I like eccentricity and eccentrics. The word eccentric comes from Greek geometry meaning “out of center.” It entered English as an astronomical description of the rotational paths of the heavenly bodies. Now it is used to describe people who are different—mostly with pejorative connotations, not often enough with admiration for their particular genius. Nature abhors homogeneity and simply adores eccentric diversity. We should celebrate the fact that most humans are at least somewhat eccentric and accept ourselves as we are, warts and all. Human difference was never meant to be reducible to an exhaustive list of diagnoses drawn carelessly from a psychiatric manual. It takes all types to make a successful tribe and a full palette of emotions to make a fully lived life. We shouldn’t medicalize difference and attempt to treat it away by taking the modern-day equivalent of Huxley’s soma pills. The cruelest paradox of psychiatric treatment is that those who need it most often don’t get it, while those who do get it often don’t need it.
So how do we save normal, preserve diversity, and achieve a more rational allocation of scarce resources? Far from an easy task, but certainly not impossible. Our professionals should act professionally and within their proper competence. Psychiatrists should stick to what they do best—treating people who have real psychiatric problems—and not expand the field to include the normal worried well, who will do just fine on their own. Primary care doctors should stick to what they do best and stop being amateur psychiatrists. Drug companies should stop acting like drug cartels, irresponsibly pushing product where it will do more harm than good. Consumer advocacy groups should advocate for their consumers, not for the group. The media should expose excessive medical claims, rather than mindlessly trumpeting them.
Do we have a realistic chance to reverse diagnostic inflation, or is the die already cast in favor of a never-ending parade of false epidemics? My rational self tells me that diagnostic inflation will win and that saving normal will lose. We opponents to inflation are too few, weak, unfunded, disorganized, and face odds that are impossibly imposing. But then I am reminded of the discouraged army in Henry V—“we few, we happy few, we band of brothers”—who were outmanned six to one but took heart and decisively won the battle of Agincourt. Never give up on an underdog, no matter how long the odds. Every once in a while, scrawny David does pull off the seemingly impossible, and invincible Goliath does bite the dust.
And we have a big advantage on our side—our cause is right, and right sometimes does make might. It remains reasonable to hold out some hope that common sense will eventually prevail. Who would have thought that Big Tobacco, once so seemingly invincible, could be taken down so quickly? When was the last time you were with someone dangling a cigarette? Big Pharma is clearly riding for the same kind of fall—this emperor really does have no clothes.
People and policy makers may eventually wake up to the fact that we are not a bunch of sick individuals, each of us having a bunch of psychiatric diagnoses, cumulatively constituting a sick society. This is a myth generated by an overly ambitious psychiatry and a remarkably greedy pharmaceutical industry. Most of us are normal enough and would like to stay that way.
My two goals—“saving normal” and “saving psychiatry”—are really one and the same. We can “save normal” only by “saving psychiatry,” and we can save psychiatry only by containing it within its proper boundaries. The legacy of Hippocrates rings as true today as it did 2,500 years ago—be modest, know your limitations, and first do no harm.
Normal is very much worth saving. And so is psychiatry.
ACKNOWLEDGMENTS
ALMOST ALL OF what I know about psychiatry (and also much of what I know about life, people, and myself) has come from my patients. Thanks to them and also to the eighteen people who contributed moving memoirs describing their sometimes dreadful, sometimes wonderful experiences with psychiatric diagnosis and treatment. Then there are the hundreds of colleagues who have helped me in so many ways during my career in psychiatry. I can’t possibly thank you all by name, but you know who you are and that I am forever and deeply grateful. There are just a few specific people I must mention. Being by nature a selfish and fun-loving person, I would not have taken on willingly the difficult burden of reforming psychiatry—especially at this late and otherwise duty-free point in my life. My hand was forced by the shaming example of several of my betters. Bob Spitzer got me started in the diagnostic game thirty-five years ago and has spent most of his waking life devoted to improving it. Barney Carroll’s tireless efforts to hold psychiatry to the highest standards forced me to step up to the plate when I saw our field falling short of them. He doesn’t know it, but Paul McHugh’s many courageous stands also influenced me not to just sit tight enjoying the beach. And although I strongly disagreed with the extremist views of the recently deceased Tom Szasz, I very much liked him personally and always admired his willingness to fight for what he thought was right, regardless of personal sacrifice. The example of my greathearted friend Yutaka Ono helped me to make the book more personal and less stilted than comes naturally to me. Suzy Chapman has done us all and history a great service by archiving a vast trove of DSM-5 and ICD-11 documents. Gary Greenberg has written a wonderful “Book of Woe” describing the DSM-5 follies. I also give special thanks to my ragtag pickup team of Internet buddies (many of whom I have never met) who helped me sort out the DSM-5 mess and contributed ideas to this book—especially Melissa Raven, Mickey Nardo, Dayle Jones, Joanne Cacciatore, Donna Rockwell, Russell Friedman, Marianne Russo, Martin Whitely, Jon Jureidini, Chris Kane, Margaret Soltana, and James Phillips. My usually noisy grandchildren displayed surprising and uncharacteristic forbearance as I spent seemingly endless hours typing out and editing this book on my beloved BlackBerry—which they delight in calling “my evil friend.” My agent, Carrie Kania, not only sold the book—she also helped conceive it and gave it shape. My American editor, Peter Hubbard; my German editor, Laurenz Bolliger; and my Dutch editor, Michiel ten Raa, all made numerous and important suggestions. And most important of all, my wife, Donna—a great reader who made me a better writer.
