“Psychiatry’s Bible: The DSM is doing more harm than good.”
This was the headline of a guest opinion piece printed in yesterday’s Washington Post. The editorial was written by psychologist Paula J. Caplan who argued that “hundreds of people [are being] arbitrarily slapped with a psychiatric label and are struggling because of it.” As an example, Caplan recounted the story of a “young mother” who had been told after a quick assessment by an emergency room doctor that she had bipolar disorder. The woman was committed to a psychiatric ward and started on dangerous psychiatric medication.
Over the next 10 months, the woman lost her friends, who attributed her normal mood changes to her alleged disorder. Her self-confidence plummeted; her marriage fell apart. She moved halfway across the country to find a place where, on her dwindling savings, she and her son could afford to live. But she was isolated and unhappy. Because of the drug she took for only six weeks, she now, more than three years later, has an eye condition that could destroy her vision.
Unfortunately, Caplan never identifies this woman nor does she provide us with the name of the hospital where the diagnosis was given. Instead, we are told the woman was simply suffering from nothing more than severe exhaustion.
Caplan writes that in our “increasingly psychiatrized world, the first course is often to classify anything but routine happiness as a mental disorder, assume it is based on a broken brain or a chemical imbalance, and prescribe drugs or hospitalization; even electroshock is still performed.”
She correctly points out that issuing a psychiatric diagnosis is unregulated. Medical doctors – regardless of their specialty – psychologists, social workers, therapists, even school officials can declare that someone has a mental disorder.
Narrowing her focus, she takes aim at the Diagnostic and Statistical Manual of Mental Disorders, which is the manual that doctors rely on to diagnosis mental disorders. She challenges the notion that the DSM is based on any scientific information and claims its editors use poor-quality studies to support categories they want to include while ignoring or distorting high quality research.
Caplan concludes: “I now believe that the DSM should be thrown out.” She announces that she is joining ten people who are filing a lawsuit against the DSM’s editors because the plaintiffs have been “harmed by a diagnosis” based on the DSM.
At last count, more than 350 readers had posted comments about her editorial. Several came from the anti-psychiatry crowd that is quick to rally around any article that attacks psychiatry. (On her website, Caplan has posted a disclaimer that states she is not affiliated with the Church of Scientology.)
I found her editorial to be both thought provoking and troubling.
I was skeptical when I read her story about the young mother. I am not suggesting that Caplan’s concocted the anecdote. But what is missing is context. Caplan suggests there are “hundreds” of persons in America today who have been arbitrarily slapped with a psychiatric label. Is that true? Are there “hundreds” who are being hospitalized unnecessarily? Are there ‘hundreds” who are being forced to take dangerous medications?
During the past six years, I have visited 47 states, toured more than 100 treatment programs and talked to persons with mental disorders and those who love them. What I have seen — and what countless studies have documented — is that community based treatment services are so scarce that it is nearly impossible for people who have serious mental disorders to obtain meaningful psychiatric care. This lack of services is a national scandal. This doesn’t mean that a young woman can’t be arbitrarily entrapped in our needy mental health system.
But hundreds?
I understand the importance of personal stories. My book describes my son’s arrest after I failed to get him help. But I backed up his story with research that showed 16 percent of inmates in jails and prisons have been diagnosed with a severe mental disorder. Studies have shown that the Los Angeles County Jail is the largest public mental facility in America today and that more than one million persons with mental disorders go through our criminal justice system.
Where are the statistics to support Caplan’s anecdotal evidence?
Caplan makes several good points. Psychiatric problems are difficult to diagnosis. Because of stigma, they should never be rushed. My son has been diagnosed as having bipolar disorder, schizo-affective disorder and schizophrenia. This has been extremely frustrating. However, an incorrect diagnosis doesn’t always mean a problem doesn’t exist. How many diagnoses made by doctors about non-mental related problems turn out to be premature or faulty? A minor stomach pain proves to be something much more serious.
