Madness and Civilization?

Perhaps very many of us are on the verge of a dangerous psychotic breakdown, only we don’t know it yet.  Perhaps we do need psychiatrists on the streets of our cities to stop us before we schiz out all over our co-workers and fellow commuters, to recruit us into their offices where they will have license to feed us mind-numbing antipsychotic medication.  Otherwise, how could we ever be secure in our own sanity?

In essence, this is the proposal under consideration for inclusion in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which will become the authoritative text of mental health in May 2013.

The definitions of madness are constantly changing.  But for psychiatry to call itself a science, it must rely on an authority that represents an official consensus that allows doctors to share a common language about mental illness, and that allows them to diagnose disorders. This is the DSM–the most recent version of it is the DSM-IV, released in 1994, which will be replaced by the DSM-5. (Among many other bad decisions they are making is the decision to drop the roman numerals just as they were getting to a good one.)

Changes in the DSM will not necessarily change the daily practice of good, independent psychiatrists and psychologists, but they will affect the way the field as a whole operates. This is why it is essential to understand the DSM in a broad public health context, not only in the context of individual cases.

This was the source of my objections as I read an article from the December 2010 issue of Harper’s, “Which Way Madness Lies” by Rachel Aviv.  (Thanks to Harper’s interesting ideas about the internet, I can’t link to the article here).

While it is wonderful to see such good writing appear in the venerable magazine on the eve of its own identity crisis, the article sparked some productive disagreements that ought to be made public. I’m a layperson, an interested citizen not trained in the psych arts. This is an important because psychiatry is deeply invested in its status as a science and discourages non-credentialed opinions, even though—especially as pharmaceuticals are ascendant in the field—matters of professional consensus in the field constitute, in my mind, a in important public health issue.

The article is primarily concerned with the phenomenon of prodromal schizophrenia (also called premorbid schizophrenia/psychosis, psychosis risk syndrome; the number of names alone for the diagnosis should send up red flags)–the condition considered to precede schizophrenia, when the mind might or might not lose its grip on itself.  Candidates for the diagnosis might have mild delusions or might, as Aviv’s extremely self-aware case studies do, consider themselves to be losing their grip on reality (a state that seems to imply a firm pre-existing understanding of reality). Or, they might not.

Any individual ought to have the right to ask for and receive help in dealing with their psychological state; there can be no question that the individuals that Aviv interviews should receive care and treatment, especially because they are self aware enough to identify as prodromal.  Their experience is valid, their treatment choices are valid.  Despite what one might assume from reading the article, their treatment is not threatened by the lack of an officially recognized diagnosis.

Their individual treatment should not cloud the more important question of whether a prepsychotic diagnosis should be included in the upcoming revision of the DSM.  Such a proposal has been made—for a new diagnosis of “psychosis risk syndrome” that would include symptoms of

“feeling perplexed, confused, or strange, thinking that the self, the world and time has changed (often in ways that cannot be described), having ideas of reference that are not perceived as directly threatening to the individual, unusual ideas (about the body, guilt, nihilism), overvalued beliefs (about philosophy, religion, magic)…”

If you didn’t identify with at least one of those symptoms at one point in your personal development, then you might not be a very interesting person. As a person with creative leanings, I think it’s utterly crucial to once and a while question or even discard my relationship to reality.   Moreover, the diagnosis assumes that there is an authority—presumably the doctor, or even the editorial board of the DSM-5—who has the correct opinions of what “unusual ideas” or “overvalued beliefs” are.  There is no room for subjectivity in the psych universe.

Aviv does a good job of questioning the condition, but she ends up concluding that premorbid psychosis should be a widely accepted diagnosis, because “doctors [have] no means of finding and recruiting patients who were, for all intents and purposes, still healthy.”  I question whether doctors ought to go out and “recruit” fully healthy patients.  That seems, at minimum, a strange thing to do.  Then, later, she says,

Although the psychiatric literature describes a premorbid personality common to those who later develop schizophrenia—withdrawn, self-conscious, alienated—few of the patients I spoke with at [either of the clinics where the author interviewed patients] fit that description. The only commonalities were that nearly all of them had moved through childhood and adolescence feeling more thoughtful, intelligent, or probing than their family or peers and that there had been an existential tinge to their preoccupations years before their symptoms emerged.

