12/7/21

Misrepresentation in Biological Psychiatry

An intriguing article, “Medicine and the Mind,” by psychiatrists Caleb Gardner and Arthur Kleinman was published in The New England Medical Journal in October of 2019. They said that something has gone wrong with academic and clinical psychiatry. “Checklist-style amalgamations of symptoms have taken the place of thoughtful diagnosis, and trial-and-error ‘medication management’ has taken over practice to an alarming degree.” While facing less and less time to work with patients, they thought psychiatry was facing the “stark limitations” of biologic treatments.

While these limitations are widely recognized by experts in the field, the dominant message to the public—and the rest of medicine—continues to be that the solution to psychological problems means making the correct diagnosis and then matching it with the right medication. As a result, psychiatric diagnoses and medications flourish in the name of scientific medicine. Yet, “there is no comprehensive biologic understanding of either the causes or the treatments of psychiatric disorders.”

Psychiatry is plagued with three things, according to Gardner and Kleinman. First is the over-prescription of medications for a large segment of the population. Second, there has been the abandonment and incarceration of individuals with chronic, severe mental illness. Third, diagnostic systems have become increasingly unwieldy with their overlapping checklists of symptoms.

The problem is not simply one of scientific and intellectual integrity. This state of affairs influences training and reimbursement and does a great disservice to patients, practicing psychiatrists, and our medical colleagues who are striving to provide the best and most humane care to people with medically and psychologically complicated conditions.

Psychiatry should be uniquely positioned to help through example, scholarship and consultation. “Yet the field seems to have largely abandoned its social, interpersonal, and psychodynamic foundations, with little to show for these sacrifices.” Science historian Anne Harrington proposed that psychiatry limit its scope to only severe, mostly psychotic disorders. In her 2019 book, Mind Fixers, she said, “Today one is hard-pressed to find anyone knowledgeable who believes that the so-called biological revolution of the 1980s made good on most or even any of its therapeutic and scientific promises.”

We believe that a fundamental rethinking of psychiatric knowledge creation and training is in order. If only the highest-quality biologic research were supported, substantial funding could be redirected to psychosocial, cultural, public health, and community studies that directly support the work of practicing psychiatrists responding to the needs of patients, families, and communities. The most pressing work is research on addiction, elder care, community care programs, consultation aimed at improving the quality of care in medical clinics and hospitals, child and adolescent psychiatry, and global mental health, as well as cultural studies of vulnerable populations.

Misrepresenting the Truth

In “Messaging in Biological Psychiatry” for the Harvard Review of Psychiatry, researchers Estelle Dumas-Mallet and Francois Gonon noted the article by Gardner and Kleiman was the first time that psychiatrists acknowledged in a prestigious biomedical journal that they have been misrepresenting the truth of biological psychiatry to their non-psychiatric peers in medicine and to laypeople. Dumas-Mallet and Gonon believe that most psychiatrists do not intentionally deceive patients or the public. They are not aware they contribute to the doublespeak or recognize how they passively accept it. “Therefore, in the absence of convincing evidence supported by observational studies, they might miss Gardner and Kleinman’s important message.”

In their article, Dumas-Mallet and Gonon sought to review the academic literature that described the misrepresentation of biological psychiatry, what its sources were, how it is diffused through mass media, and what the social consequences have been. As documented in several academic studies, there is often a huge gap between the observations reported in biomedical publications and their presentation in mass media. Focusing on psychiatry, they described the misrepresentations of the scientific observations in the biomedical literature that were spread through the media. They reviewed academic works that examined how mass media covered biomedical research. Lastly, they discussed the possible reasons why journalists, scientists, and scientific institutions “contribute to the misrepresentation of biological psychiatry.”

The percentage of scientific articles that confirmed researchers’ initial hypotheses increased from 70% in 1990 to 86% in 2007. Dumas-Mallet and Gonon thought the preferential publication of positive biomedical findings could be the result of two tendencies. First, researchers could choose to not publish their negative results. Second, journal editors have increasingly rejected articles reporting negative findings. These tendencies can be illustrated by looking at how clinical trials reporting a beneficial effect to the FDA are more often published than those reporting no effect.

Among a total of 74 randomized, controlled trials of antidepressants registered with the FDA, 37 of the 38 trials reporting a positive effect were published in peer-reviewed journals. By contrast, among the 36 trials judged as negative by the FDA, 22 had not been published, 11 were published but reported positive outcomes, and only 3 trials published results in agreement with the FDA’s judgments.

Many articles reporting a correlational relationship between a pathology and a risk factor improperly suggested it to be causative. When this wrong interpretation is reported in press releases of the research, it is likely to appear in media reports covering the study. They gave an example with a brain-imaging study that said a link between brain abnormalities and ADHD confirmed that ADHD was a brain disorder. The authors themselves acknowledged that “structural changes in certain brain areas are not necessarily the cause of mental disorders.” A large international study suggested the modest atrophy of the hippocampus could be the result of chronic depression rather than the cause.

Since positive findings are preferentially published in biomedical journals, the first study on a new subject often reports a larger effect size than subsequent studies. Dumas-Mallet and Gonon conducted a large comparative study of initial studies. They found that an average of one in two initial studies was either contradicted or significantly weakened by the corresponding meta-analysis. They observed how the public was seldom informed of research that disproved initial studies. In a second illustration, they said “only 4 of 50 newspapers covering a story on genetic susceptibility to depression also reported a later meta-analysis that disconfirmed its results.”

This example illustrates a general observation: newspapers strongly favor studies published by prestigious scientific journals, even though the initial studies that they publish are as often disconfirmed by subsequent studies, as are the initial studies published by journals with lower impact factors. Newspapers preferentially cover these initial studies because these prestigious journals also produce press releases highlighting the studies they publish. Indeed, these press releases are the direct source of more than 80% of the press articles reporting biomedical findings.Moreover, most newspaper articles are very closely inspired by these press releases and take up their biases and exaggerations without criticism. Finally, newspapers further accentuate publication biases by almost exclusively covering studies reporting a positive effect.

