Why PSYCHIATRISTS Need Your Help — Now :-(
“No ‘stress’ please — we’re psychiatrists” says the DSM
do you ‘mind’? — medical basics — the Medical Golden Rule — don’t falter now — the DSM falters — medical nitty gritty — causative factors — stress and double stress — even the Editor of the British Journal of Psychiatry, no less — DSM: Diagnoses as a Source of Money? — the DSM is ‘misguided’, says The Economist — DSM: Diagnoses for Stagnant Minds? — can you choose? — notes
do you ‘mind’?
Have you got a mind of your own? Do you ever wonder where mental breakdowns come from? Can stress unbalance the mind? Should medical diagnoses clarify your disease? Or not. The ‘DSM’ says “no” to all these four questions, for which I quote chapter and verse below. When I was a medical student in 1955, psychiatry was the Queen of Medicine — no longer. My first full-time job in psychiatry in 1963, bubbled with optimism. I was trained in what was called the Therapeutic Community approach — every morning the entire ward assembled in a big circle, even the cleaners were there — everyone, patients, doctors, nurses, all needed social support — and this approach acknowledged that, and moved to provide it. Wonderful. So what happened to it? In a word, the DSM.
There are five basic medical tasks. These apply to all doctors, past, present and future. Doctors before Hippocrates and those coming after Star Trek — all need to heed them, if they want to improve health care. The DSM reneges on four of these basic tasks — resulting in the DSM being less medical help than a telephone directory. ‘DSM’ stands for “Diagnostic and Statistical Manual”. It now comes in 5 editions, each thicker and shallower than the last. DSM-I, in 1952, was excellent and should dethrone all the others. DSM-III in 1980, pickled psychiatry in formaldehyde, from which it urgently needs your help to recover. You can do it, but only when you understand what went wrong. It’s simple enough at heart — the five basic medical tasks are just that — basic. Will you help?
First, let’s nail the DSM down. In full, it’s the Diagnostic And Statistical Manual Of Mental Disorders (DSM-I to 5). It is published exclusively by the APA, the American Psychiatric Association, which some label the Psychiatrists’ Guild, others the Psychiatric Trades Union or Cartel — you need to be the judge. I’m not arguing politics here, just medicine. I’m a passionate psychiatrist — my researches into all varieties of mental illhealth, from psychopathy to psychosis, have done nothing to discourage me — on the contrary my enthusiasm for the subject makes some doctors wince. Psychiatrists could use some of this passion — everyone would benefit if they were enthusiastic about their work — perhaps not as ebullient as me, but at least close — they’ve got stuck in the wrong groove, can you lend a hand?
A major bear-pit with psychiatry, is that it frightens people. There are innumerable non-psychiatric experts, fully conversant with how medicine should be run, too many of whom quail at the prospect of highlighting the DSM’s manifest medical errors. If they can be persuaded to review these five basic tasks, I am confident they would confirm them as something they all do, routinely, in their every day practice, and would loudly agree that to deviate from them would seriously hamper their general medical work. Climb to the top of the psychiatric tree however, and you can robustly dismiss any non-psychiatric critique. Unhappily for me, my psychiatric qualifications and experience rate as zero among too many of my psychiatric colleagues. If I have to tell them they’ve climbed to the top of the wrong tree, they know just how to disable insightful critiques — which is why I’m trying, here, to take this to a wider readership.
medical basics
Next, let’s look at those five basic tasks. I’m not here to de-mystify medicine — it has more mysteries than anywhere else in the entire galaxy — but there are, nevertheless, certain basic tasks, which everyone can understand, and which, when ‘eliminated’ as here, need everyone to put their shoulder to the wheel, to get the cart back on the road. By ‘basic’, I mean something of the order of “is the patient breathing?” As a doctor you have 4 minutes to answer this in the affirmative, else any and all remaining questions fade from medical (and patient) significance.
The five basic tasks, as seen from the doctor’s viewpoint, start with symptoms. Unless and until the doctor is provided with symptoms, he or she has simply no work to do, no contract to fulfil, no function. The patient, i.e. the doctor’s ‘customer’, initiates the medical process, which cannot continue without them. So symptoms are the FIRST basic task. The SECOND is diagnosis — this is the doctor’s critical function. A doctor, any doctor, who fails to diagnose, wastes time, and time is often at a premium in health care.
These first two basic tasks, symptoms and diagnosis, are the very foundation stones of a doctor’s work — get these wrong, and the doctor can kiss the rest of health care goodbye. The remaining three basic tasks are keys to successful health care, the more success you have in implementing these last three as a doctor, the better your health care will be as a result.
