Did 2012 prove psychiatric disease doesn’t exist?
Dr Raj Persaud and Sir Simon Wessely
It has been a year where common-sense invocations of mental illness appear the only way the public and media have found to grapple with cases like Anders Breivik, the ‘Batman’ Mass Killer and the Connecticut School Shooting. Strange, incomprehensible, counterproductive or destructive behaviour clearly exists – debate rages as to explaining it.
In the case of Breivik, court appointed psychiatrists disagreed as to what the diagnosis was, and whether he was suffering from a mental illness. The court decided he wasn’t mentally ill. All those supposed advances in how to make a psychiatric diagnosis reliably, appears to let psychiatry down just when the media spotlight is at its most intense. Although to be fair to the profession, the vast majority of psychiatrists did think the court had got it right.
The debate from the 1960s as to the very existence of mental illness has never gone away – it’s just changed. Another milestone (or millstone if the critics are to be believed) in that debate arrives shortly when the ‘Diagnostic and Statistical Manual’ or DSM is about to be formally updated, and published in May 2013. This is a kind of ‘catalogue’ published by the American Psychiatric Association, whereby lists of symptoms indicate whether you qualify for a particular psychiatric diagnosis.
In many countries insurance companies and government agencies will only grant support and benefits for mental disorders when there is a clear diagnosis. And even more significant, in the United States insurance companies will only pay for treatment when your diagnosis appears in the DSM. DSM and similar catalogues are fundamentally important because they determine what exists, whether you have it, and if you do, whether someone is willing to treat you for it.
But critics have, with some justification, drawn attention to an apparent psychiatric “mission creep”.
Back in 1917, the American Psychiatric Association (APA) recognized 59 psychiatric disorders. With the introduction of the DSM in 1952, this rose to 128 disorders. By 1968 and the publication of the DSM III, which represented a real watershed in classification, it had risen to 159, followed by 227 in 1980, and 253 in 1987. The current version, DSM-IV has 347 categories, and it is to be expected that the DSM -5 will increase this further
In the run up to the publication, debate and controversy over what disorders should be included and what counts as a symptom of psychiatric illness, tend to reach fever pitch. This doesn’t happen to anything like the same extent in the rest of medicine. For many diseases a diagnosis follows smoothly from administering tests, such as blood work or a particular scan, and then the results make it fairly clear what is going on. This is because an underlying measurable pathology can be located, which explains symptoms and signs.
But despite the best intentions, including those of the authors of the DSM, psychiatrists still rely, just as Hippocrates did, on talking to the patient, collecting symptoms and then deciding. Even if this can be made reasonably reliable, in the sense that different psychiatrists interviewing the same or similar patients around the world, can at least agree on the presence or absence of symptoms, this sadly does not go very far in explaining what actually is the cause, or even whether or not a person is suffering from any specific disorder at all. Social workers and psychologists for example might record the same symptoms, but come to a very different conclusion as to whether or not this indicates a disorder.
Two philosophical and political parties, ‘ontological realism’ or ‘operationism’ dominate the dispute and helps to explain why the debates about classification that surface every time a new DSM is about to appear, seem much more heated amongst mental health professionals than for example, amongst surgeons or cardiologists.
Most, but by no means all, psychiatrists, will follow the principle of ontological realism, even if they might not necessarily use that term. They will affirm that that an entity, for example, schizophrenia, exists independently of the instruments or methods deployed to measure it. So the medical model, which is an ontological realist position, holds that the reason we have no test for psychosis, is not that people with schizophrenia don’t have an underlying common pathology located somewhere about their person, probably their brain. It’s just that this pathology has so far eluded our best efforts to characterise it, because our instruments aren’t that advanced, while our understanding remains limited.
Behavioral symptoms are manifestations of an underlying physical difference yet to be found, but real nonetheless. The underlying pathology is distinct from the symptoms. So you could have a lurking disorder, yet to produce symptoms. You might have ‘latent’ schizophrenia, displaying as yet no symptoms, just as you could have an unsuspected brain tumour.
‘Operationism’, in contrast, defines how something is to be gauged and then asserts that the entity being assessed is the same as the method used to measure it. This perspective claims theoretical concepts don’t have meaning beyond operations deployed to measure them.
Benjamin Lovett and Brian Hood give a neat example of this in their paper ‘Realism and operationism in psychiatric diagnosis’, published in ‘Philosophical Psychology’. They say that in ‘operationism’ the meaning of ‘‘length’’ is exhausted by the operation of placing a ruler (or some similar instrument) alongside an object.
The instrument ‘du jour’ in psychiatry is DSM (there is a WHO equivalent, known as the International Classification of Diseases, which is rather less prescriptive than the DSM, but let’s leave that argument for another consultation), so if you ‘line up’ a patient with DSM, and the instrument says you don’t meet the criteria, then you don’t have the disease.
Operationism means a disorder doesn’t cause problematic behaviour; the disorder is the behaviour.
Lovett and Hood explain for ‘operationists’ psychological disorders are therefore fully specified by the set of sufficient conditions specified in a manual such as the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM).