Misrepresenting the results of biological psychiatry to the public reinforces the view that mental disorders are biomedical diseases. The percentage of Americans who believe that schizophrenia and depression are genetic brain diseases increased from 61% in 1996 to 71% in 2006. Patients that hold this view are more pessimistic about their recovery and focus their hopes on psychotropic medications. While it needs further investigation, some studies show that patients with less endorsement of biogenetic beliefs about depression appear more likely to recover, while other studies find no relationship.

Possible Causes

A scientist’s career primarily depends on the number and quality of their publications. Getting a study published in a prestigious journal ensures the author a lasting reputation, and increases the likelihood their grant applications will be funded. In order to gain publication in a prestigious journal like The Lancet or The New England Medical Journal, researchers may be tempted to exaggerate the interest of their work. On the publication side, editors of prestigious journals will select the most exciting results likely to interest a large audience. “In fact, mass media preferentially cover studies published by prestigious journals because they believe them to be the most reliable, although many of them are disconfirmed by subsequent studies.”

Scientific institutions favor researchers who publish in prestigious journals. They also encourage researchers to communicate with journalists and the public. Institutions have also strengthened their press services and are flooding national journalists with press releases. National newspapers also seem to preferentially cover biomedical publications whose authors are working in that nation. Since research is mainly funded on project-based proposals, researchers are encouraged to over-promise in their grant applications, and then to embellish their results in order to continue receiving grants.

Journalists may unwittingly worsen the distortions already present in the biomedical literature. Biomedical observations in scientific publications are frequently altered by different forms of distortion, including: partially falsified results, data spin or embellishment, improper interpretation, exaggerated conclusions. Press releases by biomedical journals and scientific institutions often aggravate these distortions. While journalists are not the main source of these distortions, they boost their distribution by preferentially covering initial studies and those reporting positive results. “Consequently, the journalistic ideal of independent and objective investigation of the facts seems to apply poorly to the media coverage of biomedical findings.”

All these observations illustrate why mass media almost never informs the public when a study they covered is contradicted by subsequent studies. To illustrate this, Dumas-Mallet and Gonon pointed to Caspi et al, “Influence of Life Stress on Depression,” where the authors suggested there was a genetic susceptibility to depression. This was covered by 50 newspapers during the week after its publication. Yet when later studies contradicted Caspi et al, there was essentially no media attention. “Only four newspapers covered the meta-analysis published in 2009.” They concluded that the psychosocial understanding of mental disorders was at least as important as the biological one to guide mental health professionals.

Dumas-Mallet and Ganon told Mad in America they were motivated to write their article because they were seeing signals that academic psychiatry was prepared to reflect on these misrepresentations and change course (See “If Not Psychiatry, What Then?”). They affirmed there is a doublespeak done with biological psychiatry that negatively effects patient care. The publication of the Gardner and Kleinman article prompted them to write theirs. “For the first time in a prestigious medical journal, the doublespeak of psychiatry was acknowledged.” The Mad in America author, Emaline Friedman, said:

The existing literature makes a compelling case that a psycho-social understanding of mental disorders is at least as important as a neuro-biological understanding. Such a shift in the dominant narrative has the potential to influence mental health treatments as well as the mental health literacy of the public, which impacts how mental health patients are treated by those around them.

05/1/18

Psychiatric Scientism

There is a curious phenomena within the debate over the evidence base of psychiatric drug treatment, namely whether psychiatry itself ever promoted or supported the chemical imbalance theory. Ronald Pies, an emeritus editor for Psychiatric Times, has repeatedly claimed that the chemical imbalance theory “was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.” Further, Pies said that to his knowledge, “No professional psychiatric organization has ever publically promoted a ‘chemical imbalance theory’ of mental illness in general.” But it seems his statements are incorrect.

The two above quotes by Ronald Pies were from blog articles he posted on the Psychiatric Times website in “Psychiatry’s New Brain-Mind and the Legend of the Chemical Imbalance,” and “Serotonin: How Psychiatry Got Over Its ‘High School Crush’”. He claimed “the ‘chemical imbalance’ trope” has been used by the opponents of psychiatry and erroneously attributed to psychiatrists themselves. Yet Robert Whitaker commented in his response to “Serotonin: How Psychiatry Got Over Its ‘High School Crush’” that it is quite easy to find numerous instances where prominent psychiatrists, including leaders of the APA [American Psychiatric Association], informed the public that “mental illnesses—such as depression or schizophrenia—are not ‘moral weaknesses’ or ‘imagined’ but real diseases caused by abnormalities of brain structure and imbalances of chemical in the brain.” This quote was in a 2001 Family Circle article, “Unlocking the Brain’s Secrets,” by the president of the APA, Richard Harding.

Another example given by Whitaker was in a 2005 brochure published by the APA, “Let’s Talk Facts About Depression.” In the section “How Is Depression Treated?” it says: “Antidepressants may be prescribed to correct imbalances in the levels of chemicals in the brain.” In 2005 APA press release, “Mental Illness Stigmas Are Receding, But Misconceptions Remain,” the results of an APA survey indicated that although 75% of consumers believe mental illnesses are usually caused by a chemical imbalance in the brain, they are more likely to consult a primary care physician rather than a psychiatrist—“a specialist specifically trained to diagnose and treat chemical imbalances and other determinants of mental illness.”

Whitaker’s thesis is that since the publication of the third edition of the DSM in 1980, the APA has been committed to the position that mental disorders are diseases of the brain; and that drugs for those diseases are safe and effective. “The chemical imbalance story comprised the heart of this disease-model narrative: Psychiatric researchers were discovering the pathology of mental disorders, and its drugs fixed that pathology, like insulin for diabetes.” He sees this narrative as serving psychiatry’s interests as a guild.

