When I asked Sandra Steingard to post here, I had little worry that we would disagree about much of anything after reading her posts on Mad in America. In a guest post from Sandy Steingard…, she calls herself muddled three times. In the face of the complexity of the narratives patients bring to us mental health types, anyone who isn’t muddled isn’t even in the game in my book, and hasn’t grasped our place in these stories. As a practicing Internal Medicine physician, away from the situation of training, I found myself muddled all the time, but it usually wasn’t about the biological issues in the case. I had been well trained. It was the people, their lives, the interactions between their personae and their physical illnesses. I didn’t find that side of things any different from the clinical medicine or the scientific research I’d done before. Find out everything you can and sooner or later, there would be clues and hunches to follow – blind alleys often, streets of gold occasionally, and sometimes small inroads that moved things forward. I went to psychiatry because it was about those muddles of life I had become interested in. So Sandy’s acknowledgement of being muddled insured we would likely be on the same page right off the bat.
I’ll weigh in on the Schizophrenia thing later. Right now there are some other reactions at the front of the line. Skipping down towards the bottom of her post, she says:
Although I end up with more questions than answers, there are people who have helped me gain some clarity. One of them is the British psychiatrist,
Joanna Moncrieff. In her books, "
The Myth of the Chemical Cure" and "
The Bitterest Pills" she makes the distinction between a drug centered and a disease centered approach to thinking about psychoactive drugs [see her
here]. She has written about this on
MIA and there was also a critique of her
recent book…
I remember that happening in the 1980s. I had left academia and was in a solo practice, and I began to see patients who had been told that they had a physical illness,
like diabetes, that it was caused by a
chemical imbalance, and that the medication,
like insulin, rectified that imbalance. That was certainly not known, and at first I tried to be gentle in talking about it with patients. Then one of them named the source as a psychiatrist I had trained. I called him up and asked where that came from. He told me he knew it was an exaggeration, but that it helped people be more medication compliant. I won’t say what I said after that, but it wasn’t pretty. That kind of malarkey didn’t last in that specific form for more than a few years, but it didn’t go away and haunts us. Dr. Moncreiff also skillfully documents the renaming of the psychiatric drugs as
anti-this-and-thats [see this
must-watch video] – antidepressants, antipsychotics, etc. That’s a double-whammy. It implies that depression and psychosis are physical diseases and amenable to ghost-buster techniques. I’m older than Sandy and never believed those widely taught simplistic ideas, but I think we’re all indebted to Dr. Moncrieff’s clarity in discussing the topic and Sandy’s highlighting it for us here. As I said in
in the museum…, these are primarily symptomatic medications at their best – not
like insulin, not like vitamins, closer to aspirin. And they all come with a downside, a downside more virulent than aspirin [which has its downside too].
Sandy mentions another blogger,
Nev Jones, and a particular post on her blog:
Another blogger whose work I admire is
Nev Jones who writes at her site
Phenomenology of Madness… Nev writes about her own and her family experiences with – to use her term – madness. One of her more poignant posts is
ain’t no way to deny it, if it’s in your soul. She is so articulate and careful with her language (among other things, she is philosophically trained) that I hesitate to say more and risk misrepresenting her. She is an activist and a scholar and I find her courageous in her willingness and ability to articulate difficult and sometimes unpopular positions. But if I were to encapsulate the one point Nev has so clearly articulated for me, it is the concept of heterogeneity.
Nev’s post [
ain’t no way to deny it, if it’s in your soul] and
Wiley’s comment to Sandy’s piece speak to some of the impossibilities of madness – for a person, for a family member, and, in my case, for a doctor. I shy away from the endless debates about such things because they’re so experience distant from those encounters that they denigrate the essence of the moments. I was never a combat soldier, but I’ve met many and heard them talk about the painful alone-ness they often feel when civilians are talking about war. Nev and Wiley are veterans. Like Sandy, I also "
hesitate to say more and risk misrepresenting" them, but I appreciate their insight about the
fog of madness – when the compass is spinning without direction for all involved.
Right now in the comments, there’s something of an interesting debate about distinguishing delusions from strongly held but idiosyncratic ideas. I’m going to add my input about that particular point later when I respond about Schizophrenia. But for the moment, this guest blogger experiment is already a success in my book, and I really appreciate the respectful tone of the comments. These topics are often divisive, but the things I’m reading right now aren’t like that at all and I’m grateful for that…
“this guest blogger experiment is already a success in my book, and I really appreciate the respectful tone of the comments. These topics are often divisive, but the things I’m reading right now aren’t like that at all and I’m grateful for that…” Amen. Much thanks to 1bom, and all involved.
I think it can fairly be said that the biomedical model of mental illness is both an overvalued idea; and, when combined with the belief that it is a scientifically valid theory that is backed by irrefutable evidence is also a delusion. It can be two delusions, the belief that it scientifically valid and the belief that one is a scientist by virtue of being a psychiatrist.
Is it another instance of reification to say that to have a delusion is to be mentally ill? There are all kinds of socially constructed delusions. Many are overcome in time, like the once “truism” that women were physiologically incapable of being scientists, which seems to have been embraced by an awful lot of scientists and social scientists.
All kinds of academics have a long history of using their “objectivity” to support beliefs and to ignore their biases and emotions while doing so. Once someone crowns themselves as being objective, scientific, or unbiased, they embrace a delusion and lose the plot.
In my comment I discussed a few (small) studies that found between 30% and 70% of hospitalized psychiatric patients in public and state institutions had physical illnesses that were deemed causal to their symptoms, but were not detected and misdiagnosed as psychiatric illness.
