In a college dorm, in a prison, in a marriage
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Christopher Lane is not a psychiatrist; he’s an English professor specializing in Victorian literature and intellectual history. But he knows as much as many psychiatric professionals do about the Diagnostic and Statistical Manual of Mental Disorders, or DSM — often described as “psychiatry’s bible.” Lane has researched the manual and the process by which new disorders are added to it. What he’s discovered has made him a critic of much of modern psychiatric theory and practice.
Six years ago Lane began to hear from his students at Northwestern University in Evanston, Illinois, that many of them were on psychiatric drugs. They would come to his office to ask for extensions on their assignments, explaining that they were suffering from anxiety or depression but were on medication for it. He had just published Hatred and Civility: The Antisocial Life in Victorian England, for which he had studied the transition from Victorian psychiatry, out of which psychoanalysis was born, to contemporary psychiatry, with its intense focus on biomedicine and pharmacology. He was already skeptical about the emergence in 1980 of dozens of new mental disorders in the DSM-III, the third edition of the manual. Among these new ailments were the curious-sounding “social phobia” and “avoidant personality disorder.” Lane wanted to know how and why those new disorders had been approved for inclusion and whether they were really bona fide illnesses.
He flew to San Francisco to speak with Mitchell Wilson, who’d written about the creation of the DSM-III years earlier, and Wilson turned over to Lane a cache of documents, including unpublished memos from the archives of the American Psychiatric Association [APA]. Obtaining the papers was itself something of a coup, as researchers had tried unsuccessfully for years to learn how the DSM was updated and transformed. Lane was dogged in seeking answers, and the APA eventually relented and gave him access to its archives.
Lane was troubled by what he found: evidence of drug-company influence, especially in the promotion of “panic disorder” by Pharmacia & Upjohn, maker of the anti-anxiety drug Xanax. He also uncovered extensive evidence of questionable research (sometimes involving just one patient), sloppy thinking, dismissal of nonmedical approaches to psychiatric problems, and a degree of inventiveness with terms and symptoms that struck him as playing fast and loose with the facts.
All of this served as the basis for Lane’s 2007 book, Shyness: How Normal Behavior Became a Sickness, in which he observes that behaviors once understood as reactions to one’s environment and upbringing are increasingly seen as innate conditions of brain chemistry, resulting from problematic levels of neurotransmitters, especially serotonin. He suggests that because of the open-ended language in the DSM and the wide range of behaviors it pathologizes, anyone who is shy, as he was as a teenager, now risks being diagnosed as mentally ill. The new disorders were “obviously music to the ears of drug companies,” he says, “insofar as they massively increased the market for their products, which the media greeted with incredible enthusiasm.”
Born in Wimbledon, England, in 1966 to a music-therapist mother and a father who worked as an antiques appraiser for auction houses, Lane spent his childhood immersed in books. After college he began traveling in Sudan, Turkey, and throughout Asia. He also did a stint teaching high-school literature in Zimbabwe. When an unexpectedly high number of his students were accepted by the University of Zimbabwe, it “kick-started me into teaching in a big way,” he says.
Lane returned to London and received his PhD in English at the age of twenty-five from the University of London. With England’s economy faltering, he immigrated to the United States and worked at the University of Wisconsin–Madison, the University of Pennsylvania, and Emory University, where he was appointed director of the interdisciplinary psychoanalytic-studies program (which is housed in the psychiatry department) on the basis of the books and articles he had published on psychoanalysis and nineteenth-century psychology. He was hired at Northwestern University in 2000 and became a full professor at the age of thirty-three.
Lane has written three other books about the Victorian era, the most recent being a study of Victorian agnosticism titled The Age of Doubt: Tracing the Roots of Our Religious Uncertainty. He is editor of the anthology The Psychoanalysis of Race and coeditor of Homosexuality and Psychoanalysis. He currently writes for the Huffington Post and has a popular blog for Psychology Today called “Side Effects.”
Cooper: Why should the average person care about the DSM?
Lane: The DSM is widely regarded as the bible of psychiatric diagnoses. Its authority extends not only to this country’s schools, prisons, court system, and health-insurance industry, where it is daily invoked, chapter and verse, but also around the world, where it is highly influential in defining mental illness. It’s currently in its fourth edition, and a fifth is due out in 2013. With each edition the number of diagnoses greatly increases, and the thresholds for meeting them are routinely lowered. The number of people who can be defined as mentally ill has grown to the point where Darrel Regier of the American Psychiatric Association says that mental disorders affect some 48 million Americans in their lifetimes. That’s one in six people. And he’s basing that judgment entirely on DSM criteria and language.
