I found this dialog a fascinating one as we seem to think Mental Illness and Gun Violence are somehow joined at the hip and when we ‘cure’ one we will solve another.
That is what I call a Weapon of Mass Distraction and no one knows how to wield those better than the N.R.A. They may be small in numbers but as Teddy Roosevelt once said “walk softly but carry a big stick.” The N.R.A has taken that to a whole new level, the walk and talk loudly and carry a Bushmaster AK 15. One would think that the statement made by the late Charleton Heston “you will pry a gun from my cold dead hands” was real. He is dead and I doubt they took anything out of them, but hey getting a faded actor with Alzheimer’s to do your bidding is not an uncommon one in this country. Now there is your crazy.
So I reprint the dialog which brings into argument the idea that a diagnosis is as only as good as the one giving it. And of course the Doctors doing so are well vetted members of the Medical Industrial Complex and have no conflict of interest what-so-ever.
What is tragic is that those who need and could use unbiased, quality help and care don’t get it. And those who try to find themselves often on the end of a prescription pad that sends them down the rabbit hole of labeling and further drug treatments that do little to solve the problem only alleviate it. We are the age of big drugs for big problems. Women and children are of course the largest recipient of the labeling and mis-diagnosis and in turn they get none of the real help and support needed. It is cheaper and easier in our 15 minute drive through diagnostic.
The letters below are interesting in they show how for many in the field they are well aware of the bullshit associated with the current DSM tool and yet I doubt they do anything to resolve it. Simply put – a second opinion required, proper testing and in turn affordable means of therapy that allows the Patient to be presented over a course of time to fully diagnose and learn about a individual
before putting a label and life time one at that on them that could affect their lives in ways that are not easily resolved.
One reader suggests just that. Won’t happen. I am self diagnosing here – I am a Pessimist.
To the Editor:
Controversy surrounding the soon-to-be-released fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM-5 — often called “psychiatry’s bible” — has cast a harsh light on psychiatric diagnosis. For psychiatry’s more radical critics, psychiatric diagnoses are merely “myths” or “socially constructed labels.” But even many who accept the reality of, say, major depression argue that current psychiatric diagnoses often “stigmatize” or “dehumanize” people struggling with ordinary grief, stress or anxiety.
We can certainly debate the legitimate boundaries of disease and “normality,” as in the controversy over “normal grief” versus major depression after a recent bereavement. But there is nothing inherently dehumanizing or “stigmatizing” about a psychiatric diagnosis. Ironically, such inflammatory charges only worsen society’s animus and prejudice toward those with mental illness, by implying that having a psychiatric disorder is grounds for shame. Diagnoses in other medical specialties rarely provoke such a reaction.
Critics typically reply that other medical specialties have “objective” criteria for diagnosis of disease, whereas psychiatrists merely apply “labels” to behaviors they (or society) find offensive. But in truth, numerous medical and neurological diagnoses, such as migraine headache, are based on the same type of data that psychiatrists use: the patient’s history, symptoms and observed behaviors. I believe that psychiatric diagnoses are castigated largely because society fears, misunderstands and often reviles mental illness.
“Diagnosis” means knowing the difference between one condition and another. For many patients, learning the name of their disorder may relieve years of anxious uncertainty. So long as diagnosis is carried out carefully and respectfully, it may be eminently humanizing. Indeed, diagnosis remains the gateway to psychiatry’s pre-eminent goal of relieving the patient’s suffering.
RONALD PIES
Lexington, Mass., March 18, 2013
The writer is a professor of psychiatry at SUNY Upstate Medical University and Tufts University.
Readers React
It is impossible to be totally for, or totally against, psychiatric diagnosis. Done well, diagnosis is the essential prelude to an effective treatment. Done poorly, diagnosis can do more harm than good. Diagnosis and the use of psychotropic drugs have both gotten out of hand; 20 percent of the adult population qualifies for a mental disorder, and 20 percent take medicine. The boundary of psychiatry keeps expanding; the realm of normal is shrinking.
How did this happen? As chairman of the DSM-IV Task Force, I must take partial responsibility for diagnostic inflation. Decisions that seemed to make sense were exploited by drug companies in aggressive and misleading marketing campaigns. They sold the idea that problems of everyday living are really mental disorders, caused by a chemical imbalance and cured with a pill.