It is not heartening to read that the psychiatric literature is incorrect.  But to read her description, we are all prodromal, If you weren’t a jock in high school, you might be psychotic.  If you’ve ever developed an interest in philosophy, you might be psychotic. If you watched Daria as a kid, you might be psychotic.  If you’ve read Nietzsche, you might be psychotic. Etcetera.

All of which describes me, so I am frightened at the prospect of having “unusual ideas” be considered a disease, an officially diagnosable pathology, with all the undeniable stigma that carries.

Aviv cites Dr. Allen Francis, who is the leading critic of the DSM-5. He was the chair of the task force that created the DSM-IV, and is a very respectable member of the psychiatry mainstream.  His article in The Psychiatric Times is essential reading.  Aviv ignores Dr. Frances’ main complaint, which procedural:

DSM-V has had an inexplicably closed and secretive process. Communication to and from the field has been highly restricted. Indeed, even the very slight recent increase in openness about DSM-V was forced on to an unwilling leadership only after a series of embarrassing articles appeared in the public press. It is completely ludicrous that the DSM-V work group members had to sign confidentiality agreements that prevent the kind of free discussion that brings to light otherwise hidden problems. DSM-V has also chosen to have relatively few and highly select advisors.

Although Aviv does cite Dr. Francis and a few other dissenting voices, she misses this main point, and overall her article leans powerfully toward the inclusion of premorbid diagnoses in the DSM. Especially practitioners in the fields of psychiatry and psychology should be worried about this methodology of the DSM, which could seriously hurt the credibility of their field.  This secretive process gives pharmaceutical companies and managed care providers more latitude to maneuver as they exert their influence to increase their profits.

This would be less frightening if it were not for the looming threat of pharmaceutical companies, who have demonstrated again and again their eagerness to get citizens their prescriptions. Psychiatry is increasingly an arm of the pharmaceutical industry, as has been documented by ProPublica.  Citizens like myself have plenty of anecdotal evidence that shows the pharma industry’s eagerness to prescribe and overprescribe its product, from Ritalin to antidepressants.

Widespread diagnoses of psychosis risk syndrome could lead to a similar epidemic of Atypical Antipsychotic prescriptions. Antipsychotic drugs are particularly serious and frightening substances.

They cause major, spectacular weight gain—which is never positive for patients who may already be dealing with a crisis in their understanding of themselves and their bodies. Moreover, these drugs utterly silence creativity.  They turn off the artistic impulse.  Many of these people who were “thoughtful, intelligent, probing” and who entertained ontological questions in their youth may identify themselves as artists.  Often, the pride of being an artist can be an anchor for the whole personality to hang on to. Moreover, their artistic output is valuable for society.

If we are taking a public health perspective—as we should—then we have to consider the effects of mass antipsychotic medication on our culture.  It will stifle our collective creativity.  Consider your favorite artists and writers.  And then ask yourself if they manifested the above symptoms for premorbid psychosis.  Consider, even: would they personally have benefited from treatment that would have allowed them to hold down steady jobs and be citizens?  Often, yes.  But at the sacrifice of their artistic output, which is often the product of intense personal struggle and sacrifice, but which we—the reading public—benefit from.  Perhaps Morrison, Joplin, Pollack, Sartre, Salinger, Pynchon, Plath, Dickenson, Burroughs, Baraka, and so on could have been better adjusted as individuals, could have been numbed to the point of being able to hold down a menial job.  But would we have been better off as a culture without their work?

Likewise, consider the (political) power that such broadly inclusive diagnoses would give the psychiatric industry (which is increasingly an arm of the pharmaceutical industry) to decide which ideas are “unusual” and to suppress them—not through the judicial system (which, as Foucault would demonstrate, is always complicit), but through the medical establishment.  This could usher in an age when dissent itself is a disease.  Huxley was never wrong.

In my next post, I want to consider the “paradigm shift” towards neurobiological diagnosis that the DSM 5 is attempting.


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