It’s also true that many of these diagnoses are rushed because psychiatrists have been pressured by insurance companies to become pill pushers. Few of my son’s psychiatrists have known anything but his name and symptoms. They have seen their job as simply figuring out which pill to dispense. This is bad psychiatry.
Caplan’s statement that doctors are quick to “classify anything but routine happiness as a mental disorder” is demeaning both to psychiatry and patients. Such claims pander to a popular prejudice that people who have been diagnosed with mental disorders really don’t have anything wrong with them, they simply are weak and looking for an excuse to explain their doldrums.
I agree when Caplan states that : “Mental health professionals should use, and patients should insist on, what does work: not snap-judgment diagnoses, but instead listening to patients respectfully to understand their suffering.” I also agree that “[Mental health professionals should ] help patients find more natural ways of healing. Exercise, good nutrition, meditation and human connection are often more effective — and less risky — than drugs or electroshock.” Finally, she concludes that “patients should not be limited in their choices of treatment, but they should be better informed. If someone knows about the many ways that suffering can be addressed, including a drug or a treatment with potential benefits and harms, and they still want to try it, they should be able to.” Yep, that makes sense.
What does not make sense is her conclusion that the entire DSM should be discarded. Improved. Yes. That is what the current rewrite is supposed to be doing. But there is no need to throw out the baby with the bathwater. Does Caplan believe the DSM’s description of the symptoms of schizophrenia are invalid?
It’s true that we live in a society that depends more and more on pills to solve our problems. How else can you explain medication for such troubles as “relestless leg syndrome?”
But I found a troubling thread in Caplan’s editorial. It was the idea that because we have trouble defining and diagnosing mental illnesses that these disorders are not real.
Those of us who have seen someone, who is hearing voices that are telling him to kill himself, know better. Those of us, who love someone so depressed that it impossible for him to get out of bed in the morning, know better. And the idea that the entire DSM is useless or that a person with schizophrenia simply needs a good night’s sleep is wrong.
About the author:
Hello Mr. Earley,
Your website is obviously a great labor of love, but I must disagree strongly with this piece.
Did you seriously expect Paula Caplan to identify the woman or the hospital? Do members of the Pro-Psychiatry Crowd routinely identify the people in their stories?
As for the DSM, it has always struck me as both a latter-day sacred text and a literally textbook example of ‘Obsessive-Compulsive Disorder’!
Why did you draw such attention to Caplan’s disclaimer about Scientology? Scientology is both a religion and the greatest red herring in the Psychiatric debate. May I suggest nobody criticize an opponent’s Scientology without disclosing their own religion or lack thereof. BTW I’m a Catholic, and Scientology has a couple of thousand years to go before equaling the horrors attributed, often correctly, to my coreligionists!
I agree Paula Caplan’s estimate of ‘hundreds’ slapped with psychiatric labels and hospitalised and fed harmful drugs is probably off-center. But that’s because I would put the figure at tens of thousands or more, even assuming one accepts the whole concept of psychiatric labels in the first place.
I really don’t think I need point out to readers of Paula Caplan’s original article that she did not ignore context, or suggested the woman did not have a problem, or that ‘people who have been diagnosed with mental disorders really don’t have anything wrong with them, they simply are weak and looking for an excuse to explain their doldrums,’ or that ‘a person with schizophrenia simply needs a good night’s sleep.’
As someone who has experienced the difficulties and injustices of inappropriate psychiatric labeling, I would like to note several points. Practically speaking, medical science is not a body of scientific truth. It is rather a body of what the medical establishment believes to be scientific truth. Throughout history, the scientific community has stated certain things as fact only to ruin the lives and careers of those who dared to challenge the established order (often rightfully so).
The first and most well-known example is that of Galileo Galilei who dared question the Pope’s legitimacy on matters of gravity and geocentrism and subsequently paid a heavy price.