But it’s the first two tasks that need amplifying. Symptoms are best thought of as medical questions. Let’s face it, you don’t go to your doctor for fun — you go for answers. “Where’s this pain coming from, doctor?,” “What can I do about it, for the best?” I’m writing as a doctor, not especially for doctors, but also for everyone else. So symptoms are essentially medical questions — for which diagnoses are best thought of as medical answers, or partial answers.
the Medical Golden Rule
Again, doctors who get these foundation stones wrong end up treating the wrong disease, so, perforce, making matters medically worse. These first two basic tasks are so fundamental, that they are linked together by the single most important axiom I learnt in all my five-years’ medical school — the Medical Golden Rule. It was propounded by William Osler, a medical genius, akin in my book to a medical Einstein. He declared that every doctor should “listen to the patient, s/he is telling you the diagnosis”. Sadly Osler died in 1919, following the death of his beloved son in the trenches.
Next, after symptoms and diagnosis, the THIRD basic medical task is patient-agency. This is short-hand for what the patient thinks, believes, choses, needs or does. The patient as agent — doctors who promote this towards the top of their agenda, increase their chances of health care success, materially. The patient is also likely to welcome his or her views, or agency, being taken fully into account. In a way, this merges the Golden Rule with the other basic tasks — but that serves to confirm that a holistic approach works best.
The FOURTH basic task is causative factors. The better the doctor clarifies what it is that brought this trouble on in this particular individual, with these particular symptoms, at this particular time, the greater the chances of that doctor providing successful health care, rather than the reverse. Note the plural. Human beings are the most complex unit you will ever encounter, so, naturally, there are a myriad things going on at once, only some of which are available for discussion. The more skilful the doctor is in eliciting these causative factors, especially via the Golden Rule, then the better will the process proceed. Note that, being plural, the doctor’s next immediate task is to rank these multitudes of causative factors in order of their medical priority, with the first at the top of the list. Clinical priorities, namely which is the most immediate, the most urgent, the most likely — all have an impact on the chances of that individual responding to treatment.
Finally the FIFTH basic task is stress-reaction. Being ill is invariably more stressful than being well. People as you will know from personal experience, vary widely in the degree of stress, or intolerable conditions they can tolerate. But no-one is super(wo)man — increase the intolerable factors on any individual, and above their personal threshold, they will succumb to stress. It stands to reason. So again, the doctor who better assesses stress reaction, increases the likely success of their health care, by that factor too.
So there you have the five basic medical tasks: SYMPTOMS, or medical questions; DIAGNOSES, or medical answers, or partial answers; PATIENT-AGENCY, what the patient thinks, chooses or does; CAUSATIVE FACTORS, which of the many triggers matters most; and finally STRESS-REACTION, how this individual is bearing up, in this particular instance.
don’t falter now
If you answered “yes” to the opening question above — “Have you got a mind of your own?” — then “use it or lose it”, as I used to say as a Family Doctor. Psychiatry is too like any other human occupation to treat it as a closed book — the more you do, the better you get at it. I’ve been doing it for 53 years, and love it. What staggers me today, and this is where I need your help, is the quantity of gobbledygook that flows so freely out of so many prominent doctors’ mouths. As I say in my title, this needs your help — what they enunciate simply cannot work out in real life, so where’s their satisfaction in a good day’s labour? But you need to check out the reliability of these general medical points first from your own experience — after all, you need to know what’s what, if, or when, you meet psychiatry for real. Act now.
Let’s ground the five basic tasks in obvious ‘everyday’ health care. Take abdominal pain. Everyone has had one, and several, several. What’s the first thing that happens? Well, you ask yourself questions, perfectly legitimate questions, you want to know how to avoid it in future. Was it something I ate? Was it that chicken, or the vindaloo? This is actually the THIRD basic medical task — patient-agency — what the patient does. You wouldn’t want to do without that, would you? The DSM does.
