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Commentary December 1999

By Paul R. McHugh
Johns Hopkins University

"THE DESIRE to take medicine," noted the great Johns Hopkins physician William Osler a hundred years ago, "is one feature that distinguishes man, the animal, from his fellow creatures." In today's consumer culture, this desire is hardly restricted to people with physical conditions. Psychiatric patients who in the past would bring me their troublesome mental symptoms and their worries over the possible significance of those symptoms now arrive in my office with diagnosis, prognosis, and treatment already in hand.

"I've got adult attention deficit disorder," a young man informs me, "and it's hindering my career. I need a prescription for Ritalin." When I inquire as to the source of his analysis and its proposed solution, he tells me he has read about the disorder in a popular magazine, realized that he shares many of the features enumerated in an attached checklist of "diagnostic" symptoms--especially a certain difficulty in concentrating and an easy irritability--and now wants what he himself calls "the stimulant that heals."

In response, I gamely point out a number of possible countervailing factors: that he may be taking a one-sided view of things, emphasizing his blemishes and overlooking his assets; that what he has already accomplished in his young life is inconsistent with attention deficit disorder; that many other reasons could be adduced for irritability and inattention; that Ritalin is an addictive substance. But in saying all this, I realize that I have also entered into a delicate negotiation, one that may end with his marching angrily from my office. For not only am I not doing what he wants, I am being insensitive, or so he will claim, to what "his" diagnosis clearly reveals. Less a suffering patient, he has been transformed, before my very eyes, into a dissatisfied customer.

It is a strange experience. People normally do not like to hear that they have a disease, but with this patient, as with many others like him, the opposite is the case: the conviction that he suffers from a mental disorder has somehow served to encourage him. On the one hand, it has rendered his life more interesting. On the other hand, it plays to the widespread current belief that everything can be made right with a pill. This pill will turn my young man into someone stronger, more in charge, less vulnerable--less ignoble. He wants it; it's for sale; end of discussion.

He is, as I say, hardly alone. With help from the popular media, home-brewed psychiatric diagnoses have proliferated in recent years, preoccupying the worried imaginations of the American public. Restless, impatient people are convinced that they have attention deficit disorder (ADD); anxious, vigilant people that they suffer from post-traumatic stress disorder (PTSD); stubborn, orderly, perfectionistic people that they are afflicted with obsessive-compulsive disorder (OCD); shy, sensitive people that they manifest avoidant personality disorder (APD), or social phobia. All have been persuaded that what are really matters of their individuality are, instead, medical problems, and as such are to be solved with drugs. Those drugs will relieve the features of temperament that are burdensome, replacing them with features that please. The motto of this movement (with apologies to the DuPont corporation) might be: better living through pharmacology.

And-most worrisome of all-wherever they look, such people find psychiatrists willing, even eager, to accommodate them. Worse: in many cases, it is psychiatrists who are leading the charge. But the exact role of the psychiatric profession in our current proliferation of disorders and in the thoughtless prescription of medication for them is no simple tale to tell.

WHEN IT comes to diagnosing mental disorders, psychiatry has undergone a sea change over the last two decades. The stages of that change can be traced in successive editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), the official tome of American psychiatry published and promoted by the American Psychiatric Association (APA). But historically its impetus derives-inadvertently-from a salutary effort begun in the early 1970's at the medical school of Washington University in St. Louis to redress the dearth of research in American psychiatry.

The St. Louis scholars were looking into a limited number of well-established disorders. Among them was schizophrenia, an affliction that can manifest itself in diverse ways. What the investigators were striving for was to isolate clear and distinct symptoms that separated indubitable cases of schizophrenia
from less certain ones. By creating a set of such "research diagnostic criteria," their hope was to permit study to proceed across and among laboratories, free of the concern that erroneous conclusions might arise from the investigation of different types of patients in different medical centers.

