First, let’s deal with the misidentification problem. Even in the most expert hands (i.e., in very highly selected research clinics), at least two of three people who get the PRS diagnosis do not go on to become psychotic. Of great counterintuitive interest, the longer the research clinic operates, the worse its correct hit rate. This doesn’t mean the evaluators get dumber. It’s just that, with time and spreading reputation, the clinic attracts an increasingly heterogeneous pool of referrals, so it becomes more difficult to pick out the needle of those truly at risk for psychosis from the haystack of those who aren’t.
In the real world, the ratio gets really ridiculous: nine misses for every hit. The raters in general practice are much less expert than specialists in research clinics, and the “patients” are closer to normal and harder to discriminate. Mislabeling may get even worse if the diagnosis ever becomes official and drug companies get into the act, trying to convince parents and clinicians to be especially alert to any strangeness in teenagers.37,38,39,40
Kids not really at high risk for psychosis would often receive a preventive medication treatment that puts them at high risk for obesity and diabetes and all the dreaded health consequences that follow.41 To top it all off, there is no proof whatever that antipsychotic medications are effective in preventing psychotic episodes.
It gets even worse. The terms “psychosis risk” and “attenuated psychotic symptoms syndrome” are filled with ominous threat and undeniable stigma. The mislabeled person bears the needless cross of unnecessary worry, reduced ambitions, and likely discrimination in getting work or insurance or a mate—thus further exacerbating the risk side of the already totally unbalanced risk-benefit ratio.
So let’s add up the score: most kids who get tagged with PRS are not really at risk for psychosis; the preventive treatment they will very often get doesn’t really prevent, but will likely make them fat and reduce their life expectancy; and the label is itself a new life burden. This is a prescription for individual tragedy and public health disaster.
Mixed Anxiety/Depression—Turning Everyone into a Patient
DSM-5 proposed a new disorder that would have been the darling of diagnostic inflation and the greatest gift ever to the drug companies. The criteria set was so easy to make that sooner or later virtually everyone would wind up qualifying for it. Mixed anxiety depression (MAD) is perhaps the most flagrant attempt ever to medicalize the transient, nonspecific, almost ubiquitous sadness and worries that are an inevitable part of everyday life. A perfectly expectable reaction to bad events—job loss, divorce, illness, or financial troubles—would have been converted into mental disorder. Not surprisingly, MAD is an unstable diagnosis that provides little predictive power. Studied a year later, most people tagged with it either will have gotten over their symptoms and need no diagnosis at all or will have evolved into another more established diagnosis. Watchful waiting is the wiser and safer course, rather than jumping the gun to what is an essentially meaningless diagnosis.
The only thing about MAD that is absolutely predictable is its huge marketing potential. Turning life’s inevitable problems into mental disorder would have been an absolute gold mine for the drug companies—the perfect combination of huge market share and high placebo response. Overnight, MAD would have emerged from nowhere to become the most common mental disorder in America. Antidepressants, already used by 11 percent of the population, would have gotten another big boost. Sanity finally prevailed on this one and MAD was shelved—but just barely.42,43
Hebephilia Creates a Constitutional Crisis
“Hebephilia” is a fancy medical-sounding term dreamed up more than a century ago as a parallel to pedophilia. Pedophiles are those who prefer or need prepubescent children in order to get sexually excited; in alleged “hebephiles” the preferential lust would be for teenagers who have already entered puberty.
Hebephilia has never caught on as a clinical entity and has generated almost no research. But it has become very popular as a fake diagnosis used in sexually violent predator (SVP) hearings to justify preventive detention through involuntary psychiatric commitment. This public safety convenience represents an abuse of psychiatry that violates precious constitutional guarantees against double jeopardy. DSM-5 unwisely considered including hebephilia as an official diagnosis but wisely dropped it in response to the almost unanimous opposition of sexual disorder and forensic experts. Support for the inclusion of “hebephilia” came only from the handful of people who research it and the somewhat larger group of SVP evaluators who make part or all of their living misdiagnosing it.
Sex with an underage, pubescent teenager is a despicable crime deserving imprisonment, not a mental disorder treatable in a hospital. There is nothing inherently psychiatric about being sexually attracted to budding teenagers. Numerous studies have proven the obvious—such attraction is common and completely within the range of normal male lust. The age of condoned sexual activity has varied widely across different times and places, with puberty often taken as nature’s dividing line to signify sexual eligibility. Until a hundred years ago, the age of consent was thirteen in the United States; it remains low in many parts of the developing world and has been raised only recently in much of the Western world.
Evolution has built teenage sexual attractiveness into male hardwiring. When our lives were much shorter and likely to end unpredictably at any moment, it made sense for our DNA to seek expression as soon as sexual maturation made this at all possible. Waiting patiently on the sexual sidelines entailed a great risk of losing out in the mating game. Remember the startling fact that the average age when people died is now the average age when people get married.
Optimal mating strategies have changed dramatically in response to longer life expectancy and lower infant mortality. If you are likely to live to seventy, there is no advantage to starting early on the path of sex and child rearing. There will be plenty of time; and both activities are safer and more wisely done as one matures. The legal age of consent has accordingly risen to protect youngsters from what is now regarded as premature sexual activity, given the conditions and expectations that prevail in our society.