It told of how its disorders in DSM III had been “validated” as real diseases.
It told of a medical specialty that was making great scientific progress, which elevated its power and authority in our society.
It told of a medical specialty that had a product—e.g. drugs—that was of great worth in treating those diseases.
Most important of all, this narrative provided a reason for psychiatry, as a medical specialty, to have authority over this part of our lives.

Whitaker said our society has responded to this narrative by organizing itself around it, and assuming it is the legitimate “story of science.” In “The Scientism of Psychiatry,” Sami Timimi said this tendency has led mainstream psychiatric literature to prefer rhetoric to scientific accuracy. Psychiatric research and discourse, according to Timimi, “are now dominated and infected by scientism — the promotion of a belief … that because what you do and talk about sounds and looks like ‘science,’ it is ‘scientific’”.

In “What Is Scientism?” Thomas Burnett said philosopher Tom Sorell defined scientism as putting too high a value on natural science in comparison with other branches of learning. A more precise and extreme definition by physicist Ian Hutchinson was also quoted from his book: Scientism: Philosophy and the Infatuation with Science: “Scientism is a matter of putting too high a value on natural science in comparison with other branches of learning or culture.” Hutchinson also said the health of science was jeopardized by scientism.

Burnett gave a brief history of scientism up through the logical positivism embodied in The Vienna Circle. “In this system, there are only two kinds of meaningful statements: analytic statements (including logic and mathematics), and empirical statements, subject to experimental verification. Anything outside of this framework is an empty concept.” However Karl Popper pointed out there were very few statements that could be completely verified in science. “A single observation has the potential to invalidate a hypothesis, and even an entire theory.” So he proposed that instead of experimental verification, “the principle of falsifiability should demarcate what qualified as science, and by extension, what can qualify as knowledge.” Timimi noted how this has been incorporated into scientific methodology as a process of rejecting or disproving the null hypothesis.

Science uses a methodological approach involving hypothesis generation and then testing the hypothesis through empirical methods. The best scientists can live with and accept uncertainty as a prerequisite to being objective in the pursuit of knowledge. Knowledge develops and builds through generating a hypothesis (often using results from previous research) and then carrying out an investigation aimed at proving that something called a ‘null hypothesis’ can’t be true. The null hypothesis is a general statement or default position that there is no relationship between certain measured phenomena. Rejecting or disproving the null hypothesis — and thus concluding that there are grounds for believing that there is a relationship and the actual hypothesis may be true — is a central task in the modern practice of science.

He then said one of the major problems with the current concepts used in psychiatry traces back to the basic assumptions on which much of psychiatric research rests. In order to scientifically evaluate a proposition that there is a natural category of dysfunction/disorder, we must start with the null hypothesis. Until proven otherwise, there is no characteristic relationship between what we are investigating (put the disorder of your choice here) and some measurable biological/neurological feature. “This is a foundational assumption behind the development of knowledge through the scientific method.” ADHD, Depression and essentially all other psychiatric disorders fail to meet this standard. “Until we have demonstrated that this basic null hypothesis can’t be true, then scientifically, we cannot proceed with research that assumes that ADHD [or any other diagnostic category] as a concept has explanatory power for the behaviours it describes.”

Mainstream psychiatry has been afflicted by at least two types of scientism. Firstly, it parodies science as ideology, liking to talk in scientific language, using the language of EBM [evidence based medicine], and carrying out research that ‘looks’ scientific (such as brain scanning). Psychiatry wants to be seen as residing in the same scientific cosmology as the rest of medicine. Yet the cupboard of actual clinically relevant findings remains pretty empty. Secondly, it ignores much of the genuine science there is and goes on supporting and perpetuating concepts and treatments that have little scientific support. This is a more harmful and deceptive form of scientism; it means that psychiatry likes to talk in the language of science and treats this as more important than the actual science.

Contrasting medical and psychiatric diagnosis, Timimi then said:

In medicine, diagnosis is the process of determining which disease or condition explains a person’s symptoms and signs. Diagnosis therefore points to causal processes. Making an accurate diagnosis is a technical skill that enables effective matching of treatment to address a specific pathological process. Pseudodiagnoses, like for example ADHD, cannot explain behaviours as there are only ‘symptoms’ that are descriptions (not explanations) of behaviours. Even using the word ‘symptom’ may be problematic, as in medicine ‘symptoms’ usually refers to patients’ suffering/experience as a result of an underlying disease process and is therefore associated in our minds with a medical procedure leading to an explanation for the ‘symptom.’ But psychiatric diagnoses do not explain symptoms.

Using ADHD as am example, Timimi said once we start interrogating basic assumptions like the validity of psychiatric diagnoses, it should be easy to see that much of the psychiatric literature is built on assumptions lacking validity. Since ADHD is a descriptive classification and not a medical diagnosis, we have no reliable empirical method for defining what qualifies as a case of ADHD. Determining what qualifies as a case of ADHD is then arbitrary and depends on the standards used by the person doing the diagnosis, “influenced by whatever prevailing ideology concerning diagnosis they have been exposed to.” So as a consequence, we cannot eliminate wide variation in ‘diagnostic’ practice.

Timimi said in Western culture, science has become a cosmology—“an ideology/faith that believes that science has an undeniable primacy over all other ways of seeing and understanding life and the world.” This makes us vulnerable to scientism. He suggested psychiatry keeps faith in scientism despite its flaws because of the value we place in our culture on technology and technological achievement; and because, “this connects with that broader ‘cosmology’ that wants to use ‘science’ to explain everything.” In order to have credibility and leverage in our society, “we are inclined to use technological/scientific-sounding language.” Michael Foucault and others have pointed out, “this is how institutional power builds up and get authority to create ‘regimes of truth’.” Robert Whitaker said if psychiatry is ever going to reform itself in a way that will serve the public, “rather than its own guild interests,” it has to confront its past.