Cooper: Since the first DSM in 1952, which had 106 disorders, the number has almost tripled. Are we getting sicker, or is something else at play?
Lane: The way psychiatrists define mental illness has itself changed radically. The first two editions of the DSM focused on observable traits and behaviors in patients, which were often described as “reactions” to particular incidents or stressors. When the third edition came out in 1980, it defined virtually everything as a “disorder,” which connotes an innate, lifelong malfunctioning of the brain rather than a moment of psychological distress that might be due to a brief change in circumstances. This new method of defining mental disease has completely transformed the way mental-health professionals and the general public think about it.
Cooper: But isn’t it possible that we are in fact getting sicker?
Lane: I think it’s difficult to gauge that accurately. If you follow the APA’s line, then most definitely we’re seeing epidemic rates of social anxiety disorder and bipolar disorder, with the latter expanding by an eye-popping 4,000 percent. But how did that massive increase come about? It’s due almost entirely to the fact that the DSM-IV formalized bipolar as a mental disorder among children. Before that, bipolar disorder was understood to be exclusively an adult phenomenon. Psychiatrists like to revise everything backward, to rewrite the past in terms of their current terminology. Doing so makes their new terminology seem natural, even inevitable. There are more than a hundred more mental disorders in the DSM today than we had in 1968, including incredible new ones such as “sibling-relational problem” and even “partner-relational problem.” But I’m not convinced that the introduction of new illnesses means that more people are actually sicker.
I have extensively researched the APA archives and can attest that their judgments were often flimsy and their rationale for including new disorders questionable, based as they were on anecdotal evidence, ambiguous clinical research, and highly inconclusive trials. One of the consultants for the DSM-III, Theodore Millon, admitted to The New Yorker in 2005 that there was little systemic research; much of it, he said, was inconsistent and hodgepodge. He was an active participant on the DSM committees.
Cooper: How did you become interested in the DSM?
Lane: I’m a teacher, and I learned that many of my students were on some kind of psychiatric medication, generally prescribed but sometimes not. I wanted to know why they and their doctors felt that drugs were necessary to treat relatively mild problems that earlier generations had dealt with quite differently. I had just finished writing a book on antisocial behavior in the nineteenth century, when the culture’s judgment of such behavior shifted radically. The Romantic Movement, which dominated arts and letters in the first half of that century, often praised antisocial behavior and misanthropy in particular as a valid criticism of social vice, greed, and stupidity. The Romantics lauded the outcast as someone capable of commenting on what was wrong in society. By the end of the nineteenth century, however, the exact same behavior was held as suspect, pathological, and even criminal, in part because the values it exemplified were not conducive to social cohesion.
During my research I discovered more-recent articles describing misanthropy again as a pathological defect, with little understanding of the intellectual and psychiatric history behind such judgments. No one considers that such behaviors might be useful, even absolutely necessary, to help us recognize social problems. For example, some people taking antidepressants and antipsychotics may not experience strong emotions in reaction to public catastrophes like the BP oil spill or the war in Iraq because the drugs cause “emotional blunting,” a phenomenon that’s been widely noted and studied.
Cooper: How has the DSM changed the psychiatric profession?
Lane: What concerned me about the publication of the DSM-III in 1980 was not just the formal creation of more than eighty new mental disorders but the suggestion that behaviors previously understood as reactions to stress and events were now being reclassified as innate conditions of the brain. The speculation at the time was that all mental illness was due to chemical imbalances — problem levels of serotonin, dopamine, or norepinephrine, but principally serotonin.
When Prozac came on the market in the late eighties, it was viewed as a kind of miracle drug. A 1994 cover piece in Newsweek was subtitled “How Science Will Let You Change Your Personality with a Pill.” On the heels of the new DSM-IV that same year came a rash of articles saying we could use antidepressants to enable “personality sculpting.” It was a trendy way of thinking about self-improvement, along the lines of the sitcom Home Improvement. [Laughter.] If these foibles or quirks were holding you back, the thinking went, why wouldn’t you take an antidepressant that could shape your personality into a more optimal one?
Cooper: Peter Kramer, author of Listening to Prozac, called it “cosmetic psychopharmacology.”
