Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274)

by Frances, Allen

  The governing principle of all of life is “homeostasis”—a portmanteau word that combines the Greek terms “homeo” (same) with “stasis” (stable) to doubly emphasize the pursuit of equilibrium. At every level from the single cell to the entire society, nature constantly seeks to compensate for all perturbations and to reestablish stable balance to return to whatever is the normal or expectable range of function. Systems don’t survive very long unless they can achieve homeostasis in the face of both external and internal challenges and disruptions. Each of our cells is a complex and hardworking factory whose survival depends on maintaining the proper metabolic balance of millions of chemical interactions. Each organ is a collaboration of cells and our body is a collaboration of organs, each dependent for its survival on the balanced functioning of all the others. Homeostasis is what keeps our body temperature, blood pressure, and pulse rate stable. Our body is a constant wonder of billions of trade-offs.

  In the interpersonal realm, marriages end in divorce if they lack the homeostatic gift of smoothing the rough edges of inevitable conflict. In the political realm, states that can’t find homeostatic balance among competing forces suffer civil war or collapse. Homeostasis also governs any inanimate physical or chemical processes that are in a prolonged steady state. We would not have our comfortable home in this solar system were it not in a state of gentle homeostatic equilibrium—a delicate balance that we are now threatening by pollution and overpopulation.

  Any failure of homeostasis in an animate system leads to malfunction, disease, and eventually (if severe and prolonged enough) death. Cancer, diabetes, hypertension, heart failure, obesity, and most other illnesses all represent the breakdown of homeostatic feedback mechanisms that normally keep our bodies in balance. And medical treatments for illness all have in common the aim of restoring an internal balance that has been lost in the face of disease.

  The human brain is our world’s grandest expression of homeostasis. It is the master regulator of most of our bodily functions and also a master at regulating that most complex of all machines—itself. Our thoughts, emotions, and behaviors are the final result of an indescribably complex coordination of billions of cells firing off in a carefully tuned, exquisite equilibrium. No computer engineer would have the audacity (much less the ability) to create something so complex—too many things could go wrong along the way. And doubtless they do. But nature has found the means to provide good enough wiring and compensatory balance most of the time. Brain homeostasis has sufficient resources and redundancies to react to internal and external challenges, bringing things back to normal and keeping us functioning pretty much within the straight and narrow.

  We are hardy survivors—men and women for all seasons, built to work in all climates, to eat every conceivable food and to survive long periods without food, to fight battles and to run away, to love and to hate, to feel a wide gamut of emotions, and to evince a startling array of different behaviors. We are not only much alike but also preserve specialized individual differences essential for the survival of the small groups that endured the rigors of the past hundreds of thousands of years. The tribe needed the proper balance of many individual capacities—it would not do well with all leaders or all followers, with all warriors or all pacifists, if everyone was paranoid or gullible.

  We can feel sadness, grief, worry, anger, disgust, and terror because these are all adaptive. At times (especially in response to interpersonal, psychological, and practical stresses), our emotions may temporarily get out of hand and cause considerable distress or impairment. But homeostasis and time are great natural healers, and most people resiliently right themselves and regain their normal balance. Psychiatric disorder consists of symptoms and behaviors that are not self-correcting—a breakdown in the normal homeostatic healing process. Diagnostic inflation occurs when we confuse the typical perturbations that are part of everyone’s life with true psychiatric disorder (which is relatively uncommon, perhaps affecting 5 to 10 percent of the population at any given time).

  Mental disorders should be diagnosed only when the presentation is clear-cut, severe, and clearly not going away on its own. The best way to deal with the everyday problems of living is to solve them directly or to wait them out, not to medicalize them with a psychiatric diagnosis or treat them with a pill. Prematurely resorting to medication short-circuits the traditional pathways of restorative natural healing—seeking support from family, friends, and the community; making needed life changes, off-loading excessive stress; pursuing hobbies and interests, exercise, rest, distraction, a change of pace. Overcoming problems on your own normalizes the situation, teaches new skills, and brings you closer to the people who were helpful. Taking a pill labels you as different and sick, even if you really aren’t. Medication is essential when needed to reestablish homeostasis for those who are suffering from real psychiatric disorder. Medication interferes with homeostasis for those who are suffering from the problems of everyday life.