Why did it tell this false narrative—of drugs that fixed chemical imbalances in the brain—to the public? Perhaps then it could understand that its duty, as a medical specialty, is to tell a narrative to the public that is consonant with the relevant science. If that were so, then the public would be hearing that the biological causes of psychiatric disorders remain unknown, and that its drug treatments are of marginal efficacy over the short term, and that over the long-term, outcomes for medicated patients are very poor.

03/9/18

Psychiatry Needs a Revolution

Peter Gøtzsche wrote a January 2018 editorial in the British Medical Journal, where he elaborated on why he thinks, “Psychiatry is a disaster area in healthcare that we need to focus on.” In his editorial, Gøtzsche said the prevailing paradigm in psychiatry was to say psychiatric drugs have specific effects against specific disorders; and that their actions do more good than harm. However, he asserted that as a consequence of its liberal use of psychiatric drugs, psychiatry actually does more harm than good. Gøtzsche and other so-called “antipsychiatry,” critics are often dismissed by psychiatry. But there was a study that surveyed the attitudes of medical teaching faculty towards psychiatry and psychiatrists; and the results had more in common with the antipsychiatrists than you might think.

Stuart, Sartorius and Linamaa published “Images of Psychiatry and Psychiatrists” in the open access journal, Acta Psychiatra Scandinavica. They surveyed 1,057 teaching medical faculty members from 15 academic teaching centers in the United Kingdom, Europe and Asia. The overwhelming majority of respondents held negative views towards psychiatry as a discipline, psychiatrists and psychiatric patients. Some of their findings were startling: 90% thought psychiatrists were not good role models for medical students; 84% thought psychiatric patients should be treated only within specialized facilities.

When the survey asked about the perception of psychiatry as a profession, 8.9% thought psychiatry was unscientific; 7.7% thought it was not evidenced-based; and 8.0% thought psychiatry was not a genuine, valid branch of medicine. Perceptions of psychiatric treatment thought psychiatrists had too much power over their patients (25.0%); treatments were not as effective as in other branches of medicine (22.6%); and most who receive treatments do not find them helpful (20.4%). Then 28.6% said they would not encourage a bright student to enter psychiatry; and 75.4% said many students at their medical school were not interested in pursuing psychiatry as a career.

Results highlight the extent to which non-psychiatrist medical faculty hold negative opinions of psychiatry as a discipline, psychiatric treatments, psychiatrists as role models for medical students, psychiatry as a career choice, psychiatric patients, and psychiatric training. The most outstanding findings were that psychiatrists were not considered to be good role models for medical students, and psychiatric patients were considered to be emotionally draining and unsuitable to be treated outside of specialized facilities or in general hospitals.

“In Search of an Evidence-Based Role for Psychiatry,” by Read, Runciman and Dillon noted this was not the only study indicating negative views of psychiatry by other medical professionals. They cited a study by Curtis-Barton and Eagles that found medical students were discouraged from choosing psychiatry as a career either a lot or a little because of a perceived lack of evidence base (51%); and the scientific basis of psychiatry (53%). Only 4-7% of UK medical students saw it as a ‘probable/definite’ career because of its poor evidence base. Commenting further on “Images of Psychiatry and Psychiatrists,” Read, Runciman and Dillon said:

Even more revealing than the survey findings was psychiatry’s response to it. The researchers themselves, including a former President of the World Psychiatric Association, wondered whether their colleagues’ opinions are ‘well founded in facts’ or ‘may reflect stigmatizing views toward psychiatry and psychiatrists’. Their own answer to that question becomes abundantly clear when, instead of proposing efforts to address the problems identified by the medical community, such as having little scientific basis, they recommend only ‘enhancing the perception of psychiatrists’ so as to ‘improve the perception of psychiatry as a career.’

The responses to the survey, all written by psychiatrists, dismissed each concern “and blamed everyone but their own profession, including their supposedly ignorant, prejudiced medical colleagues and the biased media.” Read, Runciman and Dillon then described problems with how mental health issues are conceptualized, what causes them and how to treat them. “Despite all this, biological psychiatry is trying to expand the reach of what others consider to be an unscientific, reductionistic, simplistic and pessimistic ‘medical model’.” A truly evidence-based psychiatry would recommend psychiatric medications at a last resort (and for a short time period). The adverse effects of medications should be fully disclosed and “no medical treatment should be forced on anyone against their will.”

Read, Runciman and Dillon said there were three core research areas that psychiatry should be demonstrating progress in, if it is a legitimate scientific, medical discipline. They are: conceptualization, causation and treatment of the disorders.

With regard to the conceptualization of psychiatric disorders, “psychiatry’s primary contribution is an ever expanding list of labels.” Many do not reach even minimal scientific reliability levels and calling them ‘diagnoses’ is often a misnomer. Significantly, the NIMH announced when the DSM-5 was about to be published that it was abandoning the DSM diagnostic approach to classifying mental health problems for its research to develop scientifically robust ‘research domains.’ See “Patients Deserve Better Than the DSM” for more information on this.

“In terms of causation, psychiatry has focused predominantly on chemical imbalances, brain abnormalities and genetics.” But has repeatedly failed findings of any substance in support of that premise. Genetics has an important role, if the research is done on constructs that actually exist. There is also “the role of epigenetic processes whereby genes are activated and deactivated by the environment.”

Research suggests that the safety and efficacy of psychiatric drugs has been grossly exaggerated. Documentation in support of this claim is overwhelming. See the websites for Mad in America, Peter Breggin, and David Healy and RxISK for starters. You can also search this website or start with: “In the Dark About Antidepressants,” “Blind Spots With Antipsychotics.”