So if your initial enquiry into where the abdominal pain came from works out, so much the better. If it does not, then eventually you seek medical help. Now I’ve diagnosed thousands of abdominal pains, and operated on a few. The more I’ve done, the better I’ve got at it. So currently, I’m confident in my abdominal pain diagnostic skills. For 20 years, my job was to screen such pains for seriousness — would they require operation, or reassurance? The decision matters. And in every case, and my success or otherwise relied on this, I listened carefully to the patient, s/he was telling me the diagnosis. How this works is that every abdominal pain leaves tell-tale clues in its wake — some more obvious than others. Gall stones, for example, behave differently from kidney stones — different effects manifest themselves at different times. You learn to listen for these subtle variations — you can’t just read about them in a book, and then take them all into account — your mind doesn’t work like that. Another of Osler’s incomparable axioms presses this point [1]. Only by repeated exposure to the same, or similar occurrences can you gradually ‘learn from experience’, and then come to rely on your judgement.
Bear in mind that humans are the most complex unit in the entire galaxy — so you would not be surprised to hear of a case I had of ‘abdominal pain’ diagnosed as heart disease. Bit of a stretch that. How did I reverse that diagnosis? The emergency doctor had ordered bed-rest for the duration, thereby depriving the local Christmas Pantomime of its theatre director. I listened carefully, prodded a bit, and revoked the heart disease diagnosis, authorised ‘gall stones’, and ordered him out of bed. For the record, the pantomime went ahead as planned, and he did not collapse from coronary disease. Exciting life.
That’s how health care works. You listen to the symptoms, the medical questions, because you need to come up with medical answers or partial answers — the best you can in the circumstances. Get either of these two foundation stones wrong, and you can inflict quite unnecessary trouble. When you let four out of the five basic medical tasks go hang, then even more people suffer, unnecessarily, including, in my clear view, the doctors doing the misdiagnosing.
the DSM falters
DSM-IV (1994), the fourth edition of this psychiatric tome, sold over a million copies [2]. How can this be? A psychiatric best-seller? It’s not cheap either — must have made the APA a pile. So all non-psychiatrists should legitimately ask themselves, why? What is it about this particular book which so appeals to all and sundry? This question is particularly pointed, when you appreciate that it has more pages than any of its predecessors. At 880 it is almost ten times thicker than its great-grandfather, the DSM-I (1952). (DSM-5, 2013, has 947 pages)
Just this simple word-count raises an important issue. Can it seriously be believed that psychiatry, of all the medical specialities, has deteriorated tenfold, in 64 years? Think all other branches of health care — coronary by-passes, new hips, cures for AIDS, conquering so many cancers — is psychiatry really that sick? Ten times as sick? Does your observation of the world at large justify a ten times increase in mental pathology? If ‘yes’, then continue to support the DSM; if ‘no’, then please, please, do think again.
A reasonable diagnosis for this astonishing profligacy is that the DSM sells a heavily simplified version of what ails the human mind. Oversimplified it certainly is, it omits 4 of the 5 basic medical tasks, to which we shall shortly come. But put a broader medical thinking-cap on for the moment, and consider what is really happening behind this grossly overweight paper-back.
When you look closely at the DSM, and read the actual wordage, it becomes clear that it merely provides lists of symptoms, that’s all. To be fair, it is designed as a Health Insurance Handbook — tick the right number of boxes in one ‘diagnostic’ category, and your health costs are covered, tick another, and they are not. Insurance companies have to have rules. But do doctors, and the rest of us, have to be governed by them?
So supposing that there are now 10 times as many symptoms as there were in 1952, what’s the sensible medical remedy? As in all other health care work, the only practical way to reduce symptoms is to get a more accurate diagnosis — one which applies, which works, and which helps reduce pathology, in this case psychiatric symptoms. To preside over a tenfold increase in symptomatology without so much as noticing it — this calls for a major, non-psychiatric review. I do so much hope you agree.
medical nitty gritty
Of the five basic medical tasks, SYMPTOMS, as mentioned, is the only one the DSM offers. While this might be useful for epidemiology, it is unhelpful for health-care, since none of its proliferating entries advances beyond unvarnished medical questions. Symptoms are not diagnoses, the one may lead to the other, but human intervention is required to do so, safely and reliably. The DSM doesn’t even set out. At the most basic level, diagnoses should be medical answers or partial answers. When you look closely, with an experienced eye, it’s almost as if the DSM prides itself on clouding the issue with unnecessary obscurity. Where diagnoses, i.e. ‘answering medical questions’, should be, there isn’t even a one. Check it out. I challenge anyone, medical or non-medical, to come up with even half a suggestion of any possible medical answers. If these five basic medical tasks hold water, then reneging on four of them augers ill.
The SECOND task, therefore is flunked. DIAGNOSES should add something to the clinical mix. The doctor, to effect even a minimal improvement in health care, needs to bring a fresh light on the problem, one which the sufferer themselves hasn’t been able to come up with. Thus, where diagnoses should be medical answers or partial answers, the DSM ‘eliminates’ this invaluable medical tool entirely.
