To the Editor:
Paul R. McHugh’s article [“How Psychiatry Lost Its Way,” December 1999] criticizing recent changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM) reminds me of the frustration that I felt during the twilight of the Freudian era. At the time, it seemed as if every psychiatrist who felt a touch of genius (and there were lots of them) was proposing a new and better theory of psycho-pathology and a diagnostic system to go with it. Those of us who were more interested in helping suffering patients than in new philosophies of mind had little reliable diagnostic nomenclature on which to rely.
The third edition of the DSM (1980) changed things radically for the better, because it did not require the clinician to intuit the diverse and mysterious forces that were supposed to lie “behind” clinical observations. What Dr. McHugh fails to mention is that the DSM groupings of these symptoms are guided by “external validating criteria.” That is, each symptom-based diagnosis predicts a specific family history, clinical course, and/or response to treatment. After all, the major purpose of clinical diagnosis is simply to classify people in such a way that the clinician can predict which treatment is most likely to be helpful.
Dr. McHugh seems to have lost his diagnostic way, and I am concerned that in his role as an educator, he may be leading early-career psychiatrists out into the clinical badlands with him. As he accurately notes, the DSM is fraught with inconsistencies and the potential for misuse and abuse, and it is certainly unsatisfying as a philosophical document. But the DSM has taken the field of clinical psychiatry from the clutches of theorists who, in the absence of known physiological etiologies like those mentioned by Dr. McHugh—infection, neoplasms, etc.—spin arcane theories of diagnosis and then use those theories to justify or disqualify various treatments.
Roderick Shaner, M.D.
Los Angeles, California
To the Editor:
Although it is true that the causes of most psychiatric disorders are not yet fully understood, a system of classification based on phenomenological descriptions of the relevant disturbances in thoughts, feelings, and behaviors still offers useful “face validity,” as well as the “reliability” that Paul R. McHugh extols. In addition, even if some of those who have constructed this classification system are guilty of self-promotion, as Dr. McHugh asserts, this does not vitiate the extensive field trials and other empirical support that are the basis for the diagnostic criteria of mental disorders.
The case of social-anxiety disorder, which Dr. McHugh cites as evidence of the speciousness of the current diagnostic system, may instead illustrate a point quite contrary to his thesis. Some people do indeed suffer excessively from anxiety or depressive symptoms, though they may not otherwise meet the criteria for disorders that Dr. McHugh surely recognizes. In my view, such individuals are still deserving of psychiatric treatment, just as a person with substantial but not excruciating chest pain is deserving of the services of a cardiologist.
The field of psychiatry values what Dr. McHugh calls “the richness of psychological diversity” even as it insists, as a matter of professional integrity and public policy, on the greater availability of treatment to those who needlessly suffer emotional distress. In this respect, psychiatry has not “lost its way,” but, rather, rests on firm intellectual, spiritual, and moral grounds.
Brian Ladds, M.D.
New York Medical College
New York City
To the Editor:
Paul R. McHugh praises the work of the psychiatrists at Washington University who strove to categorize mental disorders based on criteria established by empirical data, but he says that they merely achieved reliability (agreement on the presence of a disorder) and not validity (proof that a diagnosis truly represents an illness). Dr. McHugh ignores, however, the important work that members of this group did to justify categorizing a disorder as a true illness in the absence of a known etiology and mechanism of disease.
They gave five criteria: symptoms occurring together, a predictable course of illness, a predictable response to treatment, a family history of the disorder, and a biological marker. Only the few mental disorders for which we know the etiology and mechanism of illness have met all five criteria, but many disorders have met most of them. These criteria do not offer a foolproof method of validating disorders. But with all the imperfections of this system, Dr. McHugh cannot show an alternative that does a better job of prediction.
The official diagnostic schema of American psychiatry is based mainly on description with little reliance on speculative explanations. It is psychiatry’s admission that it prefers to keep its ignorance in full view, not obscured by unproven explanations.
Arthur Rifkin, M.D.