Peter Gøtzsche similarly noted concerns with the “liberal use of psychiatric drugs.” He identified four concerns with the prevailing paradigm in psychiatry and gave supporting evidence for each.

First, the effects of the drugs are not specific. “They impair higher brain functions and cause similar effects in patients, healthy people and animals.” For instance, not only does serotonin (SSRI antidepressants influence serotonin levels) seem to have a role in maintaining mood balance, it can effect social behavior, appetite and digestion, sleep memory and sexual desire and function.
Second, research in support of the paradigm that psychiatric drug have specific effects against specific disorder is flawed.
Third, the widespread use of psychiatric drugs has been harmful for patients. In every country where the relationship has been examined, an increased use of psychiatric medications has accompanied an increase in the number of chronically ill people and the number of people on disability pensions.
Fourthly, all attempts to use brain scans to show that psychiatric disorders cause brain damage have failed. “This research area is intensely flawed and very often, the researchers have not even considered the possibility that any brain changes they observe could have been caused by the psychiatric drugs their patients have taken for years” Yet this has been shown repeatedly in many reliable studies, especially for neuroleptic drugs.

Peter Gøtzsche said the prevailing paradigm in psychiatry, that its drugs have specific effects against specific disorders, is unsustainable when the research in support of it is critically appraised. He said psychiatry needed a revolution; reforms were not enough. “We need to focus on psychotherapy and to hardly use any psychiatric drugs at all.” Dr. Gøtzsche is a medical researcher and the Director of the Nordic Cochrane Center. Along with 80 others, he helped start the Cochrane Collaboration in 1993, which is “a global independent network of researchers, professionals, patients, carers, and people interested in health.” The work of the Cochrane Collaboration is recognized as an international gold standard for high quality, trusted information.

04/7/17

Souless Psychiatry

A psychiatric resident at Stanford University School of Medicine wrote an essay on the crisis with psychiatry that appeared in a Scientific American blog. The author said the field was in decline as fewer medical students sought to specialize in psychiatry. He stated psychiatry was looked down upon by nearly every segment of society; and patients avoided treatment because of the stigma related to the field. His solution was to change the name of the field—call it something else.

The crisis, in his view, stems largely from a misunderstanding of what psychiatry is. He said it was “the medical field where doctors incorporate neuroscience and medical research to treat patients with diagnosable mental disorders.” But his friends seem to think he interprets dreams and administers Rorschach tests. Administering Rorschach tests and interpreting dreams are activities associated with psychoanalytic practice that dominated psychiatry up until the 1970s. While “mental health” has made great strides raising awareness (i.e., May is now National Mental Health Awareness Month), “psychiatry has been left behind as its anachronistic forebear.” So he asked, “Would renaming the field help?”

The word psychiatry evokes thoughts of dated medical practices, like Freudian analysis and ice-pick lobotomies. Its sordid history turns away patients, providers, and the public from the progress of mental health care today.

He acknowledged where relabeling could be seen as a Band-Aid. A mere name change ignores the root causes of the problem, which from his perspective is the stigma attached to psychiatry and mental illness. However, citing studies of name changes within the U.S. and other countries, he suggested these language shifts helped psychiatry sound more reputable. He imagined most people would rather have a mental health disorder than a psychiatric disorder, “even if it were the same thing.”

“Mental Health Care” would be a simpler name for the field instead of psychiatry. Psychiatrists would then become “mental health physicians.” Medical centers could create departments of mental health, combining specialties such as internal medicine, psychiatry, psychology and social work. “By uniting these fractured disciplines under one roof, clinicians could provide more comprehensive care to patients without the stigma associated with aging terminology.” Mental health units were said by the author to be far less frightening than psychiatric wards.

In conclusion, he noted how the term psychiatry meant: “healing of the psyche,” drawn from the Greek goddess of the soul—Psyche. “It’s a romantic notion, but we don’t treat patients’ souls. We treat diagnosable diseases of the brain. Perhaps it’s time to rename the field.”

In reading this essay, I was reminded of what psychiatrist Jeffrey Lieberman wrote in his book, Shrinks about psychiatry. He commented that in the 1970s, “the majority of psychiatric institutions were clouded by ideology and dubious science,” mired in a pseudomedical Freudian landscape. But now in the twenty-first century, psychiatry offered scientific, humane and effective treatments. “Psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” You can read about the fallacies of “Freudian analysis and ice pick lobotomies” in Shrinks, but you won’t hear the complete and unvarnished truth about psychiatry.

Robert Whitaker astutely commented that Shrinks is more of a story of how psychiatry sees itself as an institution, than it is an accurate history of psychiatry. And I see the same approach here. I wonder if the Stanford psychiatric resident who wrote “Maybe We Should Call Psychiatry Something Else” is simply rehashing the received view of psychiatric history.

If you want a truly unvarnished look at psychiatry, read Whitaker: Mad in America, Anatomy of an Epidemic, and Psychiatry Under the Influence. You can read more about Lieberman and Shrinks on this website. Do a search for “Lieberman.”

The term “psychiatry” was originally coined by Johann Reil—a German physician—in 1808. And it does literally mean the medical treatment of the soul. Another German physician, Johann Heinroth was the first person to hold a chair of psychiatry. He also staked out working with the mentally ill as medical territory. Since there was little or no knowledge within the medical tradition to equip doctors to deal with mental disturbances, he proposed the creation of a new branch of medicine—psychiatry.

In his 1818 Textbook of Mental Disturbances, Heinroth said: “Since we are speaking of medical art and science, we should think that nobody but a doctor should have a right to make mental disturbance the object of his studies and treatment.” In The Myth of Psychotherapy, Thomas Szasz said of this time:

The birth of psychiatry occurs when the study of the human soul is transferred from religion to medicine, when the “cure of souls” becomes the “treatment of mental diseases,” and, most importantly, when the repression of the heretic-madman ceases to be within the jurisdiction of the priest and becomes the province of the psychiatrist.