Lane: Kramer was one of the people responsible for the giddy reception to the drug. There was virtually no discussion in his book of the side effects and other downsides to taking an antidepressant without a clinical diagnosis, let alone with one. I’m sure he’d dispute this, but I would consider the widespread embrace of cosmetic psychopharmacology to be largely responsible for the amount of off-label prescribing we’re seeing today — for example, when people (and it’s illegal to do this, by the way) take psychostimulants such as Adderall and Ritalin, which are forms of amphetamine, in order to promote what they consider “neuroenhancement.” We’re seeing widespread misuse of these drugs ostensibly on the grounds that they are enhancing neuroactivity, but, like all amphetamines, they create many problems too.
Cooper: Let’s say that these drugs had no notable side effects. What’s wrong with being, as Kramer says, “better than well”?
Lane: With meds, unfortunately, there is almost always a downside, even if it’s not immediately obvious. In the history of pharmacology many new drugs have been presented as the wonder cure, the remedy for everything. It takes about a decade for the long-term studies to catch up with that initial enthusiasm. The studies invariably point to not just a downside but, quite frequently, serious physiological and psychiatric risks. Selective serotonin reuptake inhibitors [SSRIs] such as Prozac are now associated with a litany of medical problems, including sexual dysfunction and increased risk of suicide. These are serious side effects for drugs that are represented as enabling people to be “better than well.” There’s enough risk of suicidal ideation that in 2004 the Food and Drug Administration [FDA] asked the drug companies to put a black-box warning on the label.
Cooper: The pharmaceutical industry funds much of the testing done for the FDA. Is there a conflict of interest there?
Lane: Yes. As key sponsors of much of the research, the drug companies help determine which drug trials will take place and how they will be conducted. Historically they haven’t funded studies that examine the downsides of their products. They are interested in positive results, even if the evidence of benefit is negligible. In 2008 The New England Journal of Medicine published a major study on the overall reporting of clinical trials for antidepressants. The study found that trials that had determined the drugs were not beneficial or had extensive side effects were often filed away and never published. Moreover, in trials that were published, the authors had sometimes manipulated ambiguous or negative data to make the drug look potentially useful when the data had shown otherwise.
Cooper: And by influencing the DSM task force, the drug companies help determine what constitutes sickness.
Lane: Indeed. In an ideal world they would have no influence on such decisions. The FDA has to be the watchdog that polices those boundaries, but in reality the FDA finds itself reliant on psychiatric experts, all of whom have multiple ties to drug companies. The only semblance of “neutrality” is that those FDA consultants are presumed to have ties to all the companies instead of just one or two. It’s an alarming situation. I believe the FDA could be doing more to reduce the drug companies’ involvement. Instead it’s tolerating greater and greater amounts of indirect influence.
Cooper: The leaders of the task force for the DSM-5 deny having any conflicts of interest. Even psychiatrist Allen Frances, who headed up the DSM-IV and has been very critical of the DSM-5, says that despite all its problems, there really isn’t a conflict of interest with pharmaceutical companies.
Lane: I respect Allen Frances, but I think he’s simply wrong there. The Washington Post provided figures showing that every single person working on schizophrenia and depression on the DSM-IV task force had ties to pharmaceutical companies. Requiring no ties whatsoever is an unrealistic proposition today, because it would exclude almost every expert. So the DSM-5 task force agreed that each member could receive a maximum ten-thousand-dollar annual honorarium from the drug companies. That strikes me as a high amount — certainly enough to impair judgment. Even the appearance of impropriety is enough to put the whole endeavor at risk.
For my book I interviewed Robert Spitzer, who’s considered the father of the modern classification of mental disorders. He made an interesting admission: He observed that none of his colleagues ever says the disorder that he or she is studying is rare. All of them, out of professional self-interest, play up its prevalence to the point where they are endlessly overstating — my word — its pathological significance and pervasiveness. There’s a great deal of hype and distortion built into the process.
There are more than a hundred more mental disorders in the DSM today than we had in 1968, including incredible new ones such as “sibling-relational problem” and even “partner-relational problem.”
There are more than a hundred more mental disorders in the DSM today than we had in 1968, including incredible new ones such as “sibling-relational problem” and even “partner-relational problem.”
Cooper: Is there any reward for being a whistle-blower and saying some people aren’t really sick?
Lane: Colleagues of mine in the medical school at Northwestern, who checked and agreed with my research, insisted that their names not appear anywhere in my book, because it could jeopardize their connections to drug companies that were funding their studies. That’s just one indication that there’s a strong disincentive to be critical of drug companies. Those who come forward with criticisms are likely doing so because they have nothing to lose professionally.