But that doesn’t mean that sexual wiring has caught up. Changes in basic appetites require evolutionary time frames of at least tens or hundreds of thousands of years; changes in laws can happen overnight. We don’t turn off long-established instincts just because they are no longer considered proper. The advertising industry, wise to the fact that many adults remain sexually attracted to adolescents, cynically exploits their interest by displaying young-looking models in provocative clothing and poses. The assertion that sexual urges stimulated by sexy teenagers denote mental disorder violates common sense, experience, and evidence from research. It is not a crime or a mental disorder to lust after the newly pubescent; it is human nature. But it is a very serious crime in our society to act on these impulses, one that deserves a long prison term.
The only rationale for having a diagnosis of “hebephilia” might be to describe those rare individuals who are obsessively, exclusively, and obligatorily stuck just on very young teenagers. But the many compelling reasons for not including the diagnosis in DSM-5 far outweighed this one possibly positive use. Hebephilia (if it exists at all) is unresearched; we have no idea how best to diagnose it and whether there is any effective treatment. There is no apparent clinical need for this proposed diagnosis—no army of help-seeking potential perpetrators willing and able to benefit from treatment, presuming one were available. And the careless forensic overuse in the SVP mill is already a serious problem. True hebephiles would constitute only a tiny fraction of all the criminals who violate the young. Experience teaches that this would not stop forensic evaluators from spreading the diagnosis widely and inappropriately as a lubricant to involuntary commitment in SVP hearings.
No tears need be shed for child molesters. But we lose constitutional stability whenever we allow civil rights to be violated, even for those people we most detest. If ha
ving sex with a teenager today constitutes mental disorder, what prevents future slippage in a possibly less enlightened time to revisit whether homosexuality isn’t a mental disorder, or the use of psychiatry to suppress political dissent or minority religious belief. Whatever tiny clinical utility there might be for “hebephilia” is overwhelmed by its fearsome forensic risks.44, 45, 46
Hypersexuality—“My Disorder Made Me Do It”
This was another unwise proposal for DSM-5. Fortunately, it was rejected, but unfortunately it remains very much alive in the media and public consciousness. The most recognizable prototypes for excessive sexuality come from the worlds of professional sports, rock music, Hollywood, and politics. The term might cover previous presidents in the United States and Italy as well as powerful leaders in business and government. Whether it is Mickey or Wilt or Magic or Tiger or Silvio or JFK or the local Don Juan, the script is the same. The man (only rarely a woman) can’t seem to get enough sex. Wilt Chamberlain boasted of sleeping with twenty thousand different women. A reporter ran the numbers and told Wilt this would amount to an average of about three a day. Wilt grinned, stroked his chin, and said, “Yup, that sounds about right.”
The lack of consensus on what is normal sexual behavior makes it difficult to define what is excessive. Individual and cultural biases play a large role and offer a moving target. What is completely normal in New York or Amsterdam may not be at all accepted in Topeka or Mecca. What is normal in New York today was deviant in New York a century ago. What is normal for professional athletes may not be normal for the rest of us. There is tremendous variability and no clear standard. A lot may depend on opportunity.
Sexual excess is often misguided but rarely indicative of mental disorder. Humans, especially males, cheat so often it might almost be considered normative behavior, not sickness. Sex is so pleasurable precisely because our DNA totally depends on it for survival. Evolution has wired our brains to do what it takes to get our sperm and eggs into the next generation. Considerations of love, morality, loyalty, and long-term consequence often get swamped by low resistance to temptation.
In the evolutionary numbers game, people with a high sex drive tend to have more kids. Giving in to sexual temptation has strong survival value for our DNA—that’s why we do it. This is perhaps regrettable, but it is how natural selection works, an expectable part of normal life—not mental disorder. The genes of Genghis Khan won the evolutionary crapshoot, living on in millions of modern-day descendants. The sexually meek do not inherit the earth.
The medicalization of sexual misbehavior is a serious mistake—reducing the culprit’s sense of individual responsibility and providing an inappropriate psychiatric excuse for hedonism.47
From Diagnostic Inflation to Diagnostic Hyperinflation
Just as it is unwise to add to the money supply when there is already a monetary inflation, it is unwise to coin new diagnoses when there is already a glut of diagnostic inflation. DSM-5 failed to understand the need for restraint and instead will be triggering a whole new batch of unfortunate fads on top of the ones we already have. This will open the floodgates even wider to permit ever looser diagnosis and increasingly inappropriate treatment.48 In a reasonable world, DSM-5 would have tacked in just the opposite direction to contain diagnostic inflation and to restrict treatment to situations where it is really needed. The DSM-5 damage is done and cannot easily be undone. Perhaps the only solace is that the controversy surrounding DSM-5 has widely discredited it, raising concerns about the harms done by diagnostic inflation. Many clinicians will see through DSM-5, will not give it undeserved “biblical” authority, and will perhaps be more cautious in diagnosis and prescribing. And many potential patients have been put on alert not to accept diagnoses that may make no sense for them.