The three remaining basic medical tasks are explicitly derogated by the DSM in writing — it really is hard to believe that sensible doctors can print such things, and then, for the large part, accept them as gospel truth. Yet that’s what has happened, and will continue to happen, until enough of the population at large says “enough is enough”. Will you?
The THIRD task, PATIENT-AGENCY, depends on the individual having a mind. You can debate whether we have choice, or an element of Free Will, but if you’re writing a psychiatric text book surely you shouldn’t say –“The term mental disorder unfortunately implies a distinction between “mental” disorders and “physical” disorders that is a reductionistic anachronism of mind/body dualism. . . . . The problem raised by the term “mental” disorders has been much clearer than its solution, and, unfortunately, the term persists in the title of DSM-IV because we have not found an appropriate substitute.” [My emphasis.] In other words, if we could leave out mental and the mind altogether we would — “unfortunately” we can’t. So what happens is that the DSM ‘eliminates’ the mind root and branch, taking any hint of patient-agency with it, something no other part of medical practice could possibly even begin to contemplate. Does psychiatric omerta keep this omission hidden?
I can’t resist the following. When I first read this paragraph 20 years ago (page xxi in DSM-IV by the way), I said that even a high-school student of philosophy would make mince-meat of it. What I didn’t then anticipate was that earlier this summer my delightful 18 year old grandson would fit this bill as a glove and would have just taken his philosophy exams. So, when he stayed with us this summer, I set him this paragraph as an exam question, and told him I would mark his answer out of 10. His reply is worth quoting in full. He wrote “It does clearly highlight an irreconcilable difference between DSM’s concept of mental and yours (if I can be so presumptive, XX). DSM seems to imply they want to reduce the mental to the physical. What exactly this entails is not clear and whether this would lead to the ignoring of intent and other obviously purely mental phenomena. — — — And of course we would not want that.” I marked him 10 out 10, wouldn’t you?
Want it or not, that is what the DSM delivers, and what far too many psychiatrists and non-psychiatric doctors adsorb with their morning cereal. What is at stake is denying human beings their agency. So the answer to the question “have you got a mind of your own?”, is “no” according to the DSM. Again if you agree, continue to support this (anachronistic) ‘psychiatrist’s bible’; if you don’t, then we need your voice to be heard, whether medical or non-medical — contrary to certain wishful thinking, a medical qualification does not, of itself, confer a non-stagnant mind.
causative factors
As Dr Conan Doyle repeatedly demonstrated via Sherlock Holmes, the fascination of medical practice consists of working out which factor, of the myriad involved, ranks highest, which is most likely to lead you to a solution of the problem, medical or criminal, and which therefore you should follow to the bitter end. What neither he, nor Sherlock, would ever advise is ignoring all causative factors in toto. No sensible doctor would. Would you?
Again, when I first read the following, I was flabbergasted, not that that advanced my psychiatric career any. On page xvii of DSM-IV the following appears. “DSM-III [1980] introduced a number of important methodological innovations, including . . . a descriptive approach that attempted to be neutral with respect to theories of etiology.” Translating this — “etiology”, or “aetiology” is the medical term for the cluster of factors which always precede a given disease, here rendered as ‘causative factors’, task four of the five basic medical tasks. It takes some chutzpah to claim that ever since Hippocrates, doctors have spent far too much time winkling out causative factors, or aetiologies. DSM recommends as an important ‘reform’ of medical methods — treat all causative factors with utter neutrality, don’t bother to chase up where the symptoms come from — assume they just come.
The next time you talk to a doctor, any doctor, ask if they would please leave out of consideration any of the underlying factors which could have lead to your symptoms. If they ask, for example, whether you ate too many curries recently, or too much dubious meat, simply remind them that ‘modern’ doctors retain strict neutrality towards any notion that what you eat could in any way relate to what your abdomen is telling you.