NOTES
PREFACE
1. Medco, “America’s State of Mind” (2011). http://www.toxicpsychiatry.com/storage/Psych%20Drug%20Us%20Epidemic%20Medco%20rpt%Nov%202011.pdf.
2. S. H. Zuvekas and B. Vitiello, “Stimulant Medication Use in Children: A 12-Year Perspective,” Am J Psychiatry 169, no. 2 (2012).
3. B. Vitiello, S. H. Zuvekas, and G. S. Norquist, “National Estimates of Antidepressant Medication Use Among U.S. Children, 1997–2002,” J Am Acad Child Adolesc Psychiatry 45, no. 3 (2006).
4. G. Epstein-Lubow and A. Rosenzweig, “The Use of Antipsychotic Medication in Long-Term Care,” Med Health R I 93, no. 12 (2010).
5. T. Pringsheim, D. Lam, and S. B. Patten, “The Pharmacoepidemiology of Antipsychotic Medications for Canadian Children and Adolescents: 2005–2009,” J Child Adolesc Psychopharmacol 21, no. 6 (2011).
6. Centers for Disease Control and Prevention, “Prescription Painkiller Overdoses at Epidemic Levels,”(2011); http://www.cdc.gov/media/releases/2011/p1101_flu_pain_killer_overdose.html.
7. Kim Murphy, “A Fog of Drugs and War,” Los Angeles Times, April 7, 2012, accessed September 16, 2012; http://articles.latimes.com/2012/apr/07/nation/la-na-army-medication-20120408.
8. IMS Institute for Health Informatics, “The Use of Medicines in the United States: Review of 2011” (2012).
9. M.N. Stagnitti, “Trends in the Use and Expenditures for the Therapeutic Class Prescribed Psychotherapeutic Agents and All Subclasses, 1997 and 2004” (2007).
10. Laura A. Pratt, Debra J. Brody, and Qiuping Gu, “Antidepressant Use in Persons Aged 12 and Over: United States, 2005–2008,” in NCHS Data Brief (Hyattsville, MD, 2011).
11. T. L. Mark, K. R. Levit, and J. A. Buck, “Datapoints: Psychotropic Drug Prescriptions by Medical Specialty,” Psychiatr Serv 60, no. 9 (2009).
12. Stefan Leucht, “Putting the efficacy of psychiatric and general me
dicine medication into perspective: review of meta-analyses,” British Journal of Psychiatry 200, (2012): 97–106 doi: 10.1192/bjp.bp.111.096594.
CHAPTER ONE
1. Oxford English Dictionary, Oxford University Press, http://oxforddictionaries.com/definition/english/normal (2012).
2. Jeremy Bentham, Utilitarianism (London: Progressive Publishing Company, 1890).
3. Jagdish K. Patel and Campbell B. Read, Handbook of the Normal Distribution (New York: Marcel Dekker, Inc., 1996).
4. Vivian Nutton, Ancient Medicine (New York: Routledge, 2004).
5. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, June 19–22, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. The definition has not been amended since 1948.
6. ABIM Foundation, “Choosing Wisely”; http://www.abimfoundation.org/Initiatives/Choosing-Wisely.aspx (accessed August 18, 2012).
7. “Neuron,”http://en.wikipedia.org/wiki/Neuron#Neurons_in_the_brain (accessed August 18, 2012).
8. “Roger W. Sperry—Nobel Lecture: Some Effects of Disconnecting the Cerebral Hemispheres.” Nobelprize.org. 26 Sep 2012; http://www.nobelprize.org/nobel_prizes/medicine/laureates/1981/sperry-lecture.htm.