With these criteria, the St. Louis group did not claim to have found the specific features of schizophrenia-a matter, scientifically speaking, of "validity." Rather, they were identifying certain markers or signs that would enable comparative study of the disease at multiple research sites-a matter of "reliability." But this very useful effort had baleful consequences when, in planning DSM-III (1980), the third edition of its Diagnostic and Statistical Manual, the APA picked up on the need for reliability and out of it forged a bid for scientific validity. In both DSM-III and DSM-IV (1994), what had been developed at St. Louis as a tool of scholarly research into only a few established disorders became subtly transformed, emerging as a clinical method of diagnosis (and, presumably, treatment) of psychiatric states and conditions of all kinds, across the board. The signs and markers-the presenting symptoms-became the official guide to the identification of mental disorders, and the list of such disorders served in turn to certify their existence in categorical form.

The significance of this turn to classifying mental disorders by their appearances cannot be underestimated. In physical medicine, doctors have long been aware that appearances, either as the identifying marks of disorder or as the targets of therapy, are untrustworthy. For one thing, it is sometimes difficult to distinguish symptoms of illness from normal variations in human life. For another, identical symptoms can be the products of totally different causal mechanisms and thus call for quite different treatments. For still another, descriptions of appearances are limitless, as limitless as the number of individuals presenting them; if medical classifications were to be built upon such descriptions, the enumerating of diseases would never end.

For all these reasons, general medicine abandoned appearance-based classifications more than a century ago. Instead, the signs and symptoms manifested by a given patient are understood to be produced by one or another underlying pathological process. Standard medical and surgical conditions are now categorized according to six such processes: infectious disorders, neoplastic disorders, cardiovascular disorders, toxic/traumatic disorders, genetic/degenerative disorders, and endocrine/metabolic disorders. Internists are reluctant to accept the existence of any proposed new disease unless its signs and symptoms can be linked to one of these processes.

The medical advances made possible by this approach can be appreciated by considering gangrene. Early in the last century, doctors differentiated between two types of this condition: "wet" and "dry." If a doctor was confronted with a gangrene that appeared wet, he was enjoined to dry it; if dry, to moisten it. Today, by contrast, doctors distinguish gangrenes of infection from gangrenes of arterial obstruction/infarction, and treat each accordingly. The results, since they are based solidly in biology, are commensurately successful.

In DSM-led psychiatry, however, this beneficial movement has been forgone: today, psychiatric conditions are routinely differentiated by appearances alone. This means that the decision to follow a particular course of treatment for, say, depression is typically based not on the neurobiological or psychological data but on the presence or absence of certain associated symptoms like anxiety--that is, on the "wetness" or "dryness" of the depressive patient.

No less unsettling is the actual means by which mental disorders and their qualifying symptoms have come to find their way onto the lists in DSM-III and -IV. In the absence of validating conceptions like the six mechanisms of disease in internal medicine, American psychiatry has turned to "committees of experts" to define mental disorder.

Membership on such committees is a matter of one's reputation in the APA--which means that those chosen can confidently be expected to manifest not only a requisite degree of psychiatric competence but, perhaps more crucially, some talent for diplomacy and self-promotion.

In identifying psychiatric disorders and their symptoms, these "experts" draw upon their clinical experience and presuppositions. True, they also turn to the professional literature, but this literature is far from dependable or even stable. Much of it partakes of what the psychiatrist-philosopher Karl Jaspers once termed "efforts of Sisyphus": what was thought to be true today is often revealed to be false tomorrow. As a result, the final decisions by the experts on what constitutes a psychiatric condition and which symptoms define it rely excessively on the prejudices of the day.

Nor are the experts disinterested parties in these decisions. Some-because of their position as experts-receive extravagant annual retainers from pharmaceutical companies that profit from the promotion of disorders treatable by the company's medications. Other venal interests may also be at work: when a condition like attention deficit disorder or multiple personality disorder appears in the official catalogue of diagnoses, its treatment can be reimbursed by insurance companies, thus bringing direct financial benefit to an expert running a so-called Trauma Center or Multiple Personality Unit. Finally, there is the inevitable political maneuvering within committees as one expert supports a second's opinion on a particular disorder with the tacit understanding of reciprocity when needed.

