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April 08th 2017 print

Robert M. Kaplan

Current Psychiatry and its Discontents

For those who care deeply about the profession and its goal to treat genuinely debilitating conditions, the state of the profession is cause for deep dismay. Needed is nothing less than a thorough review of the framework in which psychiatry operates, plus a clear plan for its future

shrink couchPsychiatry, it must be said, is at an all-time low, the culmination of a steady slide since the Eighties. Its practitioners have little to be excited about, and that hardly does much for patients. If we look back on history – something about which psychiatry is notoriously lax – the closest analogy would be the Thirties, when there were a number of biological treatments but, in truth, they were hardly successful cures (ECT was a notable exception). Cynicism ruled supreme until the Fifties, when a golden age of psychopharmacology started.

Several issues can be indicted for the current desuetude. The first is the Diagnostic & Statistical Manual of the American Psychiatric Association (DSM) which, in the eyes of some critics, has become the Mein Kampf of the discipline. Started, like so many things that go wrong, with the best of intentions, it has given the world an American-based classification of ‘disorders’ (no one is allowed to have a disease or illness now) derived from in-house committees subject to intense political, social and personality processes. The result has not been pretty.

Conditions that were determined by 150 years of careful psychiatric observation have been put through a bureaucratic grinder that killed off paraphrenia and Asperger’s syndrome, seriously messed up depression and inflicted such etymological nightmares as Late Luteal Phase Dysphoria Disorder (aka premenstrual syndrome). By putting everything in a neat pocket manual and providing a tick-box list for every disorder, the DSM made instant diagnosis a reality for professionals, if not the less skilled who wanted to get in on the mental health business. So much for the lengthy and careful psychiatric examination! Add to all this the appetite of a voracious legal profession for new “conditions” that might provide pretexts to sue and, with one thing and another, we are where we are today.

Then there are the drugs. It seems, a new product is launched on the market every day, judging by the journal ads, the glossy flyers in the mail and the bevvies of pert and perky sales reps who come calling with their latest brochures. The problem is that the new drugs are all variations on a theme. Antidepressants, antipsychotics and sedatives have not changed for decades; the only real difference is in the side effects.

A particularly egregious practice is the use of the so-called “atypical antipsychotics” as a kind of psychiatric penicillin. They are prescribed now for just about any disorder, regardless what other drugs are used. Their effect is to produce an emotional flattening. This can be considered something of an improvement, but hardly a cure. Add to this the most spectacular side effect is weight gain, turning skeletal figures into Michelin men and women in a few weeks. Journals are full of articles about the metabolic syndrome produced by these drugs.

It cannot be said that the public image of psychiatry is in the ascent. The disclosure that some prominent researchers have their hands deeply in the drug companies’ pockets is less than a good look. Add to this that psychiatry’s mandate – its exclusive control of the designated illnesses – is fragmenting to an unprecedented degree. There have always been turf wars with neurology and psychology, but they were but kindergarten squabbles compared with the present situation. Witness the disparate agencies which have not just a foot, but an arm and a leg, in invading (and, in the process, facilitating) the raging epidemics of autism and attention deficit/hyperactivity disorder ADHD (another user-friendly acronym that says as much as its hides). The best example is the widespread use of stimulant drugs to control behaviour in children. Add to that all the adult cases and you get some idea of the mess. Future generations will not thank us for this unwanted legacy.

More surprising is the passivity with which the profession deals with the situation. There is a good deal of posturing, leavened with oily dollops of political correctness, from the official bodies. Any steps to kick in on problems — notably rampant over-diagnosis of certain conditions and misuse of drugs — are timid and ineffective. All to often, when psychiatrists present in the media, it is all too clear they are pushing an ideological barrow, rather than representing the profession as a whole. A recent example: witness those rushing to pin diagnoses on Donald Trump in clear contravention of the Goldwater Rule (it is unethical for psychiatrists to make diagnoses of public figures).

And if the profession is deeply dispirited, there is the lot of patients to consider. The old, patronising doctor-patient relationship has gone out the door. Patients are now consumers, demanding the same service they would get from, say, their mobile phone providers. Heaven forbid, though, that they should get back from their psychiatrists the treatment the telcos give to their clients. The empowered consumers, using the internet and social media, band together against what they regard as an oppressive and remote agency, namely their doctors. Nowhere is this better seen than the festering, if not venomous, public debate over chronic fatigue syndrome (CSF). Despite decades of research, the cause of CSF remains unknown; no one has been able to prove that it is viral, the totemic belief of the CSF lobby.