There have been some radical shifts in how psychiatrists function since the early 1800s. Initially they were administrators of large institutions for the insane. Under Freud’s influence, psychiatrists began to consult with individuals living in society rather than working solely with those within institutions. Then in 1909, Freud was invited to give a series of lectures on psychoanalysis by Stanley Hall, the president of Clark University.

The cover photo for “Maybe We Should Call Psychiatry Something Else” shows seven men from the time of that conference, but only identified Sigmund Freud and Carl Jung. At the time, Jung was still friendly with Freud. The photo credit said the others were “pioneers in psychiatry,” but that is not entirely accurate. The photo shows Sigmund Freud and Carl Jung on either side of Stanley Hall in the front row. In the back row from left to right are Abraham Brill, Ernest Jones and Sandor Ferenczi.

Stanley Hall was a well-known American psychologist in addition to the then president of Clark University. He had an interest in Freud’s psychoanalytic theories and invited him to be part of a “galaxy of intellectual talent” to celebrate the twentieth anniversary of the founding of Clark University. Jung and Ferenczi were invited as the leading European disciples of Freud. Ernest Jones, another protégé of Freud, was then in Toronto Canada, building a private psychoanalytic practice and teaching at the University of Toronto. Jones would later become a biographer of Freud. Brill was the first psychoanalyst to practice in the U.S. and the first translator of Freud into English. In 1911 he founded the New York Psychoanalytic Society.

So these individuals are better seen as pioneers of Freudian psychoanalytic practice —the approach dismissed by the author of “Maybe We Should Call Psychiatry Something Else” as a dated medical practice, which he placed alongside ice pick lobotomies.

By the 1940s, psychoanalytic theory had not only taken over American psychiatry, it had become part of our cultural psyche. Alfred Hitchcock’s 1945 film, Spellbound is an example of how influential psychoanalytic thinking was. The opening credits of the film announce that it wanted to highlight the virtues of psychoanalysis in banishing mental illness and restoring reason. Look for the Freud look-a-like character as Ingrid Bergman’s psychoanalyst and mentor.

Psychoanalytic thought dominated the field until the 1970s when the birth of biological psychiatry was ushered in by Robert Spitzer and his reformulation of psychiatric diagnosis. After Spitzer was appointed to do the revisions for the 3^rd edition of the DSM in 1974, he was able to appoint whomever he wanted to the committees. He made himself the chair of all 25 committees and appointed individuals who he referred to as the “young mavericks” psychiatry. In other words, they weren’t interested in Freudian analysis. Spitzer said: “The feeling was that the same techniques that were useful in medicine, which is you describe something, you do laboratory studies; that those same kind of studies were appropriate for psychiatry.” Except it didn’t happen because in the 1970s, there just wasn’t a lot of psychiatric research. So the decisions of the committees were based on the expertise of the committee members.

David Chaffer was part of the process back then. He said committee members would gather together into a small room. Spitzer would sit with a mid 1970s “portable” computer and raise a provocative question. “And people would shout out their opinions from all sides of the room. And whoever shouted loudest tended to be heard. My own impression was … it was more like a tobacco auction than a sort of conference.” So much for using the same techniques as those used in medicine. Listen to the NPR story, “The Man Behind Psychiatry’s Diagnostic Manual” for the above information on Spitzer and the DSM.

But the real driving force behind the revisions made by Spitzer and others was because a “psychopharmacological revolution” couldn’t begin with the diagnostic process that existed before Spitzer and the DSM-III. Allen Frances, the chair of the next revision, the DSM-IV, acknowledged as much in his comments before the American College of Neuropsychopharmacology in 2000. Frances said the DSM-III was an innovative system that focused on descriptive diagnosis and provided explicit diagnostic criteria. “In many ways this aided, and was aided by, the knowledge derived from psychopharmacology. . . . The diagnostic system and psychopharmacology will continue to mature with one another.”

The psychopharmacological revolution required that there be a method of more systematic and reliable psychiatric diagnosis. This provided the major impetus for the development of the structured assessments and the research diagnostic criteria that were the immediate forerunners of DSM-III. In turn, the availability of well-defined psychiatric diagnoses stimulated the development of specific treatments and increasingly sophisticated psychopharmacological studies.

In the Foreword to his book, The Anatomy of an Epidemic, Robert Whitaker explained how he first wandered into the “minefield” of psychiatry by writing in the mid 1990s about research practices such as rapidly tapering schizophrenic patients off of their antipsychotic medications and then giving them a drug to exacerbate their symptoms. This “research” was done in the name of studying the biology of psychosis. Jeffery Lieberman took part in some of those studies, using methylphenidate (Ritalin, Concerta) to deliberately provoke psychotic symptoms in schizophrenic patients. Read “Psychiatry, Diagnose Thyself! Part 2” for more information on Whitaker’s articles and Lieberman. Incidentally, the series of articles Whitaker co-wrote for the Boston Globe was a finalist for the Pulitzer Prize for Public Service. Whitaker said in the Foreword to Anatomy of an Epidemic:

I began this long intellectual journey as a believer in the conventional wisdom. I believed that psychiatric researchers were discovering drugs that helped “balance” brain chemistry. These medications were like “insulin for diabetes.” I believed that to be true because that is what I had been told by psychiatrists while writing for newspapers. But then I tumbled upon the Harvard study and the WHO findings, and that set me off on an intellectual quest that ultimately grew into this book, The Anatomy of an Epidemic.