  A study we did twenty-five years ago taught me an unforgettable lesson about human resilience. It was at the height of the AIDS epidemic and before there were any effective treatments. Getting a positive test result was then the equivalent of a death sentence—and a very unpleasant death at that. We found that men who tested positive had an immediate large jump in measures of sadness and anxiety—no surprise, given the fatal implications of the test. Men who tested negative had a smaller, but still large, reduction in these same measures—again no surprise that they would be greatly relieved. Really amazing were the scores six weeks later. Both groups had returned pretty much to their baselines—the HIV positives were resiliently dealing with their really terrible news; the HIV negatives did not get a permanent mood lift from their really wonderful news. Homeostasis had brought both groups back to where they started. Had we immediately jumped in with medication to treat the painful symptoms in the positives, we would have interfered with their natural healing and given them another burden to add to the ones they already had. The lesson is clear—we have far too much faith in pills, far too little trust in resilience, time, and homeostasis.

  Normal Is Fuzzy and Therefore Fragile

  “Normal” and mental disorder turn out to be a frustratingly elusive—inherently incapable of anything resembling clear, bright-line definition. The realm of the “normal” has been rapidly shrinking as an expanding psychiatry stretches easily across its elastic boundary. Are my son’s temper tantrums part of growing up or an early sign of bipolar disorder? Does my daughter’s inattentiveness at school mean she has attention deficit disorder or is she just extra smart and bored with the dull stuff being covered there? Should I be pleased by my son’s precocious interest in rockets and science fiction or worried that he is autistic? Am I experiencing expectable worries and sadness or is this generalized anxiety disorder? If I don’t remember a face or a fact, is Alzheimer’s just around the corner? Is grief a useful, inevitable, and poignant sign of my broken heart, or is it a major depressive disorder? Is my teenage daughter a creative eccentric, or a psychotic-to-be who needs a dangerous drug? Is Tiger Woods a mental patient or a philanderer? Is a brutal rapist simply bad or possibly mad? All of us have mild and transient psychiatric symptoms from time to time—does this mean we are all flirting with mental illness?

  Questions about what’s normal and what causes abnormal have been with us since the dawn of man. Our ancestors found creative answers that always made good sense to them at the time. Some now seem brilliantly intuitive, others daffy, and a few were positively diabolical. A quick detour through this past will help us understand the present and avoid mistakes in the future.

  CHAPTER 2

  From Shaman to Shrink

  History doesn’t repeat itself, but it sure does rhyme.

  Mark Twain

  MAN IS THE naming animal—we can’t stop ourselves from putting a label on everything in sight. This has been our special gift, and sometimes our curse, ever since Genesis, when Adam established his dominion ov
er the plants and animals by the simple act of naming them.1 Diagnostic exuberance is built into our DNA. We have a strong need to identify patterns—to distinguish lion from lamb, food from poison, friend from foe.

  Almost as important was psychiatric diagnosis. Abnormal behavior has always threatened our survival because we are so dependent on tribal harmony. We need a name and an explanation as a way of gaining control over actions that threaten the individual and the social group (whether these occur on the savanna or at the office). Labeling was and remains an important way of reducing uncertainty and providing a sense of (often false) mastery. Finding patterns helps sort untidy experience into manageable units—an inexact or incorrect name or explanation for mental disorder beats having none at all.

  And man is not satisfied with mere naming. The natural next steps are grouping the names into categories; then the categories into a classification; and finally trying to figure out an explanation for why things sort as they do. Of course, the specific explanations have varied greatly over time. Formerly, they were the stuff of religion and folklore; now the same curiosity and need for order drives our search for scientific understanding. What seem now to be fanciful myths were once the best science of the time, and our current best science will itself in the not-too-distant future be seen as no more than fanciful myth.

