But there are vulnerabilities in the definition and assessment of bipolar II that gave the drug companies lots of wiggle room. There is no clear boundary between hypomania and simply feeling good—so advertisements began suggesting that even slight shifts upward in mood or passing irritability might be a subtle sign of bipolar disorder. This pitch could work especially well with depressed patients, who would have a lot of trouble distinguishing between being “high” and a return of normal mood. Street drugs or antidepressant medications can also provoke brief periods of elevated mood—should this be bipolar disorder?
We knew that bipolar II would expand the bipolar category somewhat into unipolar territory, but we did not think that it would double. Undoubtedly our decision resulted in more accurate diagnosis and safer treatment for many previously missed truly bipolar patients. But like all fads, it overshot and has led to unnecessary medication for many unipolar patients who have been misdiagnosed as bipolar on very flimsy grounds and are now receiving unnecessary mood stabilizing drugs.25,26
Why the big jump? It was the same old story of misleading drug company marketing. The bipolar market is potentially much larger than the schizophrenic market, so the drug companies pounced on bipolar II. The pitch in selling the ill was that any sign of irritability, agitation, temper, or elevated mood indicated a tendency to bipolar disease. Bipolar was everywhere in conferences and journals, on TV, in magazines, in the movies. Psychiatrists, primary care doctors, other mental health workers, patients, and families were bombarded with warnings on the perils of previously “missed” bipolar disorder.
Which brings up the question—knowing what we know now about the fad it caused, was it a good idea to add bipolar II to DSM-IV? I simply don’t know. The pluses and minuses balance pretty closely. But one thing is clear—in boundary cases where the call is close, people shouldn’t jump on the bipolar bandwagon created by drug company hype. The antipsychotic drugs are too risky to take unless there is a real reason.
Social Phobia Makes Shyness an Illness
Social phobia has turned everyday shyness into the third most common mental disorder, with rates ranging from 7 to a ridiculous 13 percent, depending on how loosely it is diagnosed. At least fifteen million adults would qualify for social phobia in the United States alone, making it a prime target for drug advertising. Shyness is a ubiquitous and perfectly normal human trait with the enormous survival value of keeping people safe rather than sorry. You want your tribe to have some exploratory types eager to venture out when the old water hole runs dry. And it is nice to have some aggressive types when the neighbors get feisty. But for your day-in, day-out survival under stable conditions, avoidance of the new and untried must have been the smart play. Otherwise, the DNA favoring avoidance wouldn’t have survived to be so common.
Of course, there are some people whose social anxiety is totally incapacitating and enough to meet anyone’s definition of mental disorder. But these are rare individuals, far too small a market ever to interest the drug company. Pharma’s brilliance was to see past these few—to envision a world where even slightly excessive shyness could be magically transformed into a mental illness that would require a drug fix.
The statistical normality of shyness was exactly what gave the drug company a big fat marketing target. There is no clear boundary separating normal shyness from the mental disorder social anxiety. So the company began an all-out campaign to convince all shy people that they are sick and will miss out if they don’t take the cure. It turns out conveniently that a number of public figures are really painfully shy and ready to shill ringing testimonials to the liberation that comes from owning up to the diagnosis and finally receiving proper treatment. Doctors were also blitzed and softened so as to be ready to prescribe Paxil when prospective “patients” followed the advertising command to “Ask your doctor.” Before long, social anxiety disorder emerged from its lowly status as a rare psychiatric footnote and became a blossoming diagnostic star, one of the most common and commonly treated of the mental disorders.27
Social anxiety had a second feature that made it a marketing dream. Because most of the people who get the diagnosis are not really sick, it is easy to get them well. This is a population with an appallingly high placebo response rate. For the drug companies, this was actually appealingly high. Once someone (who wasn’t really sick) got better due to the placebo effects of a drug (he never really needed), he was likely to stay on it as a good luck charm so as not to risk rocking the boat. He became a longtime loyal customer getting no benefit but set up for unnecessary complications.28
In preparing DSM-IV, we did not give social anxiety much attention. It didn’t seem to be a diagnosis of great import to psychiatry. And until several years later, when it was blown up and abused by misleading advertising, it wasn’t really of much interest. But we clearly had our collective heads in the sand and badly miscalculated. Our definition of social anxiety should have set an extremely high threshold to filter in only the really incapacitated and to filter out the merely uncomfortable. It is possible the smart advertising types could have overcome any definitional resistance on our part, but with greater foresight we could have put up a better fight.29
Major Depression Is Not Always So Major
Major depressive disorder (MDD) sometimes lives up to its ominous-sounding name; sometimes it doesn’t. At its worst, MDD is one of mankind’s cruelest afflictions. The emotional pain is worse than anything imaginable, worse than losing your closest love. But a lot of what passes for major depressive disorder is not really “major,” is not really “depressive,” and is not really “disorder.” Loose diagnosis has created a false epidemic of MDD, with fifteen million Americans now qualifying at any given time. The transformation of expectable sadness into clinical depression has turned us into an overmedicated, pill-popping population.