A great deal of the patients were physically sick, and most patient’s illnesses were detectable with an automated battery of diagnostic tests. These illnesses were already diagnosable and treatable by their respective medical fields. Yet, these patients were misdiagnosed with Psychiatric illness and their physical illness was never tested for or otherwise detected or treated.
I enjoyed the guest authors post about how difficult it is to judge recovery, properly diagnose, and use treatment appropriately on patients with unknown illness.
As far as the debate goes though, I think it’s too philosophical. Treatment is heavily influenced by illegal marketing (and corruption of knowledge), and diagnosis is based on ridiculed conjecture and failed ideas. The approach was historically wrong, and still is. The extreme degree of misdiagnosis of institutionalized patients, let alone the general public, continues unaddressed.
I hope you consider more guest bloggers in the future though, I found the ‘drug centered and a disease centered approach’ interesting.
Yes, Tin Can, there are people with medical illnesses that present with psychological symptoms and that is just one small part of the problem with the medical model of mental illness
One point in Moncrieff’s lecture that I would like to see very seriously addressed by the field, or Dr. Nardo, or anyone who is knowledgeable is the lack of in depth study on the effects of these drugs.
Now there’s a run willy-nilly to neuro-imaging, which is both the search for the holy grail of the medical model— now that every other attempt has failed— and an astounding exercise in ignoring human development which has been extensively studied in the field of neuro-biology for decades.
I don’t think the problem is “philosophy” I think it’s an assumption of knowledge that is woefully incomplete, biased beyond all reason, and neurotically embraced as a scientific understanding that cannot be legitimately challenged. I’m not talking about every psychiatrist, but about the whole, and the Gestalt of the medical model is kaput.
Anyone who has convinced themselves that they are experts in the human mind, and therefore have a special gift for assessing the problems of any mind that appears in a disturbed person in front of them on the basis of a single interview is not only deluded, but is also reductionist to a degree that lends itself to depersonalizing if not dehumanizing attitudes toward the mentally distraught.
Wiley, I chuckled when I read your riff on delusions and overvalued ideas vis á vis the medical model… it’s a smart observation that takes us straight into epistemology. So, another term that we might introduce now is paradigm, and that ties neatly into the social constructionism you mentioned. Thank you, Thomas Kuhn. Just the same, paradigm error is not necessarily delusional… it may be just wrong or incomplete… but that does not mitigate its ill effects for patients. And once again, the history of medicine is filled with instances of what we now clearly see with hindsight were paradigm errors… it’s not just psychiatry. Leeches, anybody? Bloodletting, anybody? Six weeks strict inpatient bed rest for heart attacks, anybody?
Wiley, as for the effects of drugs, the side effects (mostly psychiatric) are usually listed by incidence in the drug labeling information (from clinical trial data). If the side effects are virtually random (they are), then the desired effect is unlikely to exceed placebo either (what we hear so much about). It also directly supports that mental disorders don’t not exist because symptoms from CNS disruption are highly random and not very unique to any specific cause. The lack of study on long term side effects is extremely worrying.
The incidence of ER hospitalizations for psychiatric conditions has been increasing:
Epidemiology of adult psychiatric visits to US emergency departments.
http://www.ncbi.nlm.nih.gov/pubmed/14759965
“Psychiatric-related ED visits represent a substantial and growing number of ED visits each year.”
So yikes! from every angle.
Bernard Carroll, Ernest Hemingway was diagnosed all the way back in 1961 with Hemochromatosis. Even though it was written in his medical files, he was institutionalized and treated for ‘Depression” with ECT instead. The treatment for Hemochromatosis to this day is either Bloodletting, or a chelating agent, and both are mostly effective for those who can tolerate them.
Psychiatry’s leaders seem to be immune to hindsight. The NIMH is searching for ‘new’ physical causes of mental disorders instead of debunking the concept. The APA is claiming disorders are ‘Psycho-biological illness’, which means ‘illness of the brain caused by the mind’ (like PTSD). The two fight with each-other and both are simply blatantly wrong. *angry scribbles*
I worry about the all that ghostwriting and stupid ideas, millions of unreplicated bio-psychiatry publications, being pushed into Neurology’s literature. That scares me.. the damage they’ll do to all of medicine. 🙁
TinCan: Ernest Hemingway died July 2, 1961 and his bouts of mood disorder complicated by alcohol misuse preceded that by decades. The hemochromatosis was diagnosed just months before his suicide and it would be a stretch to attribute his psychiatric history to this incidental physical condition.
Bernard Carroll ,
Can J Psychiatry. 1994 Feb;39(1):8-11.
Iron overload and psychiatric illness.
http://www.ncbi.nlm.nih.gov/pubmed/8194001
His sister and brother also committed suicide. I think it would have been to late for his career as a writer, but not for a therapeutic benefit of some degree.
The mind is connected to the brain, and in medicine, every part of the body is connected. Something that’s messed up one place will affect something far away. One of the reasons medicine is an art 🙂
TinCan: I see the point you are driving at. Just the same, the study you cited would not be considered high quality evidence… probably Level 4 out of 5 as an uncontrolled case series.
I’m aware. It’s really up to the physician to make the connections between physical illness and symptoms.
There’s a whole list of physical conditions screened for in the Medical clearance of psychiatric patients.
“Mental Disorders Secondary to Medical Conditions”
http://emedicine.medscape.com/article/294131-overview
Unfortunately.. if patients don’t complain of physical illness, they often aren’t screened. Private practices do no screening at all.
It makes you wonder how bad the problem is. I don’t think the DSM has any instructions on how to properly rule physical illness?