PART III
Getting Back to Normal
CHAPTER 7
Taming Diagnostic Inflation
For every complex problem there is an answer that is clear, simple, and wrong.
H. L. MENCKEN
DIAGNOSTIC INFLATION HAS many complex and interacting causes; solving it will require many, complex, and interacting cures—and the result is very much in doubt. What needs to be done is completely obvious, but having brains enough to know what to do is worthless without the muscle to do it. Most of the political and financial muscle is pushing abnormal; the counterbalancing forces pushing normal don’t remotely counterbalance and aren’t nearly forceful enough. But hope sometimes redeems itself. The meek occasionally do inherit the earth, especially if right is on their side. Unforeseen social and public health miracles can occur when no one could guess they were even remotely possible. Against all odds, we have elected a black president, passed gay marriage bills, and transformed smoking from a display of sexy sophistication into a dirty little habit. So who says we can’t also tame the beast of diagnostic inflation and save the world from the epidemic spread of ubiquitous psychiatric illness. Here’s how to do it.
We Are Fighting the Wrong War on Drugs
For forty years, we have been fighting a war against drug cartels that we can’t possibly win. Meanwhile, we have barely begun to fight a different war against the misuse of legal drugs that we couldn’t possibly lose.
Interdiction of street drugs now is as big a bust as prohibition of alcohol was in the 1920s.1 Occasionally arresting a drug kingpin or confiscating a few million dollars’ worth of contraband heroin or cocaine or amphetamines makes for a nice headline, but it doesn’t do anything to stop the flow. The price of illegal drugs remains pretty constant and is never high enough to drive away the market. New sources are always ready to fill in for the odd missed shipment. However impressive the street value of the confiscated drugs, incredible quantities of drugs are always seeping through. Usage patterns aren’t significantly impacted by even the biggest drug bust, making the whole drug interdiction campaign no more than a phony Whac-A-Mole charade.
Similarly insignificant are ballyhooed reports of the spectacular arrests or the deaths of high-level drug kingpins. This also never significantly affects street availability and instead causes a mostly negative cascade of side effects from the fierce turf battles that inevitably ensue. The end result is more killing and more corruption, not less drug use. The drug trade is extremely well organized and rationally run—as would be expected of any large, immensely profitable, multinational business enterprise. It follows business models and corporate structures similar to its competitors in the licit drug industry. The success of companies like Pfizer or Eli Lilly or Jansen is not dependent on who happens to be the current CEO. They have built-in operating procedures and infrastructure that govern business decisions and ensure continuity and enduring profits regardless of who happens to be in charge at any given moment. The illegal drug trade is much more violent (and marginally more ruthless), but its administrative structures are equally effective in the long-term pursuit of profit. Chopping off one cartel head doesn’t have more than a very temporary effect on its body—the drug trade is hydra headed, resilient, and competent. Ever more ruthless pretenders to the throne are never lacking.
The main effect of the war on drugs has been the unimaginable enrichment of the drug cartels. This provides them with the means and motivation to enter into a military and political arms race with one another and with official governments; to buy officials with gold and bully them with lead; and to destabilize failing countries in what are really ongoing civil wars.2 We have repeatedly done the experiment and should by now accept the result. The war on drugs has been fought and the war on drugs has been lost. If we continue to fight it, we will continue to lose it.
We have to address the fact that the misuse of legal drugs has now become a bigger public health problem than street drugs. It is unacceptable that 7 percent of our population is addicted to prescription drugs and that fatal overdoses with them now exceed those caused by illegal drugs.3 The legal products pushed by the Eli Lillys and the Pfizers have (when overdone) become more dangerous tha
n the street drugs pushed by the cartel corner boys. Our policy decisions haven’t confronted this remarkable public health and public policy paradox. We are spending a fortune fighting the losing war against illegal drugs, while barely lifting a finger to fight an easily winnable war against the misuse of legal drugs.4
The good news is that the legal drug lords are extremely vulnerable to the law in ways that the illegal are not. They would be easy to control if only we had the political will to control them. Eli Lilly, AstraZeneca, Jansen, Abbott, Purdue et al. have the great advantage over the Sinaloa, Tijuana, and Juárez cartels that they can operate within the law and enjoy its protections. They can market (i.e., “push”) product openly using TV, Internet, and print advertising;5 distribute it cheaply through doctors and pharmacies; buy politicians legally through campaign contributions and revolving door jobs.6 They need not fear being arrested by the police or being assassinated by rival corporations. But their reliance on the law is also a weak point, making these legal drug pushers much more vulnerable to its reach. The law could overnight prohibit their questionable practices and end their worst depredations.
Curing drug-company-induced diagnostic inflation is not rocket science and doesn’t require high-level skills in regulation, jurisprudence, or policing. The list of things that need to be done could not be more obvious or easier to enforce. But the first step has to be for politicians to “Just Say No” to the financial blandishments dangled by Big Pharma—massive campaign contributions and tempting future job offers.
Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274) Page 22