The new DSM approach of using experts and descriptive criteria in identifying psychiatric diseases has encouraged a productive industry. If you can describe it, you can name it; and if you can name it, then you can claim that it exists as a distinct "entity" with, eventually, a direct treatment tied to it. Proposals for new psychiatric disorders have multiplied so feverishly that the DSM itself has grown from a mere 119 pages in 1968 to 886 pages in the latest edition; a new and enlarged edition, DSM-V, is already in the planning stages. Embedded within these hundreds of pages are some categories of disorder that are real; some that are dubious, in the sense that they are more like the normal responses of sensitive people than psychiatric "entities"; and some that are purely the inventions of their proponents.

LET US get down to cases. The first clear example of the new approach at work occurred in the late 1970's, when a coalition of psychiatrists in the Veterans Administration (VA) and advocates for Vietnam-war veterans propelled a condition called chronic post-traumatic stress disorder (PTSD) into DSM-III. It was, indeed, a perfect choice-itself a traumatic product, one might say, of the Vietnam war and all the conflicts and guilts that experience engendered-and it opened the door of the DSM to other and later disorders.

Emotional distress during and after combat (and other traumatic events) has been recognized since the mid-19th century. The symptoms of "shell shock," as it came to be known in World War I, consist of a lingering anxiety, a tendency toward nightmares, "flashback memories" of battle, and the avoidance of activities that might provoke a sensation of danger. What was added after Vietnam was the belief that-perhaps because of a physical brain change due to the stress of combat--veterans who were not properly treated could become chronically disabled. This lifelong disablement would explain, in turn, such other problems as family disruption, unemployment, or alcohol and drug abuse.

Once the concept of a chronic form of PTSD with serious complications was established in DSM-III, patients claiming to have it crowded into VA hospitals. A natural alliance grew up between patients and doctors to certify the existence of the disorder: patients received the privileges of the sick, while doctors received steady employment at a time when, with the end of the conflict in Southeast Asia, hospital beds were emptying. Anyone expressing skepticism about the validity of PTSD as a psychiatric condition-on the ground, say, that it had become a catchall category for people with long-standing disorders of temperament or behavior who were sometimes seeking to shelter themselves from responsibility-was dismissed as hostile to veterans or ignorant of the mental effects of fearful experiences.

Lately, however, the pro-PTSD forces have come under challenge in a major study that followed a group of Vietnam veterans through their treatment at the Yale-affiliated VA hospital in West Haven, Connecticut, and afterward. The participants in the study had received medications, group and individual therapy, behavioral therapy, family therapy, and vocational guidance--all concentrating on PTSD symptoms and the war experiences that had allegedly generated them. Upon discharge from the hospital, these patients did report some improvement in their drug and family problems, as well as a greater degree of hopefulness and self-esteem. Yet, within a mere eighteen months, their psychiatric symptoms, family problems, and personal relationships had actually become worse than on admission. They had made more suicide attempts, and their drug and alcohol abuse continued unabated. In short, prolonged and intensive hospital treatment for chronic PTSD had had no long-term beneficial effects whatsoever on the veterans' symptoms.

This report, which brings into doubt not only the treatment but the nature of the underlying "disease," has produced many agonized debates within the VA. Enthusiasts for PTSD argue that the investigators somehow missed the patients' "real" states of mind while at the same time overlooking subtle but nonetheless positive responses to treatment. They have also stepped up the search for biological evidence of brain changes produced by the emotional trauma of combat-changes that might validate chronic PTSD as a distinct condition and justify characterizing certain patients as its victims regardless of whether a successful treatment yet exists for it. In the psychiatric journals, reports of such a "biological marker" come and go.

Yet while we await final word on chronic PTSD, the skeptics-both within and without the VA system-would appear to hold much the stronger hand. They have pointed, for example, to analogous research on war veterans in Israel. According to Israeli psychiatrists, long-term treatment in hospitals has the unfortunate tendency of making battle-trauma victims hypersensitive to their symptoms and, by encouraging them to concentrate on the psychological wounds of combat, distracts their attention from the "here-and-now" problems of adjusting to peacetime demands and responsibilities.