Cooper: Who is running the show: the pharmaceutical industry, the APA, or the DSM task force?
Lane: The APA is ostensibly running the show, advised by the DSM task force, but there is an inescapable, mutually beneficial relationship between psychiatrists and the drug companies. The latter’s contributions also make up a sizable percentage of the APA’s annual budget. That relationship is leading to a massive escalation in the number of disorders and an overreporting of disorders that didn’t even exist two or three decades ago. Before 1980 social phobia wasn’t listed in the DSM, and the experts I interviewed in Britain, on whose work the APA drew heavily to justify the new disorder’s inclusion, said it should never have been split off as a separate disorder. It was a form of anxiety that, at low levels, was actually seen as necessary, even beneficial. Darwin argues that a certain amount of anxiety is advantageous to survival. Under mildly stressful conditions we perform better. We react to danger more quickly and become more aware of our surroundings. I don’t want to be glib about this, because some people do suffer chronic levels of anxiety. But it’s important to recognize that not all anxiety is bad for us, and that the number of people afflicted with chronic levels is much smaller than we tend to hear — in the region of 1 percent of the general population, as distinct from studies putting that level at close to one in five Americans. The highest results came from a telephone survey of urban Canadians that asked whether they were ever afraid of figures of authority, ever felt discomfort at parties, and so on.
There have been some provocative pieces on this, including one in The Daily Beast that asks whether the subprime meltdown might have been tied to overuse of antidepressants. I originally found that argument ridiculous. The main cause was obviously the deregulation of banking policies that had been in place since the 1930s. But I think it’s possible that the widespread use of anti-anxiety medication — including on Wall Street, where huge bets were being made — may have worsened the crisis by making people too tolerant of risk. Anxiety is intimately related to how we perceive risk and react to it. If someone is medicated, he or she may not respond quickly enough to dangers.
Cooper: In your book on shyness you write, “Before you sell a drug, you have to sell the disease.”
Lane: One of the givens of pharmaceutical marketing is that you have to “create need” to expand the market. The criteria for social phobia in the DSM-III included fear of eating alone in a restaurant, avoidance of public restrooms, and fear of one’s hand trembling when writing a check. In other words, the requirements were set so low that people who experience garden-variety shyness could be swept up in the diagnosis. Fifty percent of people in any population around the world will define themselves as shy. So what the drug companies set out to do was convince people that shyness might be a symptom of something more serious called “social anxiety disorder.”
Independent agencies have since determined that in 2000 GlaxoSmithKline spent more than $92 million on direct-to-consumer advertising on a single drug, Paxil, which is more than Pfizer spent the same year on Viagra, and those Viagra ads were all over TV and magazines, and even appeared on race cars. The Paxil marketing campaign took a product that had produced spotty results in early trials — including one so riddled with side effects that the company had seriously considered shelving the drug — and turned it into a blockbuster, so called because its annual revenue surpasses $1 billion.
When they realized that they could sell Paxil not simply for depression, where it was competing with Zoloft and Prozac, but also as the first FDA-approved drug for social anxiety disorder, they went all out. They organized and funded a public-awareness campaign — “Imagine being allergic to people” — that didn’t even mention the drug but helped sell the condition. Large numbers of people went to their physicians asking for free samples, which GlaxoSmithKline, of course, made sure were abundant.
It’s important to recognize that not all anxiety is bad for us, and that the number of people afflicted with chronic levels is much smaller than we tend to hear.
It’s important to recognize that not all anxiety is bad for us, and that the number of people afflicted with chronic levels is much smaller than we tend to hear.
Cooper: Is there no difference between social anxiety disorder and shyness?
Lane: In my research I found that the percentage of people who experience acute shyness overlaps almost identically with the group the APA wants to say suffers from social anxiety disorder. So precise was that overlap that the DSM-IV added a rider saying that social anxiety disorder should not be confused with shyness — which to me is an indication that they did, in fact, pathologize shyness and were worried about the overlap. But because of the sheer number of people asking for Paxil as a result of the advertising campaign, doctors were encouraged to consider whether shyness was a symptom of something more serious.
Cooper: How can we convince pharmaceutical companies to focus on serious existing illnesses rather than helping invent questionable new ones?