9. N. J. Macintosh, I.Q. and Human Intelligence (New York: Oxford UniversityPress, 1998).
10. Atkins v. Virginia (00-8452) 536 U.S. 304 (2002) 260 Va. 375, 534 S.E. 2D 312.
11. Emile Durkheim, George Simpson, and John A. Spaulding, Suicide (New York: The Free Press, 1951).
12. Sigmund Freud, An Outline of Psychoanalysis (New York: W. W. Norton 1949).
13. Jerome Wakefield, “The concept of mental disorder: On the boundary between biological facts and social values,” American Psychologist, 47 (1992): 373–88.
14. R. M. Bergner, “What is psychopathology? And so what?” Clin Psychol Sci Pract. 4 (1997): 235–48.
15. D. F. Klein, “Harmful dysfunction, disorder, disease, illness, and evolution,” J Abnorm Psychol 108 (1999): 421–29.
16. T. A. Widiger and L. M. Sankis, “Adult psychopathology: issues and controversies,” Annu Rev Psychol 51 (2000): 377–404
17. J. C. Wakefield and M. B. First, “Clarifying the distinction between disorder and nondisorder: confronting the overdiagnosis (false-positives) problem in DSM-V,” In Advancing DSM. Dilemmas in Psychiatric Diagnosis, ed. K. A. Phillips, M. B. First, H. A. Pincus (Washington, D.C.: American Psychiatric Association, 2003), 23–55.
18. Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) (Washington, D.C.: American Psychiatric Press, 2000).
19. R. L. Spitzer and J. B. W. Williams, “The definition and diagnosis of mental disorder,” In Deviance and Mental Illness, ed. W. R. Gove (Beverly Hills, CA: Sage, 1982), 15–32.
20. D. J. Stein and others, “What is a mental/psychiatric disorder? From DSM-IV to DSM-V.” Psychol Med 40 (2010): 1759–65.
21. J. C. Wakefield, “The myth of DSM’s invention of new categories of disorder: Hout’s diagnostic discontinuity thesis disconfirmed,” Behav Res Ther 39 (2001): 575–624.
22. S. A. Kirk, ed., Mental Disorders in the Social Environment: Critical Perspectives (New York: Columbia University Press, 2005).
23. Jeffrey A. Schaler and others, “Mental Health and the Law,” Cato Unbound, August 12, 2012 edition; http://www.cato-unbound.org/issues/august-2012-mental-health-and-the-law.
24. James Phillips and others, “The Six Most Essential Questions in Psychiatric Diagnosis,” Philosophy, Ethics and Humanities in Medicine, February 2012; http://www.peh-med.com/content/7/1/3.
25. D. S. Charney and others, “Neuroscience research agenda to guide development of a pathophysiologically based classification system,” in A Research Agenda for DSM-V, eds. D. J. Kupfer, M. B. First, D. A. Regier (Washington, D.C.: American Psychiatric Association, 2005), 31–84.
26. S. Hyman, “The diagnosis of mental disorders: the problem of reification,” Annu Rev Clin Psychol. 6 (2010):155–79.
27. T. R. Insel, “Translating scientific opportunity into public health impact. A strategic plan for research on mental illness,” Arch Gen Psychiatry 66 (2009): 128–33.
28. K. S. Kendler, “Toward a philosophical structure for psychiatry,” Am J Psychiatry 162 (2005): 433–40.
29. J. Paris, “Endophenotypes and the diagnosis of personality disorders,” J Personal Disord 25 (2011): 260–68.
30. T. Szasz, The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (New York: Harper & Row, 1974).
31. M. B. First and A. J. Frances, “Issues for DSM-V: unintended consequences of small changes: the case of paraphilias,” Am J Psychiatry 165 (2008): 1240–41.
32. A. J. Frances and others, “DSM-IV: work in progress,” Am J Psychiatry 147 (1990): 1439–48.
33. A. Barnes, “Race, schizophrenia, and admission to state psychiatric hospitals,” Administration and Policy in Mental Health 31 (2004): 241–52.
34. ICD-10 Classifications of Mental and Behavioural Disorder: Clinical Descriptions and Diagnostic Guidelines (Geneva: World Health Organisation, 1992).
35. A. Frances, “Integrating DSM-5 and ICD 11,” Psychiatric Times, November 2009.
36. Richard Dawkins, The Ancestor’s Tale: A Pilgrimage to the Dawn of Evolution (Boston: Houghton Mifflin, 2004), 416.
37. Paul R. McHugh, MD, and Phillip R. Slavney, MD, “Comprehensive Evaluation or Checklist?” New England J Med 366, no. 20 (2012): 1853–55.
