fordCecilia Ford, who has been a psychologist in private practice in New York City since 1987, has addressed emotional issues for Women’s Voices in many articles over the years. This week, she discusses new trends in the diagnosing of mental illness.

 

 

brain gearssmImage courtesy of the University of Michigan Health System.

In last week’s post, a reader wondered about the over-prescription of psychiatric drugs. An article in the May 7 issue of New Scientist described some of the controversies about drugs and other issues in “Psychiatry’s Scientific Reboot Gets Under Way.”  The author, Clare Wilson, argues that professionals have few tools when trying to diagnose mental illness; they must rely only on symptoms when trying to decide the appropriate course of treatment. She likened the situation to being faced with a patient who is short of breath but having no way to distinguish whether the symptoms are being caused by asthma, chest injury, or heart attack. Because there are “no blood tests or brain scans for mental illnesses, diagnoses are subjective and unreliable.”

For many years, the fact that diagnoses were not verifiable by underlying physical evidence was not seen as such a problem. Because of this, psychiatrists have long been seen as the poor stepchildren of the medical establishment, and in recent decades they have attempted to rehabilitate their image by relying more and more on the “medical model.” This view applies the same framework that is used to understand physical, bodily illness in an attempt to understand mental and psychological issues. Freud, though trained as a physician himself, thought that almost all mental phenomena were psychogenic in origin—all in your head, in other words. Indeed, for many years doctors also thought that many common physical ailments such as asthma were neurotic expressions of psychic conflicts.

In the 1960s, the nonmedical view got further support from books such as Thomas Szasz’s The Myth of Mental Illness.  Many argued that the way we see mental illness is as a “social construct.” A provocative experiment by one of my Stanford professors, David Rosenhan, attempted to prove this by having “sane” volunteers check into a mental hospital. Once admitted, they acted completely normal. Nurses and doctors would write in their charts things like “the patient is engaging in writing behavior,” when they were observed taking notes. In fact, his subjects/confederates had some difficulty getting themselves released in the end, and all but one received a discharge diagnosis of “schizophrenia in remission.”

The pendulum next swung far back to the other side, however, with the rise of the “biological psychiatry” movement. This was precipitated, in part, by the growing use of new drugs that gave relief to some of the most severe and painful psychiatric symptoms, such as hallucinations. The fact that the drugs worked was seen as proof that what mental patients really need most is pharmacological treatment. With these symptoms in remission, it was argued, most patients would be better treated in community mental health centers as outpatients, rather than housed in hospitals for indeterminate stays.

And so the hospitals were emptied; some were closed altogether. Unfortunately, the community centers were either not built or not run properly; compliance was poor. Little attention was paid to the “deficit symptoms” that remained even after a mental patient complied with drug treatment—social isolation and flattening of affect, for example. These factors are in large part responsible for the huge numbers of mentally ill people who today are either homeless or in prison.

A happy medium has never been found. Meanwhile, each successive edition of the profession’s DSM (Diagnostic And Statistical Manual), meant to guide doctors in diagnosing and treating patients, has become that much more “concrete” and cookbook-like in its approach. If a patient has three or more of these symptoms for two to four weeks, then he/she is diagnosed with _________(depression, bipolar illness, etc.)

Edition No. 5 of the DSL, many years in the making, was released last year, and, Wilson writes, the National Institute of Mental Health (NIMH) judged that it “has so many problems we effectively need to tear it up and start again.”

The solution? Neuroscience-based mental healthcare, according to Wilson. This is an exploding area of research, aided by the more sophisticated new techniques that have been developed in brain scanning and EEGs. “The NIMH has published a list of 23 core brain functions and their associated neural circuitry, neurotransmitters, and genes, and the behavior that goes with them. These have been subdivided into five categories:

  1. Negative systems—dealing with threat, loss, non-reward;
  2. Positive systems—motivation, reward habit;
  3. Cognitive systems—attention, perception, memory, language;
  4. Social systems—attachment, communication, perception of self and other; and
  5. Modulatory systems—arousal, circadian rhythms, sleep-wake cycles.

As you can see, this is exciting work. And drug trials are set to start soon, fueled by this new research. The promise is that diagnoses will no longer be made by lumping together groups of patients with superficially similar symptoms. Bruce Cuthbert, the program’s head, says, “Let’s not try to study each ‘disorder,’ but, rather, the neural systems themselves, and study how they became disregulated.” The scientists claim that the fact that some problems—such as as attention, memory and social communication—can be seen in illnesses as varied as depression, schizophrenia, and anxiety lends weight to the idea that “existing diagnostic labels are flawed.”

This observation also lends weight to the fact that people are complicated and unique. Diagnoses in psychiatry should not be used as ironclad , but as suggestions that ideally guide treatment. The idea that every symptom can be geared to a biological marker that can then be treated with biological fixes is potentially dangerous. Even in the treatment of medical illness, the trend to individualized, targeted care is growing. However, the trend in mental-illness treatment has been to lessen the patient’s contact with a doctor. Psychiatrists and others in the field bear a special responsibility, along with supporting better diagnostic tools and treatments, to rehabilitate the diminished humanity in this field.