Maybe there is a stigma against psychiatry for more than just the past use of ice pick lobotomies or insulin comas or ice baths or the electroshock treatment shown in One Flew Over the Cuckoo’s Nest. But simply changing the name of what we now call psychiatry will not change the opposition against a medical specialty that no longer treats patients’ souls. And perhaps that is really why the field is in decline.

08/12/15

A Censored Story of Psychiatry, Part 1

Doctor Jeffrey Lieberman, the Chair of Psychiatry at the Columbia University College of Physicians and Surgeons and a former president of the American Psychiatric Association (APA), recently wrote a book, Shrinks. It purports to tell the true story of how psychiatry grew from a pseudoscience into “a science-driven profession that saves lives.” But for me, it reads more like a piece of APA propaganda. What follows is an illustration of why I believe Shrinks is not a credible historical account of the history of psychiatry.

In his Introduction, Dr. Lieberman wrote: “As I write this, psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” He added that psychiatry has earned much of its “pervasive stigma.”

There’s good reason that so many people will do everything they can to avoid seeing a psychiatrist. I believe that the only way psychiatrists can demonstrate just how far we have hoisted ourselves from the murk is to first own up to our long history of missteps and share the uncensored story of how we overcame our dubious past.

He said that modern psychiatrist now possesses the tools (medications?) to lead anyone “out of a maze of mental chaos into a place of clarity, care and recovery.” He said he is fortunate to be living through the time in history when psychiatry matured from “a psychoanalytic cult of shrinks into a scientific medicine of the brain.” But in concluding his book, he said he was under no illusion that “the specters of psychiatry’s past have vanished,” or that psychiatry has “freed itself from suspicion and scorn.” Notice the implication that any current suspicion or scorn of psychiatry is illegitimate, as its missteps are in the past.

Lieberman is aware that others disagree with his sense how psychiatry has become “a scientific medicine of the brain.” Again in his Introduction, he said: “The profession to which I have dedicated my life remains the most distrusted, feared, and denigrated of all medical specialties.” He then quoted from some of the rude and abusive emails he’s received. His comment was that such skeptics don’t look to psychiatry to help solve mental health problems. Rather, they see psychiatry itself as a mental health problem. While not explicitly using the term at this point, Lieberman does seem to be referring to what he calls the “antipsychiatry” movement.

This is a term that has been applied to individuals critical of some aspect psychiatry, or even psychiatry as an institution, since the 1960s. And Lieberman touched on and dismissed many of the historically big names tied to “antipsychiatry”: Thomas Szasz, R.D. Laing, and David Rosenhan. Here, I want to look at Lieberman’s portrayal of Rosenhan and give you an alternate perspective to his to illustrate why I see Shrinks as APA propaganda.

In an aside, Lieberman seems to have neglected to mention Dr. E. F. Torrey’s 1974 contribution to the antipsychiatry movement, The Death of Psychiatry. Torrey maintained that most of the so-called mentally ill are suffering from problems in social adaptation, not from diseases of the mind. He would later become affiliated with The Stanley Medical Research Institute (SMRI), where he is now an Associate Director. SMRI has spent over $550 million researching “brain diseases” like schizophrenia and bipolar disorder since it began in 1989. It seems Torrey changed his tune. Perhaps that’s why his antipsychiatry work wasn’t mentioned. Lieberman also cited Torrey as providing anecdotal evidence (no references or footnotes) that both Laing and Szasz eventually believed that schizophrenia was a brain disease, but would not sat so publically.

In chapter three of Shrinks, Lieberman described the impact of the classic 1973 study done by David Rosenhan, “Being Sane in Insane Places.” Another copy of the article is available here on a link from Harvard University. Lieberman gave an inaccurate and unfair gloss of Rosenhan as “a little-known Stanford-trained lawyer who had recently obtained a psychology degree but lacked any clinical experience.” As a matter of fact, David Rosenhan had a BA in mathematics from Yeshiva College (1951), an MA in economics (1953) and a PhD in psychology (1958), from Columbia University—the same academic institution to which Lieberman would become affiliated in his own professional career.

In addition, Rosenhan was a psychologist for the Counseling Center at the Stevens Institute of technology from 1954 to 1956; a lecturer at Hunter College and the director of research in the Department of Psychiatry at City Hospital at Elmhurst from 1958 to 1960. He was an assistant professor for the Departments of Psychology and Sociology at Haverford College from 1960 to 1962; a lecturer for the Department of Psychology and Psychiatry at the University of Pennsylvania from 1961 to 1964; a lecturer for the Department of Psychology at Princeton University from 1964 to 1968; a professor in the Department of Psychology and Education at Swarthmore College from 1968 to 1970; and a visiting professor in the Department of Psychology at Stanford University from 1970-1971. He was a professor of law and psychiatry at Stanford from 1971. The above biographical information on David Rosenhan was taken from a February 16, 2012 article from the Stanford Law School News announcing his death at 82 years old.

This information was readily available to anyone interested enough in David Rosenhan to do a simple online search. It certainly doesn’t agree with Lieberman’s dismissal of Rosenhan’s credibility. Here’s what David Rosenhan did in his study. He had eight “pseudopatients” (individuals with no history of serious psychiatric disorders) seek admission to 12 different psychiatric hospitals. They complained of hearing voices say “empty,” “hollow,” and “thump.” They were all admitted to the various hospitals. The eight pseudopatients consisted of a psychology graduate student in his 20s, three psychologists, a pediatrician, a psychiatrist, a painter and a housewife. Rosenhan was one of the three psychologists. Three pseudopatients were women and five were men.

Once admitted to the hospital, they stopped simulating any symptoms of abnormality and waited to see how long it took before they were released. Their length of stay at the hospitals ranged from 7 to 52 days, with an average of 19 days. None of the pseudopatients were indentified as such by hospital staff members. However, it was quite common for the patients to uncover the pseudopatients. Other patients in the hospitals were reported as saying things such as: “You’re not crazy. You’re a journalist, or a professor [referring to the continual notetaking]. You’re checking up on the hospital.” Rosenhan commented: “The fact that the patients often recognized normality when staff did not raises important questions.”

