Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274)
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In contrast, losing a mental step is now the DSM-5 psychiatric illness mild neurocognitive disorder (MND). This diagnosis is intended to cover people who don’t yet have dementia but who do have signs of mental decline that may put them at risk for later developing it. I would heartily endorse MND if there were a treatment for it or if it provided a really good way of predicting the future. But there is no treatment and little predictive power. If I gave myself this diagnosis, I wouldn’t know what to do with it. Accepting mental aging makes more sense than diagnosing it until we have an accurate biological test or an effective treatment. Donna and I would not yet meet the criteria proposed for MND, but my guess is that the fine points of its criteria set will be ignored in general practice, and the diagnosis will be applied very loosely. MND will not be specific to those experiencing early symptoms of dementia but will soon broaden inappropriately to medicalize the gradual mental decline that is characteristic of normal aging.
This is not the intent of the sponsors. Their goal is to identify those at risk for Alzheimer’s before they develop the full picture of dementia—with the hope that early diagnosis will lead eventually to early intervention, before the damage is done. Alzheimer’s probably takes decades to evolve. The experts are excited by the prospect of becoming preventively proactive. Eventually, they hope that amyloid may be an early marker of Alzheimer’s, in analogy to cholesterol with heart disease. Early identification and early treatment might prevent the worst ravages of the disease.
Rapid strides are being made, with powerful new methods leading us closer to understanding causes and mechanisms.16 It is exciting that we are closing in on accurate PET and spinal tap markers for Alzheimer’s, but it will probably take at least five years before we have a test accurate enough to rely on. When that happens MND will make sense as a new diagnosis, but not before. Let’s not jump the gun, proceeding on the false belief that a diagnostic breakthrough has already been made and that a treatment breakthrough is possible in the near future. Without a laboratory test, the diagnosis of MNCD will be wildly inaccurate, pulling in many people who are not headed for dementia. And what purpose is served by revealing the early stages of a grim disease for which there is no meaningful treatment?17 Finding out that you are (only possibly) at risk for later developing Alzheimer’s would provide little or no benefit—but would create needless worry, testing, treatment, expense, stigma, and insurance and disability issues.
We also shouldn’t oversell the prospects of any immediate treatment breakthrough. Learning more about the mechanisms of Alzheimer’s may quickly lead to a rational cure or preventive—but more likely it won’t. The general experience in medicine over the past three decades is that an exponential explosion in knowledge about a disease does not often lead to any immediate miracle cure. The lack of success in developing medications for Alzheimer’s does not inspire confidence.18 The available drugs—although they have been highly profitable to the drug companies—have little, if any, efficacy for patients. Attempts to develop a new generation of effective drugs have failed despite considerable research investment. There does not appear to be any low-hanging fruit.
The experts on Alzheimer’s have a natural enthusiasm for pushing the boundaries toward earlier diagnosis. The slow pace of development of diagnostic and treatment tools is frustrating for all concerned. Most of us expected well-established laboratory testing by now and are very disappointed that drug discovery has been such a flop. MCND is offered in the hope it will jump-start the field by highlighting the potential of early identification. But this is definitely putting the cart before horse. New diagnoses that will have great influence on how people live their lives and how the country will spend limited health care dollars must follow well-established science and an inclusive public policy debate—not lead it.
The experts suggesting MNCD are acting from naive good faith that expanding their field will be good for patients. They are blind to false positive risks and societal costs because they are not trained to think in these terms, not because of conflicts of interest. But such goodwill does not motivate the corporations that market drugs and diagnostic tests. If MCND becomes official, there will be an explosion of probably useless and potentially harmful PET and spinal tap testing and medication treatment. The medical-industrial complex will have a field day.19 Only they will benefit, not patients and not taxpayers.
Gluttony Becomes Mental Illness
I meet the criteria for binge eating disorder and have for almost as long as I can remember. It started in my early teenage years. Stealth trips to my mother’s overly stocked pantry and bulging refrigerator leading to solitary nighttime pig-outs of epic proportions. In college, I wrestled at 177 pounds but after the match would begin a two-day binge that would bring me up to a Monday weight of 191—and would then have to starve and dehydrate to get back to 177 by the next Saturday. I have always been the scourge of buffet lines and all-you-can-eat restaurants. Never have I gone for more than a week without a monster binge. The only way I can stay a svelte twenty-five pounds overweight is to avoid all breakfasts and lunches and by exercising several hours a day. Am I just a run-of-the-mill glutton with terrible eating habits and lousy self-control or am I a DSM-5 mental patient with binge eating disorder?
Certainly, I am not alone. BED would be a very low threshold diagnosis. Just one binge a week for only three months and you qualify for this alleged mental illness. The early estimate is that BED would capture about 3 to 5 percent of the population, but early estimates are always far too low.20 Just wait until the public and the doctors get their drug-company-sponsored “education” selling the notion that gluttony (once a sin) has now become an illness. Rates may jump to 10 percent—adding twenty million fake mental patients in the U.S. alone.