And “lobby” is the right word, the tendentious result of patients devolving into that sociological buzz word: consumers with all the rights and expectations of supermarket customers selecting what they regard as the best washing powders. Psychiatrists are often regarded as the enemy for refusing unequivocally to accept that they have a purely physical illness and nothing else. This is, of course, Cartesian dualism gone mad. CSF consists of three overlapping clusters of musculo-skeletal, sleep and psychiatric symptoms. It is quite appropriate to treat all three clusters to provide relief to sufferers. This is not acceptable to the CSF lobby, however, whose vehemence towards psychiatry is approaching something akin to “illness terrorism”. Take a look at some of the threats being expressed on some websites devoted to and populated by CSF sufferers. The likelihood of such vehemence being translated into physical assault, perhaps even murder, cannot be excluded. So disruptive, if not dangerous are these threats that Sir Simon Wessely, president of the Royal College of Psychiatrists, has announced his withdrawal from research in the field.

Another example of the atavistic idea of illness as a sacred entity in contradiction to the observed clinical facts is Morgellon’s Disease. A certain Maria Leitao insisted that her child’s skin lesions were the result of parasitic infection, despite dozen’s of medical opinions that there was nothing to her suspicions – a case of delusional parasitosis a deux. She became convinced that it was an illness recognised as far back as the 16th century. Thus was born Morgellon’s Disease with a pullulating support group pushing the US Congress for funding, fronted by the inevitable celebrity figure  – in this case, no less than charming chanteuse Joni Mitchell.

The problem is not just the social and cultural vectors convincing people they have this particular infection, but in sorting out the actual cases from the merely convinced. All illnesses, by definition, are social concepts. In the Middle Ages, denying the existence of God meant that you were mad or a witch; either claim was likely to have the same incendiary ending. In the Soviet Union if you denied that communism worked, you would be hospitalised with “sluggish schizophrenia”, a condition unique to the Soviet Union.

Nothing sums up the problem more than the epidemic of post-traumatic stress disorder (PTSD), the most enticing acronym of them all). Or should that be “pseudo-epidemic”? The condition goes back to the beginning of recorded time: the biblical King Saul, the berserker psychosis to which Vikings were prone and, more recently, World War One’s shell shock. In 1980 the US Vietnam Veterans Association, through intense lobbying, persuaded DSM to give it the current moniker and, in the process, a user-friendly acronym.

A state previously found in survivors of battle, concentration camps or life-threatening accidents has become the gold standard for the victim culture, rapidly becoming the commonest condition in compensation claims. Demonstrating the principles of free market economics, bracket creep is at work. PTSD can now be said to arise in someone having an argument at work. It can be occasioned by watching footage of terrorist attacks  or, vicariously, from treating patients with PTSD!

And on it goes.

There are some chinks of light in the ever-deepening gloom. Some new drugs, such as ketamine, have genuine potential as antidepressants. The hallucinogens may revolutionise the management of obsessive-compulsive disorder and traumatic anxiety, if not alcoholism and drug abuse. Transcranial magnetic stimulation (TMS) is becoming a useful alternative to ECT. Vagus nerve stimulators may allow chronic depressives to come off medication. Perhaps the most notable change is the use of cognitive behaviour therapy for psychotic delusions, something unthinkable a few decades ago. And after nearly a century of near-death, catatonia has been recognised for the pervasive and treatable condition it is.

To those who care deeply about the profession and its history over 150 years of stubborn persistence to classify and treat some of the most debilitating conditions known, for all the difficulties, missteps and mistakes en route – it is deeply dismaying, if not depressing. What is needed is nothing less than a thorough review of the framework in which psychiatry operates and a clear plan for the future.

But don’t hold your breath that this is going to happen anytime soon.

Robert M Kaplan is a forensic psychiatrist and historian of psychiatry. He has written biographies of the Melbourne psychiatrist Reg Ellery and New Zealand psychiatrist Mary Barkas

Comments [10]

  1. Ian MacDougall says:

    Very informative. Well done, Dr Kaplan.

  2. Michael Galak says:

    Let’s face it – if the distinguished practitioner of the art of Psychiatry (I intentionally call Psychiatry an art, because this subdivision of medicine is still far from the science as yet) decided to pen an open letter about his specialty’s impediments – the specialty is indeed in trouble.
    Dr Caplan is, I believe, intentionally silent about quite a few problems, plaguing the discipline, especially its public part.
    The , sometimes desperate, shortage of beds, continuous intransigence of the nursing personnel and the simmering conflict between the nurses and the doctors in public hospitals, a disaster, which is called a de-institutionalisation of psychiatric patients, the harm minimisation strategy , which regards the use of illicit drugs as a legitimate life choice – the list goes on and on. Each one of these problems deserves an article of its own.
    However, I , for one, appreciate the ‘soul scream’ from Dr.Kaplan and applaud his decision to go public. I am certain – it was not easy. Thank you, Doctor.

  3. whitelaughter says:

    “In the Middle Ages, denying the existence of God meant that you were mad or a witch; either claim was likely to have the same incendiary ending.”
    Name one example *before* the renaissance(which was a far more intolerant era than any part of the Middle Ages). If you’re prepared to spout such blatantly daft comments, it’s hard to take anything else you say seriously.