Lieberman said that claim was debatable, “since many nurses did record that the pseudopatients were behaving normally.” Actually, Lieberman’s comment is itself debateable. If nursing staff recognized the pseudopatients as normal, why was the average length of stay 19 days? If nursing staff recorded impressions that particular pseudopatients were behaving normally, it seems their observations were ignored or failed to result in speedy identification and release. Seven of the eight were admitted with diagnoses of schizophrenia and their discharge diagnoses were schizophrenia “in remission.”

What Rosenhan actually said was that the pseudopatients were to secure their own release from the hospital by convincing staff that they were sane. The psychological stressors associated with hospitalization were considerable and as a result, the pseudopatients were motivated to be discharged “almost immediately after being admitted.”

They were, therefore, motivated not only to behave sanely, but to be paragons of cooperation. That their behavior was in no way disruptive is confirmed by nursing reports, which have been obtained on most of the patients. These reports uniformly indicate that the patients were “friendly,” “cooperative,” and “exhibited no abnormal indications.”

Rosenhan’s study and its opening question, “If sanity and insanity exist, how shall we know them?” remains today a powerful question of the legitimacy of psychiatric diagnosis. He noted how most mental health professionals would insist they are sympathetic toward the mentally ill. But it is more likely that “an exquisite ambivalence” characterizes their relationships with psychiatric patients. The mentally ill, said Rosenhan, are society’s current lepers. Negative attitudes are the natural offspring of the labels patients wear.

A psychiatric label has a life and influence of its own. Once the impression has been formed that the patient is schizophrenic, the expectation is that he will continue to be szhizophrenic. When a sufficient amount of time has passed, during which the patient has done nothing bizarre, he is considered to be in remission and available for discharge. But the label endures beyond discharge. . . . Such labels, conferred by mental health professionals, are as influential on the patients as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophecy.

Psychiatry had a guild interest at the time for revising psychiatric diagnosis. Citing an article by M. Wilson in their book, Psychiatry Under the Influence, Whitaker and Cosgrove noted where APA leaders felt psychiatry was under siege and worried that it could be headed for extinction.

Psychiatry in the 1970s faced a crisis of legitimacy and Rosenhan was one of its opponents who intensified the crisis. Although the publication of the DSM-III would become an answer to that crisis, Rosenhan’s study threatened to discredit psychiatry before that makeover could be accomplished—to recast psychiatry as “a science-driven profession that saves lives.” The censored history of psychiatry presented by Lieberman attempts to present “an extreme makeover” of a profession that may still be more “pseudo” than science. Whitaker and Cosgrove’s comment seems to hit the mark:

Remaking psychiatric diagnoses could be part of a larger effort by psychiatry to put forth a new image, which metaphorically speaking, would emphasize that psychiatrists were doctors, and that they treat real ‘diseases.’

05/28/14

If God Spoke to You, Would You Tell Your Psychiatrist?

As a young Christian, I remember being anxious as an agency treatment team meeting approached. A young woman I counseled reported strange things began happening to her soon after she started to read a Bible. Although her experiences seemed to have a spiritual aspect, they were also borderline delusional. And I had suggested that she read her Bible.

The thought crossed my mind to not say anything at the treatment team meeting. But I reported the woman’s experiences and my suggestion that she read her Bible. I said I did not think she was becoming psychotic, gave my opinion why, and held my breath. After a slight pause, the psychiatrist said to let him know if her condition deteriorated. The woman continued to read the Bible; the strange experiences stopped; and she eventually went to YWAM (Youth With a Mission) for a short time.

Beginning with Sigmund Freud, psychiatrists have been less religious than the general population; and sometimes even anti-religious. Freud himself was a life-long atheist and critic of religion. He said religion was a “universal obsessional neurosis.”

In 1928 Freud published a short paper entitled: “A Religious Experience.” There he psychoanalyzed an American physician who had attempted to convert him. The American doctor wrote of a time when he himself questioned whether or not God existed, and heard an internal voice say: “ I should consider the step I was about to take.” This was a religious turning point for the doctor. He said knew then that Jesus was his only hope; and that the Bible was God’s Word.

Freud wrote that he was glad the experience enabled the man to retain his faith, but that God had never allowed him to hear an inner voice. He commented that if God did not hurry, it would not be Freud’s fault if he remained “an infidel Jew.”

The American doctor wrote back that being a Jew was not an obstacle to true faith. Prayers were being “earnestly addressed” that Freud be granted faith to believe. He begged Freud to give thought to the matter of life and death. After describing this exchange in his paper, Freud said: “I am still awaiting the outcome of this intercession.”

Freud then gave an “obvious” analytical explanation of the doctor’s religious experience. “All of this is so simple and straightforward that we cannot but ask ourselves whether by understanding this case we have thrown any light at all on the psychology of conversion in general.”

By the 1970s, internal changes began in psychiatry that largely threw over the influence of psychoanalysis on the field. Research studies began to demonstrate that religion has many psychological benefits. But psychiatrists continued to be less religious than other physicians.

In 2007, a study published in the journal Psychiatric Services found that psychiatrists were less religious than other physicians. Psychiatrists were less likely to believe in God than other physicians (65% versus 77%). And they were less likely to say they looked to God for strength, support and guidance (36% versus 49%). See the original study here.

Not all psychiatrists, even those who don’t believe in God, would view an individual who said God spoke to them as delusional or psychotic. But there is a risk that what the person sees as a purely religious experience will be interpreted as a symptom of schizophrenia or a delusional disorder.

Faith Seeking Understanding

Charles Sigler, D.Phil.

Tag: Psychiatrists