Why do I binge eat? Why does anyone? Nature made it so. Our appetites are perfectly designed to ride out famine, but they make us terribly vulnerable to feast. When food was hard to come by, the best bet for survival was to be the biggest binger at the carcass. The availability of refrigerators and cheap fast food has certainly made binging a huge health risk—but I don’t see how this makes it a mental disorder.
BED is being offered as psychiatry’s answer to the obesity epidemic (which is rapidly overtaking smoking as our most deadly public health threat). Unfortunately psychiatry has no answers here—no cure for binge eating or for obesity. But even more to the point, BED distracts attention from what could provide a real cure for the obesity epidemic. We need a dramatic change in public policy. Our society is getting way too fat not because of an epidemic of this newly devised mental disorder, but rather through the ever present and always tempting availability of cheap, delicious, convenient, caloric, and horribly unhealthy fast food, snacks, and sodas. To make matters worse, we perversely incentivize this public health time bomb with government subsidies to Big Agriculture. For hundreds of thousands of years, until just three hundred years ago, the average person rarely if ever got to taste anything sweet. Then sugar entered our lives, and now fructose, and we are being fattened like cattle on a feedlot.
Mental disorder is not causing the obesity epidemic. And treating a fake mental disorder can’t fix it. It won’t help to label as psychiatrically sick the victims of our dumb public policies; it’s far better to change the policies. No more fructose subsidies. No more Coke and fries served with school lunches. No more streets without sidewalks that discourage walking. Let’s restore physical education in the schools; add calorie counts to every menu; subsidize vegetables; give people tax deductions and lower insurance premiums for losing weight; install free bikes at stands in cities everywhere. In short, we need to do whatever it takes from a public policy standpoint to encourage people to eat less and exercise more.
Phony psychiatric labels won’t help. BED has the familiar three-strikes-you’re-out combination of inaccurate diagnosis, no effective treatment, and drug side effects. Making BED focuses attention on the wrong culprit; it is not the individual who is sick, it is the pu
blic policy. We need to change attitudes about eating and exercise with the same total push educational campaign that worked so well to contain smoking.
Adult Attention-Deficit Hyperactivity Disorder Could Become the New Diagnosis du Jour
Unchastened by the false “epidemic” of ADHD already running rampant among kids, DSM-5 has set the stage for creating a new epidemic of ADHD in adults. As usual, the experts worry so much about missed cases, they fail to consider the much greater risk of overdiagnosis. Attentional problems and restlessness are nonspecific and extremely common among normal adults and in those suffering from any of the other mental disorders. The easy path to adult ADHD suggested by DSM-5 will mislabel many normal people who are dissatisfied with their ability to concentrate and get their work done, especially when they feel bored and don’t like the work they’re doing. It will also misdiagnose those whose problem in concentrating is really caused by something else—e.g., substance abuse, bipolar disorder, depression, all the anxiety disorders, OCD, autistic disorders, psychotic disorders, and many others. No one should ever get diagnosed or treated for adult ADHD until all of these are first ruled out as the primary cause—lest inappropriate stimulant treatment may worsen their already existing psychiatric problems.21
Adult ADD is already too easily diagnosed. Perceived difficulties with attention and concentration abound, especially among perfectionists and those over fifty. Symptoms are mostly subjective, based on fallible self-perceptions of poor concentration and task accomplishment. The DSM-5 lowering of requirements will capture many adults who want to be sharper but don’t have specific or serious enough problems to qualify for a mental disorder. Fake adult ADHD will also be especially common in college students, in people who have demanding jobs, and in those who have to struggle to stay awake, like long-haul truck drivers.
Stimulants are among the most effective and safe of medications in psychiatry when given under appropriate supervision for someone who is accurately diagnosed. But they can cause serious side effects in anyone and are especially harmful when taken by someone with another diagnosis that has been misidentified as ADHD (especially substance use or bipolar disorder). The increasing use of stimulants as performance enhancers or for recreation also creates a large and illegal secondary street market.22
I have often heard people say: “Why worry so much about the overprescription of stimulants, since these are relatively safe medications that are helpful in promoting improved cognitive functioning even in those who do not have clear-cut ADHD.” This is wrong for both individual and societal reasons. We have to consider the harm to people with psychiatric or medical problems worsened by stimulants. And do we want to further encourage the already rampant illegal diversion of prescription drugs for sale on the street?23 The wider distribution of stimulants is simply too important a public health and public policy issue to have been decided as an unintended consequence of decisions made by a small group of DSM-5 experts who are focused on their own narrow diagnostic question. I have no opinion on the interesting question of whether stimulant use should be allowed for performance enhancement in normals who want improved cognitive and physical functioning. But I am strongly opposed to lowering the criteria for adult ADHD in a way that indirectly promotes their fake “medical” use in those who don’t really have a mental disorder.24
Others argue that an increasingly demanding society is exposing previously subclinical ADHD symptoms. As performance standards are ratcheted up and external stimulation becomes nonstop and blaring, previously well-adapted individuals with mild ADHD may now be reaching a clinically significant level of impairment that qualifies as a mental disorder and requires treatment. My point back is that the difficulties people have in meeting society’s expectations should not all be labeled as mental disorders. Thirty percent of college students cannot suddenly have developed ADHD. When Major League Baseball finally controlled steroid use by testing, there was a sudden explosion of ADHD among the players—this was probably triggered more by a desire for improved batting averages than any of the traditional reasons for treating ADHD. If we, as a society, choose to help people enhance their performance to meet (perhaps excessive) demands, this should be an open policy decision—not one cloaked under medical auspices, done by medical prescription, and enhanced by drug company marketing.
