administered a paper test, told her that her scores showed she was depressed and referred her tot he Mental Health Clinic. If she identified herself as unhappy and determined no longer to tolerate her situation, she could perhaps with the aid of a good Psychotherapist, and perhaps adjunctive medication, regain mastery, begin an exercise and diet program, return to work, come to some resolution of her dysfunctional relationship and not only increase her level of function but increase her own happiness. Yet by defining herself as depressed, and receiving societal reinforcement of her self-identification, along with multiple social services, an attentive and concerned Social Worker, and a Physician ready, willing, and able to codify her unhappiness as a Psychiatric disorder for which medication is the prescribed treatment, she avoids taking the necessary actions to change her life and remains stuck in a miserable life, feeling helpless (and confirmed in her helplessness) and taking medication indefinitely which, at best, can "take the edge off."
Patient B is a 45 year old, slightly overweight woman with diabetes, osteoarthritis, and mild asthma. She has been in a stable, though at times conflictual, marriage for 20 years, has three children, one of whom has congenital problems, and works a half time job in order to care for her family and earn enough money to help the family's finances. Over the summer she experienced difficulty sleeping, would often cry for no reasons, began to feel listless and without motivation; she felt many of her family's struggles were her fault and that nothing would ever change. Her family prevailed upon her to seek treatment because of her overt change in functioning. On evaluation she was found to have the signs and symptoms of a Major Depression, medication was begun along with Psychotherapy, and in approximately 6 weeks time, she began to feel like her old self, curious about what had happened and determined to do whatever she could to avoid a repeat episode.
Patient C is a 24 year old woman who came from a chaotic background. Her mother had four children from four different men. The patient never knew her father. She was involved in a contentious, occasionally physically combative relationship with a man ten years her senior who drank and was unpredictable and irresponsible. She was struggling to succeed in college and had begun to smoke Marijuana and drink to excess on weekends. She came to my office complaining of being miserable and wondering if she had depression, which she considered to have been lifelong. She was not eager to take medication and readily agreed to a trial of Psychotherapy to see if she could better understand how she had arrived at such an unhappy state. Within a few months she had begun to recognize how much her own behavior contributed to her misery. Even before she made any manifest changes in her life, she had begun to feel more in control and determined not to follow the path that she had embarked upon; she would not be like her unhappy mother and sisters, who all were trapped in dependency and unhappiness. The long term outcome remains uncertain, but her prognosis is far better than Patient A. In the wrong hands Patient C could easily turn into Patient A.
All three patients were unhappy. The first self identified as "always Depressed" while the second showed a change of state and did not label herself but responded to the concerns of others. The third wondered about her mental state and worried she would end up like her mother; television commercials led her to consider that she might be depressed but she was unwilling to settle on that as a full explanation for her difficulties.
Prior to the development of the SSRIs (Selective Serotonin Re-uptake Inhibitors, like Prozac, Paxil, and Zoloft) patients were offered antidepressants only when their symptoms were profound and interfering with their usual level of functioning. This was because the older antidepressants were dangerous medications with problematic side effects. The SSRIs, despite anecdotes that appear in the press and on blogs from time to time, are extremely safe (though their use should be monitored) and as a result their use is easily rationalized for treating all sorts of human conditions that fall short of a Major Depressive Disorder.
Having, in effect, determined that unhappiness is now a diagnosable and medication-treatable disorder, the pool of potential patients for Psychiatry expanded markedly. Yet there are two more implications of this expansion that need to be understood. First, once diagnosis is based on easily expandable subjective symptoms with an assumed neurochemical etiology, the pool of potential uncomfortable and dysfunctional behaviors that can now be diagnosed as Psychiatric disorders can grow exponentially. And second, and ultimately of much greater significance, once behavior is understood as a neurochemically determined outcome, agency and responsibility are eroded dramatically.
To be continued... Better Living Through Chemistry: Part III
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