\nSuffering and Sadness Are Not Diseases<\/a>
Harvard University Press Blog<\/font><\/strong>
by Richard Noll
28 May 2013<\/div>\n<\/p>\n…<\/p>\n
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.<\/p>\n
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.<\/p>\n
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… <\/div>\n<\/strong><\/sup><\/div>\n<\/blockquote>\n
A supervisor once said, "We have a hierarchy of identities – person, physician, psychiatrist, psychotherapist – and they come in order from first to last." His meaning is obvious, but it also happens to be a way that I think in general. I think of what I call the Psychiatric Diseases<\/font><\/strong> in a specific way. They are diseases in my mind – things to be diagnosed. There are many versions of the list of Psychiatric Diseases<\/font><\/strong>. Here’s Dr. Noll’s from above:<\/div>\n\n
… 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…<\/strong><\/sup><\/div>\n<\/ul>\nDr. Ed Shorter recently came up with a shorter list<\/a> of sure things:<\/div>\n\n
<\/p>\n… The point is that, floating around in nosological cyberspace, there are diagnoses that correspond to what people really have. Some, such as melancholia, possess genuine biological validation: the dexamethasone suppression test [DST], high serum cortisol, and a host of findings from sleep studies that show melancholia is a depressive illness sui generis, a disease of its own in other words. This has been known for centuries! And the DST has been available to psychiatry since Bernard Carroll introduced it for the study of depression in 1968.<\/div>\nCatatonia 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]. <\/p>\n
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. <\/p>\n
So there we’ve got three diagnoses right off the bat that correspond to what people actually have. We don’t need a lot of cogitation about “negative valence systems” – à la RDoC – to make progress, though fundamental progress in neuroscience is devoutly to be desired…<\/div>\n<\/strong><\/sup><\/div>\n<\/ul>\n
And in a recent comment on Gary Greenberg’s blog about biomarkers, Dr. Bernard Carroll produced a list<\/a>: <\/div>\n\n
…this process of convergent validity has already given us an A-list of psychiatric diagnoses that are candidate brain diseases. Here is the list: psychosis, mania, melancholia, vascular depression, crippling anxiety, panic disorder, dementia, autism, obsessive-compulsive disorder, delirium, catatonia, and more. If you want diagnostic certainty with clear cut necessary and sufficient conditions, then by all means tell the magistrate at your next commitment hearing that you were serious when you commandeered an airliner, prevented the scheduled passengers from boarding it, declared yourself the owner of the airline, announced that you were going to fly your entire extended family to London to meet with Margaret Thatcher, and that the psychiatrist who said you suffer from mania must be wrong because he hasn’t shown the court a laboratory diagnostic test for mania…<\/strong><\/sup><\/sup><\/div>\n<\/ul>\nAll three lists were created off-the-cuff for different reasons, but they came out pretty close to each other [from a psychologist, a historian, and a psychiatrist]. With only minor changes in emphasis, mine would be pretty close too. I guess with this DSM-5 launch<\/font><\/strong>, a lot of us are thinking about what the diagnostic system actually ought to look like. I think of the list in my mind as Kraepelinian, even though some things on it weren’t even recognized in Kraepelin’s day. They are the diagnoses that go with "psychiatrist" in my version of my supervisor’s hierarchy of identities – the Psychiatric Diseases<\/font><\/strong><\/font><\/strong><\/em>.<\/div>\nThis is nothing new, nor is it really Kraepelinian. Karl Jaspers<\/a> had a version. Here<\/a>‘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<\/font><\/strong> 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<\/font><\/strong> are important in my mind.<\/p>\n
I expect most people think of the Psychiatric Diseases<\/font><\/strong> 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.<\/p>\n
Some psychiatrists think of this group of patients with Psychiatric Diseases<\/font><\/strong> as psychiatry proper and see those of us who also see other kinds of help-seeking patients as … doing other things<\/em>. I kind of think of things that way too, doing other things<\/em>. I do other things<\/em>. 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<\/font><\/strong>, 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. <\/p>\n
The current DSM model attempts to apply the medical model to all<\/u> Mental Disorders. It doesn’t work. And it never did. We’d be better off with a Diagnostic and Statistical Manual of Psychiatric Diseases<\/font><\/strong> and some other way of codifying the majority of people who present for treatment. It was tolerable with the former DSMs because they stayed etiologically neutral, at least on paper, and were little more than code books [with too many words]. This DSM-5 was so obviously driven by the biomedical model [applied where it doesn’t fit] that it is no longer of value…
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