Aetiologies are complex, agreed, but to proceed as if they didn’t count, is starkly non-medical. An “important methodological innovation” that kills medical curiosity on principle, that rules out medical consideration of any conceivable causative factors, is tantamount to a medical killjoy — no wonder too many psychiatrists are gloomier than me.
stress and double stress
Ask any member of the public, especially those with no hint of medical training, what leads to mental ‘breakdowns’, and they will say “stress”. They may use a different label. They may say hassle, troubles, calamities, divorce, abuse, loss of a loved one — but the underlying meaning is crystal clear. Human beings can take a hill of problems, but underneath they are not built of steel. Weigh down on them too heavily, and they crumble. No point in fretting we are not stronger — just make sure you have access to a ‘support network’, people you trust, people who won’t always bite you when you’re down. We all do go down from time to time — life can indeed be mighty heavy — but humans are miraculously resilient — the “healing hand of kindness” approximates to a panacea.
One of the overwhelming advantages of 20 years as a Family Doctor is that it brushes away the cobwebs of pre-conceived ideas. I estimate I’ve talked to 20,000 people about every conceivable topic under the sun. I used to joke that I’d seen a smattering of every disease, except leprosy. Marvellous. In a small town, they will even stop you in the supermarket to discuss their bunions, or whatever — it is one of the best educations about the human condition you can find. After 10 years or so, I found myself saying, rather to my surprise, “stress is a killer” — I still find it uncomfortable, but that’s a small price to pay for something which materially improves health, which, as my medical confidence grew, it did.
With this stark phrase ringing in my medical ears, imagine how I felt on reading the following. “The use of the term reaction throughout DSM-I reflected the influence of Adolf Meyer’s psychobiological view that mental disorders represented reactions of the personality to psychological, social, and biological factors. . . . DSM-II was similar to DSM-I but eliminated the term reaction.” (DSM-IV, page xvii). In case you didn’t get the drift, further down that page “even death of loved one” is also explicitly “eliminated”. “Reaction” though heartily approved of by Dr Adolf Meyer, was decisively and utterly spurned by DSM-III (1980). We’ve now had 36 years of eminent psychiatrists blandly contradicting the humanly obvious — we all react to what happens to us, especially stress, whatever top-selling psychiatric texts might choose to aver to the contrary.
Now you may wish to support the prevailing view. How can so many doctors, at the top of their profession err? If they say, as they do, that Dr Meyer was wrong, and that psychiatry proceeds best when you disregard all references to “reactions of the personality to psychological, social, and biological factors”, then read no further, because I don’t.
even the Editor of the British Journal of Psychiatry, no less
I’m struggling here, to bottle up the purple ink — purple prose may release frustration, but it can confuse the issue. Since this all gets rather heavy, let’s take a breather, put on the coffee, turn up the music, a change is as good as a rest. Let’s bring in Sherlock Holmes again, he is endlessly fascinating. I once did a study of his 50 cases or so, and checked out the motivation in each of them. So what’s my motivation here? What do I expect to gain, personally, from this exploration into one aspect of human nature? Well it can’t be money — I’m writing this for free, I wrote a whole chapter on consciousness, which I even paid for free distribution — so money is not my motive.
When I was 16, working on a holiday job as an orderly in the local mental hospital, I conceived the ambition to uncover a talking-cure for psychotic symptoms — which the last few years have convinced me I have now done. This coupled with the fact that I shall shortly reach my 80th year, means that career advancement no longer drives me as once it did. And, as noted elsewhere, I have accordingly closed my clinic, so shedding a medical burden of more than half a century. So my motive in writing this is to tell a story, to clarify what some find utterly mysterious, to give an account of my experiences since 1955, of 61 years close, upfront observation of what doctors do, and what they try to achieve. Parts of the story will never be fully understood, that’s life — but enough of it is sufficiently clear to make a difference, if you can persuade a willing listener.
Looking back over more than half a century, what is striking is that ‘knowledge’ comes and goes as fashions do. What held water decades ago, no longer fits the bill. People now tell the time, and take videos with their telephones — something my late father would find incomprehensible — he had difficulty pressing the same switch for off and on — a toggle switch is second nature to a two-year old — but mystified a man born in 1909.
So it is with more important matters. Oliver Wendell Holmes proclaimed that he liked paying taxes, because he said he was buying civilisation — where is the truth in that rather obvious statement, today? Indeed where are sagacious well regarded individuals whose views are widely respected, especially on ill-defined, but vitally important topics, such as money, taxation, health-care and other strategic issues? Recent political events prove the point. Unlimited self-contradictory things were said during the British referendum on the European Union, leading some to suggest we are now in a post-truth era. What kind of politics produces an Education Minister who publicly and vociferously discounts expertise — what is education for?