Meanwhile, we are neglecting the severely ill who can be accurately diagnosed and effectively treated. State budgets for mental health have been slashed, radically reducing access to care for the people who most need medicine and are likely to benefit from it.
The soon to be published DSM-5 will worsen this absurd misallocation of resources by recklessly introducing new and untested diagnoses and reducing the thresholds for existing ones. People who don’t need diagnosis and treatment will get it, while people in desperate need will be frozen out; and drug companies will laugh all the way to the bank.
We badly need a conversation about a diagnostic system that is far too loose, a drug industry that is far too unregulated and a mental health system that is badly broken. But the pages of The New York Times are not enough; it is time for a Congressional investigation.
ALLEN FRANCES
Coronado, Calif., March 20, 2013
The writer is professor emeritus of psychiatry at Duke University.
I write as someone who has received a psychiatric diagnosis, and as director of a recovery community for others who have been so labeled. Yes, many of us rail against the diagnostic system not only because it is theory masquerading as scientific fact, but also because those labels have the power to take away our most basic civil liberties. As someone who has received diagnoses of both ophthalmic migraines and psychiatric disorders, I can assure you that no one has attempted to hospitalize or medicate me against my will for the former.
On a regular basis through my work, people introduce themselves as a psychiatric diagnosis sometimes before even stating their name. Yes, it is true, as Dr. Pies claims, that many find relief in their diagnosis, but what about when relief becomes identity and resignation?
Had I resigned myself to the psychiatric labels I was given in my teens and 20s and followed the recommended course of treatment (hospitalizations, therapy and medication), I would not now be director, mother, wife and homeowner. Those are the labels that I find humanizing. The others I have shed.
SERA DAVIDOW
South Hadley, Mass., March 20, 2013
The writer is director of the Western Massachusetts Recovery Learning Community.
Why are many people worried about the DSM in general, and the DSM-5 in particular? Dr. Pies claims that it is because our society “fears, misunderstands and often reviles mental illness.” Quite the opposite: We have domesticated mental illness, we have made it into an integral and somewhat banal part of our culture. On TV, Tony Soprano suffers from panic attacks and depression, and Carrie Mathison (“Homeland”) struggles with bipolar disorder. We all know someone who suffers from a psychiatric disorder, whether it is depression, anxiety or A.D.H.D.
It is precisely this omnipresence of mental illness in our culture that worries many critics of psychiatric diagnoses. Do we want a society in which each and every flaw of character is understood as a disease? What are the moral and legal implications?
Of course, this concern is reinforced by our knowledge of the dark history of psychiatric diagnoses. In the 19th century the diagnosis of “drapetomania” was suggested to describe slaves who flee from their masters, and until the 1970s “homosexuality” was in the DSM.
Instead of wondering whether receiving a diagnosis is stigmatizing or relieving for the patient, we need to reflect on the much larger ethical, legal and social consequences of creating (or deleting) diagnoses.
PATRICK SINGY
Niskayuna, N.Y., March 20, 2013
The writer is a historian and philosopher of science who is co-editing a book about the DSM-5.
The problem with the DSM is that psychiatry over at least the last four decades has attempted to categorize mental and psychological manifestations as distinct illnesses, similar to the categorization of medical and surgical illnesses, instead of recognizing that the best way to understand psychological health is on a spectrum. All of us are a little depressed, a little obsessional, a little histrionic and a little borderline. Some of us have a little more of one of these qualities and less of one of the others. We seek help when one of our traits cause us or those around us too much psychic pain.
Sigmund Freud taught us an important lesson: The border between the normal and the abnormal is not as distinct as we think. There are many shades of gray. Mental health professionals should approach each patient as a unique individual and together decide on the best treatment.
LEON HOFFMAN
New York, March 20, 2013
The writer, a psychiatrist, is director of the Pacella Parent Child Center at the New York Psychoanalytic Institute and Society.
Surprising though it may seem, psychiatric diagnosis is not scientifically grounded, does not reduce human suffering and carries risks of a wide array of serious kinds of harm. Even more disturbingly, it is totally unregulated, making it even less regulated than the financial institutions in this country.
I served for two years on two committees that wrote the current DSM but had to resign on ethical and professional grounds when I saw the way they ignored or distorted what high-quality research showed but presented junk science as though it were good when it suited their purposes.