  The labeling of mental disorder has evolved over time because the lens of cultural attention extracts figure from ground in many different ways. We see elephants in clouds if we look for them, but could equally well find whales or rabbits if these better fit our preconceptions—the cloud doesn’t have to change for people to see different shapes in it. Psychiatric diagnosis is seeing something that exists, but with a pattern shaped by what we expect to see. Because there is no one right way, fashions prevail. The ancient shaman had different names and explanations—but these worked almost as well for him as current names and explanations work for the modern shrink. Understanding our current methods of psychiatric diagnosis requires that we make a quick study of how we got here.

  The Shaman and the Spirit World

  Psychiatry seems like a young profession, barely two hundred years old, but you could fairly say it is the oldest. Diagnosing and ministering to the mentally ill was part of the job description of the shaman, or medicine man. He (often she) was a tribe’s first paid professional, the only person to have a specialized role outside the round of hunting and gathering. While everyone else was off finding food, the shaman got to stay home doing sick call, using his magic to assess the causes and apply the cures for mental and physical symptoms.

  Of course, to earn his keep, he had to do lots of other jobs as well. The word shaman means “one who knows,” and he had to know a lot.He kept the world in balance and the game plentiful. He could reveal the past and predict the future. He memorized the stories telling how the earth began and the tribe was born. He owned the sacred objects and could find magical plant medicines. He led the rituals. The shaman was medicine man, spiritual medium, judge, intellectual, and entertainer. He literally had to sing the tribe’s songs for his supper. And he could dance.2

  But doing psychiatry was always a big part of a shaman’s practice. We are social animals whose survival is completely dependent on good relationships and group cohesion. Abnormal behavior constitutes a threat not only to the individual; it is also a clear and present danger to the future of the tribe. Psychiatric emergencies must be quickly labeled, understood, treated, and cured. The shaman had all the tools to define and deal with abnormality. He could diagnose mental disorder, explain its origin, and make it better.

  The most popular diagnoses invoked a malevolent spirit, a mischievous curse, or a broken taboo. The treatment required entering the spirit world with trance, vision quest, or dream work, perhaps facilitated by a psychedelic mushroom or plant. Healing rituals included singing, dancing, fasting, sweating, and sleep deprivation. The shaman would invite the patient to leave the everyday world and temporarily enter his magic circle. They would fight with or cajole the spirits until a deal was brokered so that all could be well again. The shaman had great authority and healing power.3 Magical belief and suggestion can go a long way. But beyond the hocus-pocus, he had practical common sense, wisdom about human nature, and medicinal plants. Cures were expensive, and the shaman was the richest person in the tribe.

  The Priests and the Gods

  The domestication of plants and animals in the last ten thousand years gave man greater control over the natural world and a larger sense of his place in it. Nature animism never completely disappeared but was partially replaced by the birth of a pantheon of gods who (though gifted with immortality and extraordinary powers) seemed otherwise to speak and act just like you and me. Amongst agriculturalists, the shaman was as obsolete as a blacksmith is now, replaced by a new professional—the priest (or the priestess). The job descriptions were very different in some ways, similar in others. The shaman had been intermediary to the spirit world. The priest became the intermediary between man and gods, retaining the shaman’s magical spirit powers but augmenting them with divine authority. The shaman was mobile and treated people wherever the tribe happened to be that day on its round of nomadic migration—the spirits lived everywhere. Though relatively rich, he could carry his lifelong possessions on his back. In contrast, the priest was sedentary, working out of a temple complex on holy ground consecrated by the gods, usually near a spring of purifying holy water. Befitting the surplus wealth of a prosperous agricultural society, many of these were elegantly appointed facilities with spas, a library, a gymnasium, and a theater.

  But, in fundamental ways, the priest’s job description was the same as the shaman’s. Keep the gods happy and the world in balance; ward off catastrophic punishments; bring on the food. And minister to the ill, among whom were many with problems we would label mental disorder. The priest spent a lot of his time being a shrink.