Returning swiftly to the issue in question, where are the psychiatric experts to gainsay, or support the uncomfortable points made here? Surely the Editor of the British Journal of Psychiatry would count as the best arbiter in these challenging times? And sure enough, one such has written decisively and with irrefutable clarity on the point — but not with a straight face. He suggests that ‘DSM’ might stand for Diagnoses for Simple Minds, or Diagnoses as a Source of Money [3]. In some ways these calumnies are more damaging than the ‘tasks’ I write about here. If he seriously believed that the DSM grossly oversimplifies, or was invented to make more money for doctors than before, then he should not hide these condemnations behind a smirk, but should broadcast them as widely as his position as Editor of a prestigious medical journal would require.
But he doesn’t. Why not? Unhappily, if he’d voiced them too loudly, his job would have gone out from under him, as mine have. This Editor had climbed to the top of the tree — how could he possibly admit it was the wrong tree? But he could see the stark flaws in the DSM, as clearly as I can, but he declined to use his prestige to correct them — which leaves that burden for you and me.
DSM — Diagnoses as a Source of Money?
When I first read this, it didn’t click. Being reared in the NHS, and therefore cossetted by a system which limits the cash pollution of health care, I had never really thought of psychiatry in terms of income. Sadly, I was mistaken. A far fiercer criticism of today’s psychiatry comes in the latest book by one of my heroes, Robert Whitaker [4], which he co-authored with the Harvard Law School. What an indictment. The foreword starts with the paralysis in the US Congress, which even declined to fund Zika research — Professor Lawrence Lessig attributes this to ‘institutional corruption’. None of the individuals, he writes, are evil — but en masse they deliver devilry. Don’t go away, until you see that Whitaker says precisely the same about today’s psychiatry. What a travesty. A branch of a caring profession, dedicated to aiding humanity, somehow being ‘corrupted’, and being perfectly content to pursue lines of health care which don’t, so long as they pay well. Oh dear, I fear that purple ink is leaking out again.
Whitaker and his co-author Lisa Cosgrove, close the book by likening the APA, the American Psychiatric Association, to a Guild, as interested in maintaining a tight hold on the ‘market’ as it is in delivering what it purports to, as a branch of health care should. I’ve known Whitaker since 2004 when I invited him to speak at our conference in York, having learnt some dark truths about my profession from his ground-breaking book, Mad in America, which I happened to have reviewed for The New Scientist. The phrase “the healing hand of kindness” comes directly from him, though you have to have a stronger stomach to acknowledge his other killer-line “brain destruction as therapy”.
Institutional corruption, as Whitaker and Cosgrove see it, is funded by a slick PR team, an efficient lobby which snuffs out notions which might muddy the unfettered pursuit of that profession. But don’t take my word for it — read his final pages, and if you don’t wince, then take a rather closer look at yourself in the mirror.
Again, what is astonishing, and also rather sad, is that this critique, aimed at the very heart of the psychiatric profession, and backed by as august an institution as the Harvard Law School, has zero impact on its target. Despite the pre-eminence of its provenance, it might as well be gossip. Yet another reason to prompt me to seek a different and wider readership.
It is this unsettling notion that, having been hood-winked by the DSM, psychiatrists now neither read nor take note of anything to the contrary. What will it take? When I asked Whitaker in 2004, what was needed to rectify the obvious flaws that he saw, and continues to see — he said, a ‘consumer movement’. When I met him a year ago, even this had faded somewhat. How about a tweet going viral — would that move anything?
the DSM is ‘misguided’, says The Economist
The list of books pointing out these gross flaws in today’s psychiatry grows by the day, I estimate I have around 50 on my shelves, currently. If even only half of what I’ve written here is correct, then this number must inevitably balloon. Meanwhile, the number of plangent emails in my inbox, asking me to correct the gross mistreatments these gross misdiagnoses deliver, is also likely to grow. What I’m writing here, is in part my answer to that — but I need help, will you?
The story goes that Bill Gates declines to have a TV in the house, else he’d never get the time to read The Economist. Well, I too have read it since 1963, and though its politics are sometimes doolally, its coverage of events, especially those impacting on money, is unparalleled. And since cash, in its many forms, seeps into every corner of our lives, The Economist coverage increases all the time.
Thus in the May 18th 2013 issue, we find a review of the DSM-IV, or rather of the DSM-5 which is about to be launched. The most gruesome feature of this article is the cartoon. It depicts a harassed doctor, holding a youth by the collar, and tipping an enormous jar of multi-coloured tablets down his throat. But this doctor has clearly never heard of the Golden Rule, since instead of looking at the unfortunate lad, he is scrutinising an enormous tome on a book stand, the DSM. The book here is vastly more important than what he is doing to his patient — Osler would be spinning in his grave, twice.