The potential damage caused by a diagnosis is virtually limitless, including loss of custody of a child, loss of employment, skyrocketing insurance premiums, and loss of the right to make decisions about one’s medical and legal affairs.
PAULA J. CAPLAN
Palm Desert, Calif., March 20, 2013
The writer is a clinical and research psychologist and the author of “They Say You’re Crazy: How the World’s Most Powerful Psychiatrists Decide Who’s Normal.”
When I was a teenager, I embraced a diagnosis given to me by a psychiatrist because I was desperate for an answer to the emotional and existential pain I’d been experiencing for several years. Initially, as Dr. Pies suggests, that diagnosis provided me relief. But that relief was short-lived, for in internalizing that diagnosis, I stopped thinking of my emotions as part of the spectrum of human experience, and instead came to see them as “symptoms” of a “disease.”
That psychiatric diagnosis stripped me of an authentic sense of self and of a connection to those around me, because my “condition” made me different. Only in leaving behind that psychiatric diagnosis and the treatment it required did I find a path through my emotional struggles to the other side, where I could accept myself as I was, and be fully human again.
LAURA DELANO
Boston, March 20, 2013
Dr. Pies gets it right that psychiatry’s first priority is to alleviate suffering, that a respectfully given diagnosis for often confusing symptoms can be a great relief for many patients and that social stigma against mental illness may extend to the field of mental health.
Psychiatric diagnosis and its manual, the DSM, are a work in progress, with the shortcomings of any human endeavor in which scientific knowledge is incomplete. Psychiatric problems, whether influenced by genes or life events, are rooted in the brain, arguably the most complex organ in the body. The science of what goes wrong in the brain to cause psychiatric symptoms has only scratched the surface of this mysterious organ.
While we wait for better science, we still need ways to organize symptoms to guide research and treatment that may relieve mental or emotional pain. That, after all, is what a patient wants most.
MICHAEL F. GRUNEBAUM
New York, March 21, 2013
The writer is an assistant professor of clinical psychiatry at Columbia University.
Much of the criticism of psychiatric diagnosis comes from within the profession, not just from its “radical critics.” Mine are twofold.
First, Dr. Pies is too quick to dismiss our own tendency to confuse social and biological constructs. Our profession has a long and not always admirable history of fostering that confusion.
Responsibility for the stigmatization of large groups of people can partly be laid at our door. Just ask gay people who were around before 1973, when homosexuality was finally removed from the DSM.
Second, an emphasis on making diagnoses tends to get in the way of our understanding people in depth. Dr. Pies says, “For many patients, learning the name of their disorder may relieve years of anxious uncertainty.” It’s all very well for a patient to know what he “has.” But what he really needs is to know who he is. When that happens, the “diagnosis” tends to disappear. It’s just too little an idea to account for human complexity.
VICTOR A. ALTSHUL
New Haven, March 20, 2013
The writer is a psychiatrist.
The Writer Responds
I agree with Dr. Frances that careful diagnosis is “the essential prelude” to effective treatment. That diagnosis is sometimes not “done well” — for example, after a perfunctory evaluation — argues for reforming our health care system, not castigating psychiatry. I also agree that psychiatric diagnosis should focus on seriously impaired, suffering individuals, not the “worried well.”
But no classification scheme should be held responsible for the excesses of “Big Pharma” or for overzealous prescribing practices. Nor is it fair to blame psychiatric “labels” for the abridgment of civil liberties, as Ms. Davidow does. Psychiatrists, like all physicians, are governed by civil law and judicial oversight.
Re Mr. Singy’s comments: Sadly, Hollywood’s “domesticated” depiction of psychiatric illness hardly reflects the animus and prejudice of society at large. Furthermore, the straw-man argument that psychiatry turns “every flaw of character” into a disease amounts to a caricature of standard psychiatric diagnosis, which derives its medical and ethical legitimacy from recognition and alleviation of the patient’s suffering.
Dr. Hoffman is right that the border between “normal” and “abnormal” is often indistinct — but this is true in most of general medicine. Even in oncology, the boundary between an “atypical” and a “malignant” cell is sometimes unclear. Finally, I fully agree with Dr. Hoffman that clinicians should consider each patient a unique individual. As Maimonides taught us eight centuries ago, “The physician should not treat the disease but the person who is suffering from it.”
RONALD PIES
Lexington, Mass., March 22, 201
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