This makes sense. After any traumatic event--whether we are speaking of a minor automobile accident, of combat in war, or of a civilian disaster like the Coconut Grove fire in Boston in 1942--exposed individuals will undergo a disquieted, disturbed state of mind that takes time to dissipate, depending (among other things) on the severity of the event and the temperament of the victim. As with grief, these mental states are natural--indeed, "built-in," species-specific-emotional responses. Customarily, they wane over time, leaving behind scars in the form of occasional dreams and nightmares, but little more.

When a patient's reaction does not follow this standard course, one need hardly leap to conclude he is suffering from an "abnormal" or "chronic" or "delayed" form of PTSD. More likely, the culprit will be a separate and complicating condition like (most commonly) major depression, with its cardinal symptoms of misery, despair, and self-recrimination. In this condition, memories of past losses, defeats, or traumas are reawakened, giving content and justification to diminished attitudes about oneself. But such memories should hardly be confused with the cause of the depression itself, which can and should be treated for what it is. America's war veterans, who are entitled to our respect and support, surely deserve better than to be maintained in a state of chronic invalidism.

MEDICAL ERRORS characteristically assume three forms: oversimplification, misplaced emphasis, and invention. When it comes to chronic PTSD, all three were committed. Explanations of symptoms were oversimplified, with combat experiences being given priority quite apart from such factors as long-standing personality disorders, independent (post-combat) psychiatric conditions including major depression, or chronic psychological invalidism produced by prolonged hospitalization. Misplaced emphasis followed oversimplification when treatment concentrated on the psychological wounds of combat to the neglect of here-and-now problems that many patients were dodging, overlooking, or minimizing. Finally, the inventive construction of a condition called chronic PTSD justified a broad network of service-related psychiatric centers devoted to maintaining the veterans in treatment whether or not they were getting better-and, as we have seen, they were not.

Variants of these same mistakes can be discerned in the identification and treatment of other diseases du jour. Multiple personality disorder (MPD), for example, posits an unconscious psychological mechanism, termed dissociation, that occurs in people facing a traumatic life event. When such dissociation occurs, it disrupts the integrative action of consciousness, causing patients to fail to link experience with memory.

Typical dissociative "conditions" include dissociative amnesia, dissociative fugues, and dissociative identity disorder, the last-named being the DSM-IV term for MPD. Thus, a person who leaves home and travels to another city, only to remember nothing of the interval and amazed to find himself away from home, is said to have undergone a state of dissociative fugue. Patients claiming they cannot recall prominent events-their school years, their childhood friends-are said to suffer from dissociative amnesia. Finally, a person who displays over time two or more personality states that take control of his behavior is said to be in a condition of dissociative identity disorder.

The problem with dissociation, as with so many purported unconscious mental processes, is that it cannot be discerned and studied apart from the behaviors it is intended to explain. What generates and sustains those behaviors is the power of their effect on others, whether doctors or onlookers. But once attention has been transferred from the behavior itself to the imagined mental state of the patient exhibiting it, a diagnosis--dissociation--can be triumphantly invoked through reasoning that goes in circles: Why don't I remember first grade-/ Because you have dissociated your memory./ How do you know that-/ Because you can't remember first grade. This justifies, in turn, a long, arcane, melodramatic process of treatment.

MPD is, in fact, a form of hysteria-that is, a behavior that mimics physical or psychiatric disorder. Hysteria often takes the form of complaints of affliction or displays of dysfunction by people who have been led to believe that they are sick. More than occasionally, those doing the leading are the psychiatrists themselves, especially those in the business of helping patients recover "repressed" or "dissociated" memories of childhood sexual abuse.