Having castigated the DSM as ‘holy writ’, the ‘psychiatrist’s bible’, and clearly labelled it ‘misguided’, The Economist includes the devastating fact that the leading research doctor in the US advises strongly against psychiatric researchers using this text book as a basis for their work. What a calumny. It’s perfectly fine to use it for ‘treating’ patients, but when it comes to research, to find, for example if any of those treatments work, don’t. Preserving research is more important than ensuring better health care by ditching the DSM. What is going on? Nothing so far appears capable of denting the well constructed concrete wall currently built around the profession I love — could Twitter do it?
DSM — Diagnoses for Stagnant Minds?
Gloomy psychiatrists are good neither for themselves nor for health-care generally. And it doesn’t really take long, as a doctor, to put the mind at the top of the human tree. What happens there overpowers almost everything else. So if, as a doctor, you mishandle that, then you and anyone you treat, is going to be in trouble.
Well, as the next and closing section emphasises, we are profoundly ignorant of any number of things around us — so we have to make guesstimates, we have to chance our arm at ‘supposing’, and see how we get on with that. What seems so obvious to begin with, may lead us into a deeper mire shortly thereafter. Take today’s fashion of scrutinising the brain — it seems too good to be true, that whenever we cogitate, different electrical impulses power through our grey matter. The plea to be concrete, to uncover solid, reproducible printable data overwhelms a more subtle approach, sadly.
But take a step back, have a look at the wider implications of this, and the thing becomes not only far-fetched but ludicrous. Things go wrong in the mind, daft ideas lead to painful problems — but why blame the brain? Things go wrong with all sorts of bodily organs, but we don’t blame them. A cardiologist who blamed the heart for coronary disease, or the liver for cirrhosis, would be laughed to scorn, and would soon cease to carry the confidence of any patient, nor government nor insurance funded health care. It makes no common sense whatsoever — so how can it make medical sense either?
Let’s suppose, for the sake of argument, that you carefully researched all the scientific literature, did a real professional researcher’s job, and concluded that there was not a scintilla of evidence worth the name to justify the wishful thinking that ‘brain insufficiency’ had even the remotest connection to mental illhealth — what would you do? How about publishing a book entitled “The Myth Of The Chemical Cure” — that would seem to be a rational thing to do. Indeed if you were employed as a university lecturer at the time, such a publication would be expected of you. This is even harsher than the 4 basic medical tasks. Dr Joanna MonCrieff did just this [5]. Given its utter lack of impact on today’s psychiatry, should she have bothered? Something extra-medical is called for, something outside the psychiatric closed circle — would that be you?
What I found increasingly in my work, is that if you can’t think, you’re sunk. The particular relevance for psychiatric disease, is that the mind becomes too befogged to think through it’s problems, which is what the mind is for. If it keeps solving yesterday’s problems, using tools that the passage of time has made obsolete, then no wonder there’s no solution. Sadly what we have with the DSM, is a reversion to almost a Mediaeval view of the mind. And having established a grip over the last 36 years, the DSM has become impervious to re-thinking, or even to allowing innovative ideas, such as described here, to see the light of day.
As a doctor, I too was bemused by the decidedly odd notions my patients kept offering me. I floundered. Gradually however, a pattern beneath these oddities made itself known — the person in front of me was operating perfectly rationally, but on a different time frame. They had got stuck in a context where parents knew everything, and should never be gainsaid. I call it ‘infantism’. When persuaded to think, they ceased to sink.
My plea therefore to psychiatry, and therefore to readers of this description, is to think again. To put the problems of the mind into a wider context, where sounder reasoning can prevail. Not for some zany reason, nor crazy ideal — don’t touch anything that doesn’t work — but think things through. Sadly, the DSM, as I see it, stops just this re-thinking, for several of the reasons outlined above — so my transliteration of DSM is Diagnoses for Stagnant Minds
My answers to the opening questions, accordingly, are as follows. Yes, you do have a mind of your own. Yes, it pays to question where mental breakdowns come from. And, yes, stress regularly unbalances the mind. And if any medical diagnoses you receive fails to clarify your disease — complain, and perhaps even Tweet.
can you choose?