  4. Jody says:

    There are yet more disturbing consequences which arise from this article and which are the basis of the public’s perception of psychiatry. The most significant of these is the fact that ‘reports’ from psychiatrists are often used as the basis for downgraded sentencing or even acquittal in the criminal jurisdiction – not to mention being used by the parole board to unleash criminals into the community. This has always been a point of angry skepticism by me.

    Secondly, the medicalization of ‘difference’ has been responsible for the explosion in drug therapies for people who may not be mentally ill or emotionally disturbed at all. The drug companies have worked in tandem with psychiatrists and other practitioners to render endemic. this extremely dubious practice. Off with their heads!!

  5. Macspee says:

    Quote. For centuries people were burned at the stake, stretched to death or otherwise tortured for failing to be Roman Catholic. But, if research released by the Vatican is right, the Inquisition was not as bad as one might think.[Thank goodness girl that!]
    According to the documents from Vatican archives relating to the trials of Jews, Muslims, Cathars, witches, scientists and other non-Catholics in Europe between the 13th and the 19th centuries, the number actually killed or tortured into confession during the Inquisition was far fewer than previously thought. Unquote. https://www.theguardian.com/world/2004/jun/16/artsandhumanities.internationaleducationnews
    How much easier would their job have been had they access to the wonder drugs of modern psychiatry.

  6. LBLoveday says:

    Not sure if Idiopathic Hypersomnia (characterized by excessive daytime sleepiness) can be considered a psychological problem, but it seems to me that the drug Modafinil (used by the French Foreign Legion to help the troops “soldier on”) is a “drug of modern psychiatry”.
    At 20 my daughter had consultations, tests, more consultations, including with a professor who, she tells me, laughed when she told him what I said, (all free she though, as Medicare picked up the tab) and ended up being prescribed Modafinil, presumably for life.
    Anyone with me in suggesting the first step should have been to see what happened if she had stopped taking the iPhone to bed and being on “social media” until 2 or 3 am?
    I pay for the internet and can, and did, track the hourly usage, and heavy usage until 2-3am was the norm (at least 5, sometimes 7 days a week), not an occasional aberration. She was a full-time uni student, part-time waitress, not a shiftworker knocking off at 11pm. I put that to the GP by email, but was fobbed off with psychobabble.

  7. padraic says:

    Congratulations to Dr Kaplan for identifying this important issue and bringing it out in the open. I agree with Jody about lawyers misusing “mental health” as a means of excusing the most heinous crimes as well as agreeing with the author about the suing of doctors and showing that the development of new psychiatric conditions leads to more litigation. This new industry has led to significant increases in the cost of profesional indemnity insurance to such a degreee that in some specialties such as obstetrics doctors are leaving for less litigious areas of medicine and younger doctors are less inclined to pursue a career as an obstetrician. This is compounded by the problem, as pointed out by Dr Kaplan, that patients are getting information from dr internet. This is a real issue in obstetrics where some patients advise their obstetrician how they want their pregnancy to be managed.

    Suddenly we are discovering conditions such as ADHD which have been unknown to mankind previously. The official symptoms for this condition look like what used to be considered to be the usual and normal elements of developmental behaviour in children. The stimulant dexamphetamine used to “treat” this new condition has been shown to be a factor in the development of cardiomyopathy in adult chronic users of this drug. This may have implications down the track for children now taking it. The author’s comments about chronic fatigue syndrome and it’s activists groups are well founded. No one is sure what causes CSF. One plausible theory is that it is caused by the ingestion of organophosphate pesticides in foodstuffs imported from countries where their use in treating pests in agriculture and animal husbandry is not well regulated. Some years back I was at a conference in one such country where a senior government health official advised conference participants not to eat potatoes during their stay because they contained unsafe residue levels of organochlorines used to treat the soil.

    Also pertinent to the discussion was the comment by Michael Galak about the “harm minimisation strategy which regards the use of illicit drugs as a legitimate life choice “. Use and abuse of harmful drugs has become a political correct sacred cow and renamed “mental health “. These drugs are often the cause of mental health issues but the media and politicians and others are in denial. The harm minimisation industry consists of well funded activist groups who pressure legislators to make harmful drugs mainstream so as normal items of trade they can be sold, for the financial benefit of those promoting this obscenity. The drug abusers they support will never admit there is a health probslem from using illicit drugs. If a problem occurs it is put down to their grandmother or their ductless glands – never the drug. A classic example of this was in an article in Saturday’s Australian which discussed the psychotic behaviour of Van Gogh and its possible causes. To my knowledge the generally accepted reason was he was a heavy drinker of absinthe which was the boisson of choice among many artists at the time and is known to cause serious and permanent damage to the brain resulting in a psychosis. However, in the article various, more PC reasons were put forward e.g. 1. “A big city like Paris drove him out of his mind”. 2. “alcohol abuse” and 3. because he was “a failed Protestant preacher who onace set up house with a prostitute”. These reasons were suggested by a museum curator, so they must be right. I’ts this kind of non-scientific PC guff that is helping our civilisation to go down the gurgler.

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