Glen Oaks, New York
To the Editor:
Paul R. McHugh takes us through the development of categorical thinking in the DSM over the past 30 years and correctly points out many of its pitfalls. But he ignores the field trials that went into making these categories. In psychiatry, as in every other area of medicine, symptoms are often classified diagnostically without a clear understanding of what causes them, and yet our therapeutic efforts still seem to relieve them.
This is not to allow for what Dr. McHugh calls “symptomatic push-button remedies” or to encourage the dangerous fantasy that “life’s every passing symptom can be clinically diagnosed . . . and alleviated, if not eliminated, by pharmacological intervention.” Rather, it is a humble effort to alleviate pain and suffering in the face of incomplete knowledge.
Gary N. Cohen, M.D.
Buffalo, New York
To the Editor:
Paul R. McHugh is right on the mark in many ways, but I believe he owes a much greater intellectual debt than he acknowledges to Dr. Thomas Szasz. Over the years, Szasz has articulated the following points that Dr. McHugh makes in his own article:
- that we are witnessing a proliferation of new, nonorganic, bogus psychiatric disorders;
- that in dealing with disorders, psychiatry substitutes reliability (agreement among diagnosticians) for validity (ascertaining whether diagnoses measure what they claim to measure);
- that in psychiatry, as opposed to somatic medicine, the symptom is the disease, rather than a sign of the disease;
- that there is collusion between some pharmaceutical companies and some psychiatric diagnosticians;
- that there is a profound element of self-fulfilling prophesy in the public positing of new psychiatric disorders;
- that changing someone’s behavior with psychotropic drugs is not a valid indicator of psychiatric disorder because such drugs affect anyone who takes them;
- and finally—the one point for which Dr. McHugh gives Szasz credit—that “exercises in mental cosmetics should be offensive to anyone who values the richness of human psychological diversity.”
From discussions with Dr. McHugh, I know of his distaste for Thomas Szasz, but this should not prevent him from citing the lineage of these important points.
Richard E. Vatz
To the Editor:
Paul R. McHugh complains that patients now come to the psychiatrist’s office with their own diagnosis in hand, just wanting their doctor to write out a prescription. He blames this new attitude on changes in American psychiatry’s classification system, especially on the DSM.
But Dr. McHugh overlooks the role of pharmaceutical companies, which now appeal directly to the public in the print and electronic media. Just about everyone has seen such advertisements, but very few people have seen the DSM. Moreover, some physicians now say that a third of their patients get medical guidance from the Internet.
Wayne State University
To the Editor:
More than a decade ago an editorial in the Journal of the American Medical Association commented on an international meeting of neuroscientists and looked forward to the world’s achieving “Peace Through Mind-Brain Science.” The editors’ expectation was that the early diagnosis of mental illnesses and the use of modern psychotropic medications would eventually lead to the disappearance of human discord.
As a psychiatrist at a large urban hospital, I can offer the following data indicative of “progress” toward this goal. At present, each patient in our acute psychiatric inpatient unit is prescribed an average of five psychotropic medications, while each of our (several thousand) outpatients is prescribed an average of two such medications. It is elsewhere reported that psychotropic drugs comprise the majority of pharmaceuticals manufactured, sold, and consumed in this country.
Paul R. McHugh correctly describes modern American psychiatry. Whether it is a restless boy in a crowded classroom; a sulking, oppositional teen; or an overburdened and unloved mother, today’s psychiatrists are like mental cosmeticians, ever ready to normalize chemically any example of “human psychological diversity” (in Dr. McHugh’s phrase) that exceeds the current limits of social tolerance.
Dr. McHugh dwells too lightly, however, on what he calls the “fundamental obstacle to all students of consciousness”: the “brain-mind problem.” Modern American psychiatry behaves as if it had achieved an utterly materialistic explanation of human consciousness. The most flagrant example of this is the widely believed (but not proved) biochemical basis of depression. Millions of patients are labeled as if they had a well-understood brain disease called “depression.” They are then prescribed powerful “antidepressants,” which cause changes in the way they think, feel, and behave—but psychiatry knows not how or why.