It was the 1973 best-selling book (and later TV movie) Sybil, describing an abused patient with sixteen personalities, that launched the whole copycat epidemic of MPD. That book has recently been unmasked as a fraud. According to Dr. Herbert Spiegel of Columbia, who knew the patient in question and disputed her case with the author of the book prior to its publication, Sybil was in fact "a wonderful hysterical patient with role confusion, which is typical of high hysterics." Spiegel, whose protests at the time got him nowhere-"If we don't call it a multiple personality, we don't have a book! The publishers want it to be that, otherwise it won't sell!" he quotes the author as remonstrating-observes ruefully that "this chapter . . . will go down in history as an embarrassing phase of American psychiatry."(*)

ALTHOUGH THE MPD epidemic is now subsiding, the "disease" itself remains enshrined in DSM-III and DSM-IV, a textbook case of an alleged disorder whose identification is based entirely on appearances and then sustained as valid by its listing in DSM. So it is, too, with adult attention deficit disorder and social phobia.

Defined as a tendency to fear embarrassment in situations where one is exposed to scrutiny by others, social phobia relates in about 90 percent of cases to a fear of public speaking, an almost universal condition that can usually be overcome by practice. Some psychiatrists claim that one of eight Americans suffers from this supposed disorder and should receive pharmacological treatment for it. If that figure were accurate, we would be confronted with a mental disorder almost as common as depression and alcoholism-a dubious proposition on its face. Whether medication to make patients more comfortable (but perhaps less self-critical) in their public speaking will improve their lives or careers is another question altogether.

As for ADD, a diagnosis of that condition often rests on a perceived failure to attend to details: mistakes are made, and work performance is impaired, by restlessness and difficulty in concentrating. This, too, is a characteristic of many people, one that can emerge with particular salience in the face of challenges at home or work or with the onset of an illness like depression or mania. An individual seeking treatment for it may be expressing nothing more than a desire for "self-improvement." Whether it is the proper role of a prescription-dispensing psychiatrist to act as the patient's agent in such an enterprise is, again, another question altogether.

Although people may differ in such qualities as attentiveness and confidence, it is simply not true that most individuals deficient in these qualities are sick. What is true is that they will be changed by the medications proposed to heal the alleged sickness. Everyone is more attentive when on Ritalin; many are less emotionally responsive when on selective serotonin re-uptake inhibitors (SSRI's) like Prozac or Paxil. The fact that emotional and cognitive changes are associated with certain drugs should come as no surprise-even small amounts of alcohol will loosen your inhibitions. But that hardly means that the inhibitions constitute a mental disorder.

For the psychiatrists involved, there is another consideration here. In colluding with their patients' desire for self-improvement, they implicitly enter a claim to know what the ideal human temperament should be, toward which they make their various pharmacological adjustments and manipulations. On this point, Thomas Szasz, the vociferous critic of psychiatry, is right: such exercises in mental cosmetics should be offensive to anyone who values the richness of human psychological diversity. Both medically and morally, encumbering this naturally occurring diversity with the terminology of disease is a first step toward efforts, however camouflaged, to control it.

WHY ARE psychiatrists not more like other doctors-differentiating among patients by the causes of their illnesses and offering treatments specifically linked to the mechanisms of these illnesses? One reason is that they cannot be. In contrast to cardiologists, dermatologists, ophthalmologists, and other medical practitioners, physicians who study and treat disorders of mind and behavior are unable to demonstrate how symptoms emerge directly from activity in, or changes of, the organ that generates them--namely, the brain. Indeed, many of the profession's troubles, especially the false starts and misdirections that have plagued it from the beginning, stem from the brain-mind problem, the most critical issue in the natural sciences and a fundamental obstacle to all students of consciousness.

It was because of the brain-mind problem that Sigmund Freud, wedded as he was to an explanatory rather than a descriptive approach in psychiatry, decided to delineate causes for mental disorders that implicitly presupposed brain mechanisms (while not depending on an explicit knowledge of such mechanisms). In brief, Freud's "explanation" evoked a conflict between, on the one hand, brain-generated drives (which could be identified by their psychological manifestations) and, on the other hand, socially-imposed prohibitions on the expression and satisfaction of those same drives. This conflict was believed to produce a "dynamic unconscious" whence mental and behavioral abnormalities emerged.