The criteria for a first-time diagnosis of ADHD in adults should be more, not less, rigorous. In evaluating any given adult for ADHD, we must be sure that all the many psychiatric causes of inattention are first ruled out and that the problems are a continuation of ADHD symptoms that started in early childhood. Any late onset of attentional problems is caused by something else, not ADHD. Let’s keep DSM as a manual of mental disorders and not turn it into a vehicle for performance enhancement.
Mourning Is Confused with Melancholia
DSM-5 has made it easier to diagnose major depressive disorder (MDD) among the bereaved, even in the first weeks after their loss. This was a stubbornly misguided decision in the face of universal opposition from clinicians, professional associations and journals, the press, and hundreds of thousands of grievers from all around the world. People routinely have symptoms exactly like clinical depression as part of their normal mourning process. Feeling sad, losing interest, trouble sleeping and eating, reduced energy, difficulty working—this is the easily recognizable, classic picture of grief. But these very same symptoms define clinical depression. MDD need not be diagnosed unless the bereaved becomes suicidal, or delusional, or suffers from symptoms that are severe, prolonged, and incapacitating.
Psychiatry should tread lightly when dealing with the basic rhythms of life. Mammals grieve. It is the flip side and necessary price of the quintessential mammalian characteristic—attachment to loved ones. We start life needing a mother not only for milk, but also for love. Our lives consist of a series of attachments and losses. And then we die and others grieve for us. Man is not alone as a caring and grieving social animal. We are just doing what mammals do.
Medicalizing grief reduces the dignity of the pain, short-circuits the expected existential processing of the loss, reduces reliance on the many well-established cultural rituals for consoling grief, and would subject grievers to unnecessary and potentially harmful medication. There is no uniform code of correct grieving. Different cultures prescribe a wide variety of time-honored behavioral and emotional reactions and rituals. Even within a given culture, normal individuals vary enormously in the content, symptoms, duration, and impairment of their grief and in their ability to draw consolation and sustenance from others.
There is no clear line separating those who are experiencing loss in their own necessary and particular way from those who will stay stuck in a depression unless they receive specialized psychiatric help. Except when the need is clear, psychiatry should not impose its own rituals when they are so often unneeded and out of place. The medicalization of grief sends just the wrong message to the misidentified “patient” and to the surviving family. To mislabel grief as a mental disorder reduces the dignity of the life lost and of the survivors’ reactions to its loss. We would be substituting a half-baked, superficial, and depersonalizing medical mourning ritual for the solemn, time-tested death rituals that are at the heart of every culture. Most people will recover just fine after the loss, without medical meddling and pill popping.
There is a legitimate concern that major depression sometimes occurs among the bereaved. When a griever becomes suicidal, psychotic, agitated, or incapacitated, the diagnosis of depression is certainly warranted and treatment should begin immediately. People with a previous history of depression are at high risk for recurrence and should be followed expectantly and treated promptly. But these are exceptions. Grief is part of life, and most people work through it best with family and cultural supports, not psychiatric diagnosis and treatment.25, 26, 27, 28, 29
Turning Our Passions into Addictions
This actually happened today, just a few hours ago. I was walking up the hill,
head buried in my BlackBerry, thumb thumping away e-mail responses, guided by my wife to avoid cars and obstacles, stumbling only occasionally over tree roots. It was an absolutely gorgeous Indian summer day, and my beloved beach and ocean would be clearly visible on all sides if only I bothered to look up. But I am head down, fully absorbed, totally oblivious, blind to everything but tiny keyboard and screen. Along comes a guy approaching quickly from the opposite direction, and we almost crash into each other. I quickly apologize. But he smiles sympathetically and says, “No problem, I understand—‘Crackberry’ addict, huh?” I smile back sheepishly and then quickly return to my thumping.
Guilty as charged. You know you are busted and badly hooked when everybody calls your cell phone the “crackberry.” Me hunched intently over my BlackBerry reminds people of King Kong playing with his cute pocket-size playmate. And I don’t want to get too intimate here, but my wife does express feelings of jealousy and chagrin that she is forced to play second fiddle to what she calls “your mistress.”
Is this mental disorder or just my avid utilization of a remarkably versatile device? “Behavioral addiction” or “BlackBerry affection”? Up until now this was no more than a lame joke, but it’s now a dead serious problem since DSM-5 has introduced the concept of “behavioral addictions.” 30 For starters, only pathological gambling will qualify as an official mental disorder. But watch out for false epidemics of addictions to the Internet,31 shopping,32 working,33 sex, golf, jogging,34 tanning,35 model railroads, cleaning house, cooking, gardening, watching sports on TV, surfing, or chocolate,36 or whatever else commands passionate interest and media attention. The list is long and can easily expand into every area of popular activity, turning lifestyle choices into mental disorders.