The DSM definition of MDD is one of the most stable in the book, remaining essentially unchanged since its initial development in DSM-III in 1980—an endurance that reflects its usefulness. But there is a fatal flaw. Because the same criteria set defines both the most and the least severe depressions, it was written to meet the needs of both. The MDD definition works well at the severe end, but at the mild end it has led to the creeping repackaging of everyday normal unhappiness into mental disorder.
Mild major depression is a peculiar contradiction in terms; the descriptors “mild” and “major” are awkwardly juxtaposed and internally inconsistent. This semantic clumsiness reflects a clinical conundrum. There is no way to demarcate a clean boundary between the milder forms of clinical depression and severer forms of ordinary, normal sadness. If we try to diagnose everyone who really has major depression, inevitably we will misdiagnose many people who are simply having a rough patch in their lives that needs no medical label and requires no treatment.
There has been much controversy whether antidepressants work better than placebos precisely because many patients treated in studies are not very depressed or not depressed at all and really don’t need an active medication.
Sadness should not be synonymous with sickness. There is no diagnosis for every disappointment or a pill for every problem. Life’s difficulties—divorce, illness, job loss, financial troubles, interpersonal conflicts—can’t be legislated away. And our natural reactions to them—sadness, dissatisfaction, and discouragement—shouldn’t all be medicalized as mental disorder or treated with a pill. We are usually resilient, lick our wounds, mobilize our resources and our friends, and get on with it. Our capacity to feel emotional pain has great adaptive value equivalent in its purpose to physical pain—a signal that something has gone wrong. We can’t convert all emotional pain into mental disorder without radically changing who we are, dulling the palette of our experience. If we can’t tolerate sadness, we can’t experience joy. Huxley’s dystopian Brave New World shows how quickly pain-free translates into brain-dead.
The DSMs have made it too easy to get a diagnosis of MDD. The biggest weakness is no
t recognizing the role of severe life stress in causing reactive sadness. Suppose something terrible happens and you respond with two weeks of sadness, loss of interest and energy, and trouble sleeping and eating. Sounds perfectly understandable and completely normal, but DSM tags it major depressive disorder. The “epidemic” of MDD initiated by the loose DSM definitions was then driven by a combination of biological reductionism among physicians and fancy drug company marketing. Doctors bought the story line that all depression results from a chemical imbalance in the brain and therefore requires a chemical fix—the prescription of an antidepressant medication. This is absolutely true for severe depressions, absolutely false for most milder ones. The proof of this pudding is that psychotherapy is just as effective as medication for milder depressions, and neither has a big edge over placebo. Millions of people take medicine they don’t need for a diagnosis of MDD that they don’t really have, on the false assumption of chemical imbalance.30,31,32
I have saved the most sobering question for last. Suppose we had appropriately raised the thresholds for major depressive disorder so that it lived up to its name and no longer overinclusively captured the aches, pains, and sufferings of everyday life. Would this return to a saner and tighter diagnosis of MDD have resulted in saner prescription habits cutting into the excessive sales of Prozac, Zoloft, Paxil, Celexa, and the others? Or would 11 percent of the population still be taking antidepressants whether or not there is a clear diagnostic indication for them? How relevant was the excessive diagnosis of depression in supporting the vast overtreatment with antidepressants?
There is no way of knowing for sure. Certainly DSM-IV legitimizes the easy availability of antidepressants by fostering depressive diagnosis. But there is a recent historical precedent illustrating that promiscuous prescribing can occur even if there is no specific diagnosis to prescribe for. The antianxiety drugs Valium and Librium ruled the 1970s and 1980s with a dominance almost as impressive as that enjoyed now by antidepressants—and without a clear target diagnosis. It may be that the American public, under the auspices of profit-driven drug companies and careless doctors, will pop one pill or another whatever the DSM chooses to say or not say.
There is another historical precedent—a much older one going back all the way to shaman times. The wisdom of the ages is that whenever they feel bad, people want to take something to feel better. The five-thousand-year-old mummified man, wonderfully preserved in the ice of the Alps, was carrying his little bag of plant medicine—the Prozac of his day. As we have seen, most medicine taken for most illnesses, most of the time, since the dawn of time, has at best been of very little specific help, usually has been completely inert, and very often has been directly harmful, even poisonous. But shamans, priests, and doctors prescribed them and patients dutifully took them and seemed to benefit. The magic of medication manages to survive its ineffectuality and potential harm. The popularity of placebo seems to be built into our DNA.
My medical purism rebels against the idea that millions of people are taking expensive, potentially harmful, largely placebo medication for a psychiatrically endorsed, drug company promoted “illness” that is really no more than an expectable discomfort or existential problem, inevitable in life as we know it. For a significant percentage of people with mild or transient symptoms, SSRIs are nothing more than very expensive, potentially harmful placebos. There are better ways to deal with sadness. People should have more faith in the remarkable healing powers of time, natural resilience, exercise, family and social support, and psychotherapy—and much less automatic faith in chemical imbalance and pills. There is some good news from DSM-5 on this issue. Under much external pressure, DSM-5 makes it easier to withhold the diagnosis of MDD when the person’s sadness is an understandable reaction to loss or stress.
