Marcia Angell, a former editor of JAMA, may be the most prominent critic of drug companies. The most recent two issues of the New York Review of Books contain a two-part critique by her of psychiatry. I liked Part 1 because she described the excellent work of Irving Kirsch (The Emperor’s New Drugs). Part 2, however, is a disaster.
She goes on and on about the evils of the DSM s — the diagnostic manuals of psychiatry. Improving the reliability of diagnosis is playing into the hands of the drug companies, she seems to say. She complains that the number of diagnoses is increasing. Well, yes, all diagnostic systems get larger over time. This is a good thing; if you don’t have a name for a problem, it is hard to do cumulative research about it and hard to communicate research results to everyone else. She complains, apparently, that new categories are being added:
There are proposals for entirely new entries, such as “hypersexual disorder,” “restless legs syndrome,” and “binge eating.”
She does not say why this is bad. Maybe she thinks it’s obvious. It isn’t obvious to me. Diagnostic categories help researchers and doctors and the rest of us communicate. For example, Dennis Mangan’s research shows why it is a good idea for the term restless legs syndrome to have an agreed-upon meaning.
She complains that the DSM doesn’t have enough “citations”:
There are no citations of scientific studies to support its decisions. That is an astonishing omission, because in all medical publications, whether journal articles or textbooks, statements of fact are supposed to be supported by citations of published scientific studies. (There are four separate “sourcebooks” for the current edition of the DSM that present the rationale for some decisions, along with references, but that is not the same thing as specific references.)
Please. This is clueless. A diagnostic manual is a dictionary. It assigns meanings to diagnostic categories. You can make a useful dictionary without “citations of scientific studies”. Long before you can do scientific studies about the best way to define dog you can come up with a definition of dog that is better than nothing.
She ends her review with this:
Above all, we should remember the time-honored medical dictum: first, do no harm (primum non nocere)
Gag me with a spoon. Time-honored? Doctors — with the support of JAMA, not to mention the rest of the health-care establishment — continually prescribe drugs with bad side effects and high prices and suppress innovative alternatives. (Not only that. My own surgeon recommended a dangerous surgery of no clear value.) How they can claim to do no harm escapes me.
Sure, psychiatry is awful. For a long time psychiatrists rallied around a transparent intellectual fraud (Freud and his offshoots). Now they rally around a less transparent intellectual fraud (neurotransmitter theories of mental illness). Psychotherapists and their wacky theories and no-more-effective treatments are no better so I wouldn’t blame the drug companies for the underlying problem. I put the problem like this: Our health care system consists of a very large number of people, many with very large salaries, who must get paid. Being human, they strongly oppose any progress that would reduce their salary or influence or, heaven forbid, eliminate their job. Because of them, many promising lines of research, such as prevention via environmental change or cure via nutrition, are completely or almost completely ignored. This is the fundamental reason Angell’s critique is so bad: She is part of the problem. She is very smart, but she’s been brainwashed (“ primum non nocere“!). She utterly ignores the fact that we don’t know what causes depression, what causes schizophrenia, what causes autism, and so forth. Only when we learn what causes these and other mental disorders will we be in a good position to improve our mental health.
“She does not say why this is bad. Maybe she thinks it’s obvious. It isn’t obvious to me.”
I’d guess she’s talking about hypermedicalization of situations that do not really warrant a medical treatment, or at least a treatment with drugs. Maybe she’s confusing both of these (e.g. prescribing changes in exercise patterns or diet rather than drugs), but that’s the general point I think she’s trying to make.
How can we learn how to treat a problem if we don’t have a name for the problem? The term “hypermedicalization” doesn’t answer that question.
I think the issue is whether the problem exists in the first place, or whether the DSM contains a bunch of self-serving pseudo-diagnoses that allow the mental-health industry to prescribe harmful “treatments”, dis-empower people, and further entrench the status quo. See, for example:
‘Shyness: How Normal Behavior Became a Sickness’
regarding increasing diagnoses–why do we even need a formal diagnostic manual? doctor’s obviously want to get a handle on what people have, and will use words to express problems, and if they have a set of official diagnoses, then they might be constrained in what they would diagnose. ‘it must be one of these diagnoses on this table.’ in other words, getting rid of official tables of diagnoses would allow for many more possible diagnoses, and inventions of diagnoses. french is guarded by a body that approves words that are ‘officially’ french, while english doesn’t–which language do you think is going to be more expressive in the long run?
two, freud and his disciples seem to be getting bashes too much. where’s the appreciative thinking? he seemed to apply the empirical approach to introspection and challenged orthodoxy, trusting his lying eyes over authority, very much in the spirit of self experimentation. his disciples often seemed to do this too, breaking with freud. i think albert ellis was a freudian, and then he went his own way and developed an obviously effective cognitive behavioral approach.
So far as restless leg syndrome is concerned, I have a friend who’s plagued by it– if she doesn’t take meds for RLS, she can’t get nearly enough sleep. There may be some other solution (I’ve heard a little good stuff about acupuncture), but meds seem to be legitimate for that one.
On the other hand, I can’t see why it’s filed under psychiatry. It’s pretty clearly neurological, with no emotional or cognitive component.
“the issue is whether the problem exists in the first place” — you are saying that a large fraction of the disorders in the DSM are not problems? Angell doesn’t say this. And I don’t agree with this. I have never heard this claim made. Even Szasz never said this.
I don’t know the fraction of problems vs. non-problems. Recall that homosexuality was apparently a problem prior to 1973 — but then suddenly ceased being a problem. Now, apparently, shyness is a problem worthy of medical attention.
Angell’s point (or one of them) is that the ever-expanding scope of the DSM is an underhanded attempt by the psychiatric establishment to medicalize (problemetize?) the range of normal human traits and behaviors.
I’m not really a big fan of Thomas Szasz, but for whatever it’s worth, see this essay about his views on the DSM: https://www.themoralliberal.com/2010/12/20/the-illegitimacy-of-the-%E2%80%9Cpsychiatric-bible%E2%80%9D/
“On the other hand, I can’t see why it’s filed under psychiatry. It’s pretty clearly neurological, with no emotional or cognitive component.”
Not clear at all… lots of seeming “neurological” problems have emotional and cognitive underpinnings, sometimes nonconsious (see Freud, who made acute observations and had some revolutionary insights regarding nonconscious mental activity, even if much of what he said was wrong)
ps Seth, have you ever actually read Freud or are you just going off how he’s been represented by others?
I have read about 15 books by Freud.
Part One and Part Two are of a piece. Superficial, or perverse, not to recognize that. Both of them of a piece with her 1995 “The Truth about Drug Companies”.