Suffering and Sadness Are Not Diseases
Harvard University Press Blog
by Richard Noll
28 May 2013
But the DSM effect on human lives is dramatic. Justification is provided for the widespread misapplication of drug therapies for millions of people who, as collateral damage, now suffer needlessly from side effects and withdrawal symptoms. Symptom relief, if it occurs, is often temporary and mild. Psychosocial factors, especially in children and adolescents, are often ignored. But this reflects the implicit cognitive categories of our historical epoch: in a radically biological psychiatry there can be no epistemic space for the unique individual circumstances or personal context in which symptoms arise. Neither DSM-5 nor ICD-10 reflects the wisdom of centuries of clinical observation, deep phenomenological understanding, or biomedical research in psychiatry. All mental disorders are not created equal.
Indeed, there is only a small subset of the hundreds of DSM mental disorders which serve as useful heuristics for clear biomedical conditions: schizophrenia, bipolar I disorder [in post-pubertal adolescents and adults, only rarely in children], obsessive-compulsive disorder, autism, dementia, panic disorder, and a presumed small fraction of those so loosely diagnosed with ADHD. Not included in DSM-5 are melancholia [a severe endogenous depression] and catatonia. For some, future treatments may target the endocrine system, the immune system, the microbiome, and other novel “whole body” physiologies. Let’s continue to deepen our understanding of genes, receptors, neurotransmitters, and brain circuits, but let us also widen our imagination to explore other medical hypotheses.Whether the hundreds of remaining DSM mental disorders will continue to fall under the jurisdiction of psychiatrists as biomedical specialists within general medicine is doubtful. Other primary care medical specialties and non-medical professions already perform most of those services. Most of these conditions respond well to empathy and effortful changes in diet, exercise, cognition, and behavior. None of these actual remedies comes in pills…
Catatonia is another basic disease entity that only now is being detached from “schizophrenia,” a non-disease, and made a disease of its own. DSM-5 goes part way in acknowledging catatonia as a separate illness. And there exist pharmacological verifications and validations of catatonia: the response to benzodiazepines and electroconvulsive therapy. So it’s a real disease too [no other serious disorder in psychiatry responds to benzodiazepines, though many garden-variety illnesses do].
And what do we do about chronic psychosis, all forms of which up to now have been called “schizophrenia”? The term embraces many different patterns of illness. One in particular is onset of social isolation and withdrawal in adolescence, first psychotic break, then stabilization with some kind of mental “loss” – or “defect,” just to use the ugly technical term – at a relatively high level of functioning. You can work as a porter; you can get married and be a good husband and family father; but a neuroscientist … ahem … you’ll never be. Let’s call this hebephrenia, core schizophrenia.
This is nothing new, nor is it really Kraepelinian. Karl Jaspers had a version. Here‘s a century old version from Alienist John Turner. They don’t differ a lot. Tertiary Syphilis came and went. Some causes of Delerium change with the culture. But the gist of things stays close to the same. The list hardly encompasses the breadth of people who report feeling mentally ill or the even people brought for care identified by others as mentally ill. I haven’t thought about it before, but I guess for me, these Psychiatric Diseases are a small subset of the Mental Disorders. As a matter of fact, I don’t actually think the term Mental Disorder actually holds much meaning for me. But Psychiatric Diseases are important in my mind.
I expect most people think of the Psychiatric Diseases with some version of the medical model, biomarkers or not. I certainly do. These illnesses can be devastating to a life, and deserve all the attention we can muster and the front page at the NIMH. Biological interventions, psychosocial interventions, whatever it takes qualified by the "do no harm" prescription and solid evidence-bases including long term follow up studies. These are the afflicted among us and they deserve our focused and informed attention. They [still] don’t belong in prison where many of them currently live.
Some psychiatrists think of this group of patients with Psychiatric Diseases as psychiatry proper and see those of us who also see other kinds of help-seeking patients as … doing other things. I kind of think of things that way too, doing other things. I do other things. I expect that Gary Greenberg, Richard Noll, and I might have differing ideas about how to approach a given patient who presented for the treatment of mental symptoms but didn’t have a Psychiatric Disease, but that a fly on the wall wouldn’t see a massive difference in general approach over time. If we were forced to make a diagnosis, we might diverge, but if we talked about the patient’s problems and were allowed several paragraphs, we’d probably converge.