Of course, none of this applies when the depression is persistent or more severe. It is a shame and a tragedy that one third of the people with severe and incapacitating MDD get no treatment whatever for it. Medications would be enormously valuable in these situations when they are so sorely needed, but instead they have been oversold for situations when they are not. I would prefer a psychiatry doing what it can do well, taking care of the really sick who need and can benefit from our help—not wasting time, money, and effort turning normal into mental disorder.
Post-Traumatic Stress Disorder: Hard to Get Right
Of all the many conditions in DSM-IV, post-traumatic stress disorder (PTSD) is paradoxically one of the most underdiagnosed and also one of the most overdiagnosed. Errors in both directions are common and easy to make; I know this well because I have made them both ways. PTSD is missed when people suffer its symptoms stoically and in silence. PTSD is overdiagnosed when it is a trigger for financial gain.
PTSD has probably been with us since the birth of humanity. Our ancestors were slow, weak creatures exposed and dreadfully vulnerable at the water hole. Life was always at risk, likely to be “nasty, brutish, and short.” Death lurked everywhere—unpredictable, sudden, and often violent. The human reaction to trauma is a great equalizer—regardless of all the differences in our personalities or previous life experiences, we all have the same set of remarkably uniform and stereotypical symptoms in response to a life-threatening stress. We relive the moment over and over and over again in a profoundly emotional way. Images, memories, or flashbacks bring it alive again, intruding incessantly during the day, and at night there are terrifying dreams. Anything resembling the event cues avoidance and terror. Every strange male face is a reminder of the rapist. A car backfiring is a reminder of being under rifle fire. Driving seems impossibly difficult after a bad car accident because the driver keeps visualizing the accident about to happen again. This set of reactions must have had enormous survival value—providing an absolutely indelible object lesson in the importance of avoiding similar dangers in the future. It was the ultimate in powerful one-trial learning—our ancestors had to learn fast and learn well because predators don’t often give second chances.
Almost everyone has at least some intrusive imagery and emotional reactivity to cues after a shocking event—this is part of the human condition and until recently was not defined as illness. For most people the intrusive images gradually become less intrusive and the triggers become less terrifying. The mental disorder PTSD should be diagnosed only when the symptoms persist and cause significant disability. At the severe extreme, PTSD can become chronic and incapacitating. Life is filled with haunting memories and scary triggers. It feels empty, stale, flat, and without meaning. The suicide rate is high.
What determines whether the reaction is transient enough to be considered normal versus devastating enough to be a mental disorder? A lot has to do with the nature and duration of the trauma. PTSD is more likely the more terrible the stress, the longer it lasts, the more intense and intimate the exposure, the more helpless the person feels. Someone who is shot is more at risk than someone who sees the shooting, and seeing is more risky that just hearing the shot at a distance. Horrors intentionally inflicted by humans—torture, rape, and assault—tend to cause worse symptoms than accidents or natural catastrophes. The course also depends on the person and his context. People who have had more emotional troubles before the trauma are more likely to have worse and more prolonged reactions to it. And traumas accumulate—the more one experiences, the greater the risk of PTSD. Family, job, support systems, and treatment are healing; drinking or using substances makes things much worse.
Although PTSD is straightforward and absolutely characteristic on paper, its accurate evaluation in real life is often difficult or impossible. The first part of the definition—describing the nature of the traumatic stress—is easy. It has to be absolutely terrifying, far beyond the expectable problems that plague our everyday life. Rape, assault, totaling a car, natural disaster, torture, war, violent death or injury of a loved one—these all qualify. Nonviolent disasters—divorce, job loss, financial catastrophe, romantic disappointment—these don’t cause PTSD.<
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But then things get difficult. The diagnosis of PTSD is imprecise because it is based exclusively on the person’s own self-report—there is no laboratory test or objective measure. It is inherently difficult for people to accurately report their reactions to an overwhelmingly terrible event. Many and complex psychological and contextual factors may lead them, consciously or unconsciously, to downplay or to exaggerate symptoms. It is no surprise that rates of PTSD in returning veterans can vary so dramatically—just a few percent to as high as 20 percent—depending on how the diagnosis is made and which country is surveyed, even if the troops have had similar wartime experiences.33
Underreporting helps people reduce fear and pain in the short run, but at great cost in the long. It is in the very nature of PTSD that people suffering from it will attempt to avoid reminders. Who wants to keep describing and reliving the worst moment in his life? Some will fear that talking about symptoms will make them worse or cause a breakdown. Some are too depressed to speak of the pain. And some underreporting is macho, particularly among military types who prefer to brave out debilitating symptoms rather than admit to what they regard as weakness in having them.
Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274) Page 17