Oddly enough for a publication produced by the American Psychiatric Association, this position isn’t the medical model. The medical model asserts there can be latent disorders—that is, diseases for which the patient is asymptomatic. As medicine has advanced the notion of catching a pathological process before it has deteriorated into causing morbidity has become ever more important. Hypertension is treated before it becomes a heart attack.
Lovett, Assistant Professor of Psychology at Elmira College, and Hood, Assistant Professor of Philosophy at the University of West Florida, explain that socioeconomic status (SES) is a good example of ‘operationism’ in action – level of income, educational attainment, and occupational prestige are not caused by your SES. Instead social scientists derive SES from these variables. The concept of SES refers to a composite of these measurements.
The medical model would argue some as yet undiscovered underlying pathology causes schizophrenia and schizophrenic symptoms – the ‘operationists’ would contend that a particular pattern of auditory hallucinations, delusions and thought disorder, are schizophrenia. It would make no sense to diagnose asymptomatic schizophrenia. But you can have an asymptomatic brain tumour.
It is no coincidence then that one of the new diagnostic categories proposed by the DSM that has attracted the most controversy is Attentuated Psychosis Syndrome, in which people present with symptoms that are admittedly a little strange, but fall well short of what psychiatrists previously have labeled as schizophrenia.
Some argue this is fine, because such people are at considerably increased risk of going on to develop schizophrenia, and also that treating them early (with drugs) prevents this, but others see this not as a prodrome, but an attempt to medicalise mental phenomena that are not symptoms let alone disorders, such simply hearing voices, which turns out to be rather commoner in normal people that hitherto believed.
Likewise, as the New York Times reported recently (24.1.2013), removing the so called “bereavement” exclusion from the diagnosis of depression might mean that many elderly people grieving for their spouses will receive antidepressant medication rather than the support of their friends and family.
In response to what has become a storm of criticism the chief architect of the DSM, Professor David Kupfer of the University of Pittsburgh welcomed the debate, but countered that the committee was mindful of the reverse possibility, that serious depression could masquerade as grief, and also that clinicians needed to be aware of how easily normal grieving could give way to clinical depression. He told the New York Times that the distinction will require “good clinical judgement”.
That’s the fascination and also the problem with psychiatry. It does require good clinical judgement. It is perhaps easier for those who work entirely within the strict medical model, or ontological realism, as the philosopher Lovett calls it. Your brain tumour will be illuminated by the brain scan, whether you have symptoms or not, whether you disagree with the training of your doctors, or whether you are even conscious or not.
On the other hand the training of your psychiatrist, his or her beliefs about normality and disease, and your willingness to co operate with the interview, will all influence whether or not you currently receive a diagnosis. DSM or no DSM, it often does come down to, as Kupfer says, “clinical judgement”. No wonder it is sometimes so difficult, but also so interesting..
So at the heart of the debate about DSM V are some fundamental challenges. Can we really reliably diagnose disorders such as depression or schizophrenia until we make a fundamental breakthrough in brain scan technology? Is depression something more and deeper than a cluster of symptoms such as tearfulness and suicidal thoughts? Are we living in a society now where children are no longer allowed to be shy, but instead have something called social phobia that needs treatment? Or is it possible to have psychiatric disease while not exhibiting any symptoms, just as it is possible to have hypertension yet look and feel totally healthy?
And finally, is there any point in making any psychiatric diagnoses in the absence of a definitive test, or possibly proper treatments? If you are interested in any or all of the above, then you might enjoy a two day conference at the Institute of Psychiatry, Londonin June 2013, details below.
Benjamin J. Lovett & S. Brian Hood (2011): Realism and operationism in psychiatric diagnosis, Philosophical Psychology, 24:2, 207-222 http://dx.doi.org/10.1080/09515089.2011.558498
Span, Paula. Grief Over Depression Diagnosis. New York Times January 24th 2013 http://newoldage.blogs.nytimes.com/2013/01/24/grief-over-new-depression-diagnosis/?smid=tw-share
Professor Simon Wessely
Simon Wessely is Vice Dean, Chair and Head of the Department of Psychological Medicine at the Institute of Psychiatry, King’s College London, and a Consultant Liaison Psychiatrist at King’s College Hospital. His clinical work is in general hospital psychiatry, with a particular interest in unexplained syndromes including chronic fatigue syndrome (CFS), and he continues to work in the dedicated service that he set up 20 years ago. His research interests are in the grey areas between medicine and psychiatry, clinical epidemiology, psychiatric injury and military health. His first paper was called “Dementia and Mrs Thatcher”, whilst his doctoral thesis was on crime and schizophrenia. He has written over 600 papers on various aspects of psychiatry, but latterly much of his research has been in military health, and he is Director of the King’s Centre for Military Health Research and Civilian Consultant Advisor in psychiatry for the British Army. He cycles each year, albeit slowly, to Paris to raise funds for the Royal British Legion. He was knighted for services to military health and psychological medicine in 2013.