This explanation had its virtues, and seemed to help "ordinary" people reacting to life's troubles in an understandable way. But it was not suited to the seriously mentally ill-schizophrenics and manic-depressives, for example-who did not respond to explanation-based treatments. That is one of the factors that by the 1970's, when it became overwhelmingly clear that such people did respond satisfactorily to physical treatments and, especially, to medication, impelled the move away from hypothetical explanations (as in Freud) to empirical descriptions of manifest symptoms (as in DSM-III and -IV). Another was the long-standing failure of American psychiatry, when guided by Freudian presumptions, to advance research, a failure that led, among other things, to the countervailing efforts of the investigators in St. Louis.

At first, indeed, the new descriptive approach seemed to represent significant progress, enhancing communication among psychiatrists, stimulating research, and holding out the promise of a new era of creative growth in psychiatry itself, a field grown stultified by its decades-long immersion in psychoanalytic theory. Today, however, twenty years after its imposition, the weaknesses inherent in a system of classification based on appearances-and contaminated by self-interested advocacy-have become glaringly evident.

In my own view, and despite the obstacles presented by the brain-mind problem, psychiatry need not abandon the path of medicine. Essentially, psychiatric disorders come under four large groupings (and their subdivisions), each of them distinguished causally from the other three and bearing a different relationship to the brain.

The first grouping comprises patients who have physical diseases or damage to the brain that can provoke psychiatric symptoms: these include patients with Alzheimer's disease and schizophrenia. In the second grouping are those who are intermittently distressed by some aspect of their mental constitution-a weakness in their cognitive power, or an instability in their affective control-when facing challenges in school, employment, or marriage. Unlike those in the first category, those in the second do not have a disease or any obvious damage to the brain; rather, they are vulnerable because of who they are-that is, how they are constituted.

The third category consists of those whose behavior--alcoholism, drug addiction, sexual paraphilia, anorexia nervosa, and the like--has become a warped way of life. They are patients not because of what they have or who they are but because of what they are doing and how they have become conditioned to doing it. In the fourth category, finally, are those in need of psychiatric assistance because of emotional reactions provoked by events that injure or thwart their commitments, hopes, and aspirations. They suffer from states of mind like grief, homesickness, jealousy, demoralization-states that derive not from what they have or who they are or what they are doing but from what they have encountered in life.

Each of these distress-generating mechanisms will shape a different course of treatment, and its study should direct research in a unique direction. Thus, brain diseases are to be cured, alleviated, and prevented. Individuals with constitutional weaknesses need strengthening and guidance, and perhaps, under certain stressful situations, medication for their emotional responses. Damaging behaviors need to be interrupted, and patients troubled by them assisted in overcoming their appeal. Individuals suffering grief and demoralization need both understanding and redirection from circumstances that elicit or maintain such states of mind. Finally, for psychiatric patients who show several mechanisms in action simultaneously, a coordinated sequence of treatments is required.

But the details are not important. What is important is the general approach. Psychiatrists have for too long been satisfied with assessments of human problems that generate only a categorical diagnosis followed by a prescription for medication. Urgently required is a diagnostic and therapeutic formulation that can comprehend several interactive sources of disorder and sustain a complex program of treatment and rehabilitation. Until psychiatry begins to organize its observations, explanatory hypotheses, and therapeutics in such a coherent way, it will remain as entrapped in its present classificatory system as medicine was in the last century, unable to explain itself to patients, to their families, to the public--or even to itself.

That is not all. In its recent infatuation with symptomatic, push-button remedies, psychiatry has lost its way not only intellectually but spiritually and morally. Even when it is not actually doing damage to the people it is supposed to help, as in the case of veterans with chronic PTSD, it is encouraging among doctors and patients alike the fraudulent and dangerous fantasy that life's every passing "symptom" can be clinically diagnosed and, once diagnosed, alleviated if not eliminated by pharmacological intervention. This idea is as false to reality, and ultimately to human hopes, as it is destructive of everything the subtle and beneficial art of psychiatry has meant to accomplish.

(*) The role of the "repressed-memory" movement in a whole line of celebrated cases and legal trials, from supposed satanic rituals to the alleged sexual abuse of children in schools and day-care centers, is a subject unto itself. I have reviewed this issue in "Psychotherapy Awry," American Scholar, Winter 1994.

© Commentary 1999
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