Psychotropic medications do not really cure diseases in the way that, say, penicillin cures diplococcus pneumonia. They are more akin to aspirin, which will ameliorate any fever, whatever its etiology.
Gary Almy, M.D.
To the Editor:
Paul R. McHugh’s criticism of psychiatry is on target, but I am not as optimistic as he is about the profession’s ability to reverse itself and abandon the symptom-based diagnostic system that has taken root. This system serves two immensely important functions: it brings in a lot of patients, and it reinforces the biological reductionism that is necessary for psychiatry to remain a medical specialty.
Regarding this second point, a symptom-based approach allows researchers, clinicians, and patients to assume that abnormal biological processes underlie unpleasant emotional states. While this paradigm is probably valid for schizophrenia (though the disorder has yet to be related to any brain abnormality), it more often than not misleads patients.
Consider the case of major depression, a disorder that easily makes up half of any psychiatrist’s practice. An estimated eighteen million Americans are said to be depressed at any given time, and those who have sought psychiatric treatment are likely to have been “educated” to believe that there is something wrong with their serotonin levels. I doubt, however, that there is one depressed person for whom it can be shown that this is the cause of his mental state. Yet, millions will continue to go from clinic to clinic, from one antidepressant to another, trying to correct their serotonin levels.
Michael J. Reznicek, M.D.
To the Editor:
Thanks to Paul R. McHugh for his insightful exposition of the mischief created by the DSM. His article could not have been more timely, with Surgeon General David Satcher and his mental-health experts having just released a report claiming that one-fifth of the American public has a serious mental illness—a “crisis” that requires, in their view, a complete revamping of social attitudes toward the mentally ill and changes in the provision of mental-health services.
As Dr. McHugh points out, psychiatry has been perverted into a sort of shopping expedition in which the professional finds a picture that fits a patient and—voilà—an excuse to put another sad person on medication. He proposes a return to what we know: that some people have serious derangements, chemical and anatomic in nature, such as schizophrenia and manic-depression; that others are unhappy and dysfunctional because of poor social skills and a failure to adapt to their social surroundings; and that still others have acquired abusive and destructive habits.
This is a system we can actually use—elegant in its simplicity and in the systematic approach to therapies that it encourages. By contrast, today’s mental-health diagnostic criteria are so loose that everyone could be labeled at least temporarily mentally disabled.
John Dale Dunn, M.D.
To the Editor:
Paul R. McHugh’s assessment of the current state of psychiatry resonates with many of my own experiences as a psychiatrist. For combat veterans, as well as for survivors of childhood abuse and victims of other traumas, we fool ourselves into thinking that we have identified a disease and are giving a specific treatment. I think of this as “neurology for dummies.”
But this approach has become predominant for strong financial reasons. Managed-care companies, which in many places have achieved a chokehold on the practice of psychiatry, exert considerable pressure to confine psychiatrists to the role of medicating physicians. They prefer to allocate the functions of information-gathering, counseling, and psychotherapy to our colleagues in the allied mental-health professions—that is, those without medical degrees—because they are less expensive.
But psychoanalytic therapy is an essential part of psychiatric practice. Remove it, and what is left is simple-minded and boring and does not properly serve patients. Even in the managed-care world, where problem-solving with behaviorally measurable goals is mandatory, over 80 percent of outpatient therapy is psychoanalytical. Patients prefer and expect this. They do not feel well served by filling out forms, receiving prescriptions, and having their therapy restricted to manual-driven procedures. They want to be understood.
Ronald Abramson, M.D.
To the Editor:
The problems created by the promiscuous writing of prescriptions for psychoactive drugs go far beyond what Paul R. McHugh was able to explore in his insightful article. The attempt to find the proper combination of medications can be more debilitating to the patient than the original problem.
I have watched several people go through an endless process of trial and (mostly) error with various combinations of medications. The drugs produce both side and interaction effects. Moreover, many people become habituated to the medications, so the dosages often have to be increased to produce the same punch.
