PSYCHIATRY LOST ITS WAY
Commentary December 1999
By Paul R. McHugh
Johns Hopkins University
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.
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."
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.
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
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.
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.
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.
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.
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.
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.
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
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.
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.
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
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.
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.
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.
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.
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.
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
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.
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.
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.
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.
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.
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.
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
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.
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.
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."(*)
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.
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.
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
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.
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.
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
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.
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.
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.
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.
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.
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.
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.
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.
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
© Commentary 1999
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