Less known is the case of Dr. Ignac Semmelweis of Budapest. Several hundred years ago, Dr. Semmelweis observed that maternal mortality was much higher in hospital births than in home births. He could not understand why until he witnessed that physicians performing autopsies and then proceeding directly to the delivery room experienced much higher patient mortality than physicians who did not perform autopsies or who experienced time gaps between the morgue and the delivery room. The existence of microbial pathogens was unknown at the time and disease was thought to be caused by humoral imbalance within the body for which treatment consisted of bloodletting. Semmelweis theorized that there was some kind of poison that was transferred from the corpse to the doctor and then to mother and infant. His proposed remedy: rinsing the hands in alcohol before delivering the infant. While Semmelweis’s remedy proved effective, the medical establishment of his time paid Semmelweis no heed believing that handwashing was undignified for a man great enough to literally hold patients’ lives in his hands. Semmelweis continued his advocacy, was subsequently stripped of his medical credentials, and placed in an asylum where he ultimately died in obscurity.
More recently is the case of Dr. Joseph Goldberger who worked for the US Public Health Service in the 1920s. At the time, pellagra was an American epidemic whose cause was believed to be an untreatable infectious disease. Through experimentation on prisoners in the American south, Goldberger proved that pellagra was in fact not an infectious disease, but rather a B vitamin deficiency. In doing so, he once again turned medical “knowledge” on its head.
With respect to mental illness, we “know” that the proximate cause of most mental illness has something to do with either an imbalance of catecholamines (serotonin, dopamine, norepineprine/noradrenaline) and/or hypo/hypersensitivity of catecholamine receptors in various parts of the brain. However, this is the most proximate cause. Even if we accept the catecholamine theory as true (which is quite possible), the treatment for such mental illness is purely symptomatic, does not address the underlying causes, and is, arguably, an inferior treatment in many cases. I posit that most mental illness is a result of metabolic disorders caused by environmental toxins and malnutrition arising from improper diet or from digestive abnormalities. For simplicity’s sake, I will use unipolar depression, bipolar depression, and schizophrenia as examples.
Unipolar depression is believed to be a manifestation of either hyposensitive catecholamine (serotonin, dopamine, noradrenaline) receptors or insufficient production of catecholamines or both. Lower than average metabolic rates (body mass index taken into account) are strongly correlated with unipolar depression. (It is widely believed that testosterone regulates, at least in part, the synthesis of catecholamines). This is especially so in farmers who use synthetic pesticides. Pesticides are known to suppress testosterone levels (and lower metabolism as a result) and farmers who use synthetic pesticides routinely are known to suffer from depression at a rate 3-5 times that of their non-synthetic pesticide using counterparts. The exact mechanism is unclear, but most endocrinologists believe that metabolism is regulated via testosterone and estrogen. An increase in testosterone levels has been documented following the administration of dopamine agonists (drugs that increase dopamine levels in the blood and in the brain). Among other things, dopamine suppresses prolactin levels, thereby lowering the production of estrogen and increasing testosterone production, resulting in increased metabolism and presumably in increased serotonin and norepinephrine. Interestingly, women have higher estrogen levels, lower testosterone levels and metabolic rates, and a higher incidence of unipolar and bipolar depression than men.
Bipolar disorder is characterize by alternating mania (often delusional or hallucinative) and depression, the former being characterized by abnormally high levels of catecholamines and the latter by abnormally low levels. As with most mental illnesses, the underlying cause is unknown and likely varies. However, a strong theory posits that those who suffer from bipolar disorder have either high levels of both testosterone or a high concentration of aromatase enzymes in the liver. When the body produces excess testosterone, the excess amount is converted to estrogen via a liver enzyme called aromatase. Aromatization increases the levels of estrogen and decreases testosterone. Lower testosterone results in lower serotonin and norepinephrine, while increased estrogen increases cortisol production (aka the stress hormone) which inhibits dopamine and testosterone production.
Bottom line: improper b and d vitamin levels.