IGNORANCE is humungous, and growing rapidly. Scientifically speaking, Dark Matter and Dark Energy grow apace, squeezing the ‘known’ universe into an ever smaller ‘remnant’, leaving us such little room for all our atoms and molecules of which everyone of us is composed. But this has now been going on uninterruptedly for aeons, and during all that time, living organisms seem, so far, to have made the best of it. Take a look at the biosphere. Plants grow where you’d least expect it, ledges, odd corners, abandoned buildings — against all the physical odds, they still manage to bloom. Why don’t we learn to blossom too? Let’s borrow this ‘evolutionary’ optimism from them — after all we share 30% of their DNA. Why should the rest of the biosphere have all the fun? For me, as I describe elsewhere [6], the Natural comfortably overawes the Supernatural.
The current fashion is to wait for computers, and so-called artificial intelligence, to save the day. Well, digital machines have certainly changed most things dramatically, and we haven’t seen anything yet. And certainly I wouldn’t have written this article, had I not had access to the digital web — medical journal editors are deaf to my stoutly medical protestations.
But before you support the DSM in supposing that we really are no more than mechanical chemical machines, ponder the very heart of what makes computers tick. Everyone knows that binary digits, 0 or 1, underlie their every move. It is precisely because these two building blocks are so obvious, so clear cut, so unforgivingly unblurred that computers can do what they do, speeding through digital data at astronomical speeds. But pause, and translate zero and one into human, and see what happens then. It’s easy enough: ‘1’ means ‘yes’ and ‘0’ means ‘no’. Then look at your everyday life. Check what you actually mean when you next use these apparently obvious words. “Yes” can mean anything from enthusiastic support to sarcastic negation. You have learnt to tell the difference, but if you start to teach the machine, you’ll slow it down, and a slow computer is a contradiction in terms.
But the biggest bear-pit into which the DSM and many other experts who should know better, have fallen is ‘choice’. Your brain is not a computer, and never will be, because it supports your mind, which is actually where the choosing takes place. Computers, all computers do precisely what they have been told to do — once they turn out to be doing something that they’ve not been designed to, we call it a ‘bug’ and work hard to prevent its recurrence. You can’t have it both ways — either these are wonderful machines, because they are slaves to the choices that human ‘programmers’ have previously chosen for them — or they are wobbly and fluid, and vary on a whim, like our mental images.
Choice is the computer-killer. Check back as to how you got to this screen. You clicked various icons, you decided what you wanted to read next, you chose. You did something you’ve never done before. Something way outside your ‘programme’, your schedule, what you’d already ‘intended’ to do today. You initiated a course of action which would never have occurred, had you not done so — and you could repeat this creative innovation, if you wanted to, by, for example, re-tweeting this. If you don’t, it will fester on a database, and decay. If you do, you might, just might, start an injection of optimism into what has recently become the dismal science of psychiatry — well think about it, and ‘choose’. OK?
Dr Bob Johnson Originally written on Tuesday, 25 October 2016
disclaimer: these are my personal opinions. They are based on my subjective personal experiences — if yours differ, please discard mine. If you find them disturbing, please consult your doctor or a person you trust, as my clinic is closed.
health warning: never stop psychiatric drugs abruptly — your brain tissue has got used to them, and needs to be skilfully weaned off them. . . .
notes
[1] “To see patients without reading books, is to go to sea without charts. But to read books without seeing patients is never go to sea at all”.
[2] The Economist, “DSM-5, By the book”. May 18th 2013
[3] Dr Peter Tyrer “DSM — 100 words”. Editor British J Psychiatry. (2012) 200: 67
[4] Robert Whitaker and Lisa Cosgrove, 2015. Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform. ISBN : 978–1–137–50692–4
[5] Dr Joanna MonCrieff. The Myth of the Chemical Cure ISBN 978–0–230–57431–1 first published 2008.
[6] Dr Bob Johnson. Chapter 6 : Consciousness: Using Clinical Evidence To Link Consciousness With Its Twin Perils Of Psychosis And Violence, in “Consciousness: Social Perspectives, Psychological Approaches & Current Research”. ISBN: 978–1–63485–023–0 Editor: Lloyd Alvarado. Nova Science Publishers, Inc. 2016 . https://www.novapublishers.com/catalog/product_info.php?products_id=60019 free
Synopsis: Abstract — Introduction — Simplifying Consciousness — Dethroning Newton — All The Unknowables — How ‘Simple’ Are Computers? — The Roots Need Pruning — The First Clinical Case: Violence — The Second Clinical Case: a prisoner’s letter — The third Clinical Case: Psychosis — Conclusion — IN SUM, my 5-rules-of-thumb — References