  Greek myth is full of madness, clear evidence that mental disorder has always puzzled us. Whatever man did that seemed beyond himself (either exceeding or failing expectations) was attributed to the action of a divinity. When a hero acted crazy, and many did, the standard diagnosis was “the goddess made him do it.” Early on, abnormal behavior was blamed on the goddess named, fittingly enough, Mania—a primal, primitive demon figure who existed before there were men and whose function was to drive them out of their minds. Later the familiar Olympian gods and (more often) goddesses got into the act—with jealous Hera being the most likely crazy-maker.

  Why were goddesses so likely to drive men crazy? Woman’s rights had taken a big hit when farming and shepherding replaced hunting and gathering. The new power and land-owning relationships greatly favored the patriarchs and their male divinities, making women household furniture. The vengeful goddesses represented the feared forces that had been suppressed in the masculine takeover. Divine wrath was a great excuse for (usually male) bad behavior. Madness was a punishment, but also a way to off-load responsibility—the diagnosis both explained deviant behavior and excused it. If Hercules is murderously destructive, it must be Hera punishing his hubris and impiety. If Ajax is mindlessly slaughtering his cattle, it must be Athena misdirecting his envious anger.

  Special gifts were also linked to madness; divine inspiration comes at a price. Cassandra and the priestess at Delphi can see the future, but they must be mad in the present. The Muses often bring madness with their poetry. The cult of Dionysus threw substance abuse into the mix. Wine, sex, and religious frenzy were a way to bring voluntary states of madness that took a person temporarily away from everyday normality and brought him closer to the gods. Normals might also malinger madness: Ulysses unsuccessfully feigned madness to avoid military service at Troy, King David to save his life.

  The gods were jealous and whimsical and definitely played favorites. The rules were unclear and unfair. You needed a priest to teach you how to keep the gods on your side and out of your head. He exercised the authority conferred by sacred be
liefs, holy prayers, magical rituals, and a grand temple. In the eighth century BCE (at the very time Homer was compiling his songs of Troy), the first medical temple was dedicated to the cult worship of Asclepius, god of healing. You could recognize Asclepius by his distinctive rod with coiled snake, which remains the symbol of medicine. Their ability to shed skin had made snakes terrific models of immortality and healing; harmless ones in large numbers were given the run of the temple grounds. The healing cult thrived. Soon three hundred temples dedicated to Asclepius were consecrated all over ancient Greece, usually sited in remote and beautiful places with a sacred spring or mountain view, or both. For a thousand years the institution was wildly popular and remarkably effective. The Romans adopted it and brought healing temples to the reaches of the empire. The Asclepieia were all-purpose—temple, hospital, hotel, health spa, resort, entertainment center, and medical school —some combination of Lourdes, the Mayo Clinic, and a Ritz-Carlton. Access to the temples required an extended and difficult pilgrimage, impossible for those with severe medical or psychiatric illness. The temples were probably treating a population of patients who presented with a combination of milder physical and emotional symptoms, not very different from many patients seen today in a primary care doctor’s office. The pilgrims had proven, by the long hike, that they had high motivation to get better and a profound belief in the cure.

  The priests had developed a new theory of mental illness, a new system of diagnosis, and a new treatment. The theory was visitation by angry or jealous gods. The diagnostic procedure, called “incubation,” required a meeting of the minds with the god. After being purified, the pilgrim would be permitted the privilege of sleeping near the god’s sacred altar in the holiest room of the temple. He was expected to have revelatory dreams or visions that would signify a successful divine visitation. The god might make his message clear and provide an obvious dream or might remain obscure in a confusing one. The temples delivered a treatment that anticipated aspects of psychoanalysis. The priest, dressed in the robes and carrying the rod of Asclepius, was on duty to assist with expert dream interpretation. He would help you discover the meaning of your dream—deciphering the god’s message about the nature of your illness, its cause, and the steps needed to placate divine forces. If you couldn’t muster a dream or vision of your own, or were too sick or busy to make the trip, there were professional dreamers who did incubation-by-proxy on your behalf.