The problem is the belief that there is a magic pill out there somewhere and we can find it if only we search long and hard enough. This mentality leads a patient to look to medication, rather than to his own behavior or lifestyle, as the primary agent of change in his life.
Jennifer Roback Morse
To the Editor:
Many thanks to Paul R. McHugh for his description of the present state of psychiatry. In the DSM, the potential symptoms of a disorder are often described in such general terms as, say, “impulsivity” or “failure to plan ahead.” If a sufficient number of the symptoms are present, the diagnosis can be made. Needless to say, this sort of evaluation is highly subjective and often depends on the predisposition of the therapist making the diagnosis.
As a trial lawyer for a busy public defender’s office, I often see the same behaviors described in radically different terms by different therapists, with correspondingly different diagnoses. A recent client was diagnosed by four different court-appointed doctors as suffering from, respectively, Adult Attention-Deficit Hyperactivity Disorder, Post-Traumatic Stress Disorder, Antisocial Personality Disorder, and Alcohol-Induced Anxiety Disorder.
Though judges, lawyers, and (increasingly) juries are skeptical of these psychiatric evaluations, I often see clients and their families clinging to a diagnosis as if it were the defining fact of their lives, an all-purpose excuse for their troubles. It is disheartening to think that some of these people might not be in trouble with the law if they had dealt instead with their real problems.
Michael C. Lukehart
Kern County Public Defender’s
To the Editor:
Paul R. McHugh describes the sea change that has occurred in American psychiatry during the past two decades as a result of successive editions of the DSM, and he is right to place part of the blame on the failure of Freudians “to advance [psychiatric] research.” In the 1950’s and 1960’s, when Freudian psychoanalysts were the premier psychiatric educators, they did not promote the empirical investigation of psychoanalytic concepts and interventions. As a result, the field of psychiatric research came to be monopolized by those who were funded by the pharmaceutical industry, with its vested interest in finding “scientific evidence” for the effectiveness of its products.
Many potential patients had to be excluded from these studies because in real life people are very complex and few fit neatly into the narrow diagnostic categories required for testing. Moreover, the studies only evaluated the immediate response to these drugs, allowing them to be touted as “breakthroughs” despite growing evidence that their long-term therapeutic effects were often very limited. Traditional trials of antidepressants, for example, have typically run six to eight weeks, even though the disorder can last a lifetime.
Only genuine collaboration between psychoanalysts and psychiatric researchers can lead to progress in the assessment and treatment of mental disorders.
Leon Hoffman, M.D.
New York City
To the Editor:
Paul R. McHugh deserves all the support he can get in what may become a lonely and futile scientific struggle within the psychiatric profession. The crowd that believes “for every crooked thought, there is a crooked molecule” may eventually triumph, but at a lamentable cost.
The residents in psychiatry at Johns Hopkins are fortunate to have Dr. McHugh as a teacher and mentor. One hopes he has time to instruct them about the “richness of psychological diversity” that he rightly values.
D. M. Collins, M.D.
Paul R. McHugh writes:
I thank my correspondents for their vigorous rejoinders to my essay and for the opportunity to amplify its thesis: that contemporary psychiatry has lost its way because of its overcommitment to a system of classification that banks too much on clinical appearances, blurs the crucial distinction between reliability (consistency among diagnosticians) and validity (whether diagnoses represent actual disorders), and permits the proliferation of dubious diagnostic categories.
Roderick Shaner holds that “external validating criteria” such as “family history, clinical course, and/or response to treatment” are “predicted” by the DSM’s categorical diagnoses. But where is such validating evidence for Multiple Personality Disorder (MPD) or Chronic Post-Traumatic Stress Disorder (PTSD) as they are conceived by the DSM? No family histories exist for these disorders. Their clinical courses are wildly unpredictable, and the responses elicited by treatment are disputed. Like several of my critics, Dr. Shaner decries “theory” in psychiatry, but vast quantities of theory are embedded (and shamefully camouflaged) in the DSM, and all of us are the worse for it.