CHAPTER TWO
1. Genesis 2:20, Holy Bible, King James Version (Cambridge Edition, 2000).
2. Encyclopaedia Britannica, online edition, 2012, s.v. “Shamanism,” http://www.britannica.com/EBchecked/topic/538200/shamanism.
3. Jerome D. Frank and Julia B. Frank, Persuasion and Healing: A Comparative Study of Psychotherapy (Baltimore: The Johns Hopkins University Press, 1961).
4. M. Fornaro, N. Clementi, and P. Fornaro, “Medicine and Psychiatry in Western Culture: Ancient Greek Myths and Modern Prejudices,” Ann Gen Psychiatry 8 (2009): 21.
5. Hippocrates, The Corpus: The Hippocratic Writings (New York: Kaplan, 2008).
6. Galen (edited and translated by Ian Johnson), On Symptoms and Disease (Cambridge, U.K.: Cambridge University Press, 2011).
7. Roy Porter, Madness: A Brief History (Oxford, U.K.: Oxford University Press, 2002).
8. Heinrich Kramer and James Sprenger (translated by Christopher Mackay), Malleus Maleficarum (Cambridge, U.K.: Cambridge University Press, 2006).
9. “Medicine in the Medieval Islamic World,” Wikipedia, last modified August 18, 2012, http://en.wikipedia.org/wiki/Medicine_in_the_medieval_Islamic_world.
10. Joseph Frank Payne, Thomas Sydenham (Charleston, SC: Nabu Press, 2010).
11. Wilfrid Blunt, Linnaeus, the Complete Naturalist (Princeton, NJ: Princeton University Press, 2001).
12. Jan E. Goldstein, Console and Classify: The French Psychiatric Profession in the Nineteenth Century (Chicago: University of Chicago Press, 1987).
13. E. Shorter, A History of Psychiatry: From the Era of the Asylum to the Age of Prozac (New York: John Wiley, 1997).
14. Hans Pols, PhD, and Stephanie Oak, BMed, “War and Military Mental Health,” Am J Public Health 97, no. 12 (2007): 2132–42.
15. Walter E. Barton, MD, History and Influence of the American Psychiatric Association (Washington, D.C.: American Psychiatric Association Press, 1987).
16. DSM-I: Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1952).
17. DSM-II: Diagnostic and Statistical Manual of Mental Disorders (Washington D.C., American Psychiatric Association, 1968).
18. John E. Cooper and others, “Cross-National Study of the Mental Disorders: Some Results from the First Comparative Investigation,” Am J Psychiatry 125 (1969): 21–29.
19. R. L. Spitzer, J. Endicott, and E. Robins, Resea
rch Diagnostic Criteria (RDC) for a Selected Group of Functional Disorders, 3rd ed. (New York State Psychiatric Institute, 1978).
20. J. Endicott and R. L. Spitzer, “A diagnostic interview: the schedule for affective disorders and schizophrenia,” Arch Gen Psychiatry 35 (1978): 35, 773–82.
21. DSM-III: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. (Washington, D.C.: American Psychiatric Association, 1985).
22. H. H. Decker, The Making of DSM-III: A Diagnostic Manual’s Conquest of American Psychiatry (Oxford, U.K.: Oxford University Press, 2013).
23. DSM-IIIR: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., rev. (Washington, D.C.: American Psychiatric Association, 1987).
24. DSM-IV: Diagnostic and Statistical Manual of Mental Disorders (Washington, D.C.: American Psychiatric Association, 1994).
25. A. J. Frances, T. A. Widiger, and H. A. Pincus, “The development of DSM-IV,” Arch Gen Psychiatry 6 (1989): 373–75.
26. Thomas A.Widiger, PhD, and Allen J. Frances, MD, DSM-IV Sourcebook, volumes 1–4 (Washington, D.C.: American Psychiatric Press, 1994).
27. A. J. Frances, M. B. First, and H. A. Pincus, DSM-IV Guidebook (Washington, D.C.: American Psychiatric Press, 1995).
28. A. J. Frances and others, “DSM-IV: work in progress,” Am J Psychiatry 147 (1990): 1439–48.
29. L. Cosgrove, S. Krimsky (2012) “A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists,” PLoS Med 9(3): e1001190. doi:10.1371/journal.pmed.1001190.
30. L. Cosgrove, H. J. Bursztajn, and S. Krimsky, “Developing unbiased diagnostic and treatment guidelines in psychiatry,” N Eng J Med 360 (2009): 2035–36.
Saving Normal : An Insider's Revolt Against Out-of-control Psychiatric Diagnosis, Dsm-5, Big Pharma, and the Medicalization of Ordinary Life (9780062229274) Page 30