Brian Ladds suggests that “extensive field trials” and “phenomenological” descriptions provide “empirical support . . . for the diagnostic criteria” of the DSM. But Dr. Ladds is defending the method while ignoring the results. The field trials of the DSM prove only that instructed workers can employ its criteria reliably—that is, to reach agreement on the existence of “cases.” These trials do not confront the issue of validity any more than did the witch-hunters of the 16th and 17th centuries, who were taught (also by means of official manuals) to apply empirical criteria in identifying their “cases.” As the computer teaches, method by itself guarantees nothing: garbage in, garbage out.
Dr. Ladds believes that “social-anxiety disorder”—one of the diagnoses du jour promoted by the DSM—is a condition that calls for treatment. My objection rests not on whether someone with a fear of public speaking deserves help, but on whether such a problem rises to the level of a categorical mental disorder afflicting one in eight Americans—all of whom, it is suggested, should receive prescriptions for Paxil. For the introverted, anxious individuals who typically suffer from this problem, medication is useful in that it reduces their emotional responsiveness, but is does not specifically heal something called social-anxiety disorder.
Arthur Rifkin notes that the psychiatrists at Washington University mentioned in my article proposed various ways of confirming a category of psychiatric disease. But such validating criteria are satisfied by only a tiny minority of the conditions listed in the most recent edition of the DSM, and for many DSM categories the search for biological criteria is a bow to the false notion that we must seek a twisted neuron for every twisted thought. Despite claiming to be “atheoretical,” the DSM encourages the presumption that all mental disorders are fundamentally biological, arising from problems in the structure or function of the brain. This is true in some cases, but in others, mental disorder is a product of the conflict between what a person hopes for and what life delivers.
Gary N. Cohen charms with his support of the “humble effort” to provide patients with relief from their suffering. I am on his side, but when a system of classification becomes a rationale for treatments that do not work (as in PTSD), for treatments that create addiction (as in Attention Deficit Disorder), or for treatments that misdirect efforts at recovery (as in MPD), then psychiatrists should think more carefully about what they claim.
Richard E. Vatz wants me to acknowledge that Thomas Szasz has been correct on occasion. I would do so more readily if it were not for the outrageous claims often made by Szasz, like his insistence that schizophrenia is a construct of psychiatrists in the same way that slavery was a construct of slaveowners. My views may at times align with those of Szasz, but I deny any “lineage” from him.
Ralph Slovenko would have me pin some of the blame for psychiatry’s plight on the aggressive advertising of pharmaceutical companies, but it is the conceptual world psychiatrists have engendered with their diagnostic system that has made both them and their patients so vulnerable to such promotions.
I agree with Gary Almy and Michael J. Reznicek about the overprescription of medications and the egregious error of thinking that relieving symptoms in this way confirms a diagnosis. Where we may disagree is on whether there exists, as I believe, a kind of depression (particularly of a bipolar form) that is, in every sense of the word, a disease—and one, moreover, deserving a considerable investment in biological research to find a “broken part,” just as we have done with epilepsy.
I thank John Dale Dunn for his kind endorsement of my “system” of categorizing mental disorders. Though discussed only briefly in the article, this system is spelled out at some length in The Perspectives of Psychiatry, a book I co-authored with Phillip Slavney. Our basic argument is that the scientific study of psychiatric disorders must begin by recognizing that such disorders vary in their essence.
I certainly agree with Ronald Abramson that what patients most want is to be understood. He and Leon Hoffman write approvingly of psychoanalytic methods as the best means of achieving this understanding. In the department I direct, I appoint psychoanalysts primarily because of their skill at proposing meanings that comfort some patients. But I wonder—openly to them—whether their therapeutic skills depend upon the theories of human nature they champion or upon the long experience they have in developing an emotionally and cognitively supportive atmosphere for their patients—the latter being no mean feat, of course.
Jennifer Roback Morse and Michael C. Lukehart write as thoughtful observers of the psychiatric practices conducted under the DSM banner, and I am pleased that my article fit and illuminated their own experiences.
Finally, I am grateful to D.M. Collins for a wise and empathetic perception of my situation. I can report that, so far, I am weathering well and my pupils prosper.