Lane: One way to do that would be for Congress to prohibit direct-to-consumer advertising. If the ads were once more restricted to professional journals, drug companies would stop trying to push their products on concerned but essentially healthy people or to license drugs for new, off-label uses. Once you’ve got a drug cleared by the FDA, it’s much cheaper and easier to press for additional licenses than to develop new products.
© Lloyd Wolf
Cooper: Only the U.S. and New Zealand allow direct-to-consumer advertising. How did that happen?
Lane: In August 1997 the FDA, with the backing of the Clinton administration, relaxed what had previously been strict rules. For the first time drug companies were allowed to market directly to consumers, in effect bypassing providers and doctors and leading to a pattern of self-diagnosis, including through the use of online quizzes and such. The change was supposed to address unmet need — segments of the population that apparently didn’t know they were suffering from a treatable problem. The ad campaigns were expensive and slick, with the drugs’ side effects mentioned hurriedly at the end, and usually just nausea and headaches, unlike some of the more dramatic lists today, which will even mention risk of death. Even so, the ad campaigns were very successful, and they continue to be. In 2011 almost $11 million a day was spent on direct-to-consumer advertising.
Cooper: I’ve seen ads for Seroquel in which the devastating side effects constitute the majority of the narration. Why are so many people willing to take this drug?
Lane: The Seroquel phenomenon is interesting in itself. Right around the time that the patents on SSRI antidepressants expired, we saw a massive shift in advertising resources to anti-psychotics such as Seroquel, whose patents made them major revenue earners. Bipolar became the diagnosis of the day. So drug companies tried to bundle bipolar disorder with depression to reach both markets — even though bipolar by nature would include depression as a symptom. Of course, when the patent ends and competing versions of a drug surface on the market, the rate at which the brand-name drug is prescribed falls dramatically. President Clinton allowed a six-month extension of the patent on Prozac through the brand name Sarafem. The formerly yellow-and-green pills were recolored lilac and prescribed for premenstrual dysphoric disorder [a severe form of premenstrual syndrome], a heavily contested diagnosis. The extension yielded another $1 billion in revenue for Eli Lilly.
The moment the patents on antipsychotics end, we’ll almost certainly see a desperate effort by drug companies to find new markets for them — which means we’ll see antipsychotics prescribed for much milder disorders. For example, I unearthed a clinical trial that was testing Seroquel on people with public-speaking anxiety. Think about that: an anti-psychotic for fear of public speaking, one of the most common and widespread fears in our society. The idea they could market an anti-psychotic for a common fear is shameless, but I can easily imagine them trying.
Cooper: But how likely is it that Seroquel is actually going to be used in that way?
Lane: There are precedents for it in licenses already granted for generalized anxiety disorder on equally flimsy evidence. Of course, one-time medications such as beta blockers already exist for performance anxiety, and the list of side effects from them is relatively small. But prescribing a powerful antipsychotic for that kind of routine condition, when the drug in question comes with a litany of dangerous side effects, is flat-out wrong and unacceptable.
Cooper: So if you could take a drug for performance anxiety that had zero side effects, you wouldn’t have any problem with that?
Lane: Even if we could get to zero side effects — which is something of a medical fantasy in itself — ethical concerns would clearly surround drugs that give only an illusion of competence or excellence. In fall 2010 I wrote an article for Phi Beta Kappa magazine on the risks of using Adderall and other “neuroenhancers” for undergraduate work. Among students there seems to be a widespread myth that these drugs enhance creativity and mental performance. In fact, those outcomes are greatly overstated, and pronounced side effects are frequently associated with abuse of these drugs. Yet studies show that undergraduates are taking them in large numbers, apparently not recognizing the difference between caffeine and what is essentially a refined amphetamine. To the extent that real learning and deep efforts in creativity are being replaced by adjustments in brain chemistry — potentially involving tens of thousands of students across the country — I would consider that a risk to public health, to say nothing of a phenomenon that should raise concerns about academic integrity and cheating.
Cooper: You mentioned earlier that the DSM-IV allowed for children to be diagnosed as bipolar. What do you think of that?
Lane: First of all, I’d be leery of giving any child an antipsychotic, a class of drugs that’s considered too dangerous for seniors. They are proven to lead to muscle tics and twitches, to increase weight, to raise the risk of diabetes and hypoglycemia, and to cause strokes. We’re not just talking about nausea or mild sexual dysfunction, as with antidepressants. We’re talking about serious physiological changes in growing children. Seroquel hasn’t been formally approved for kids — and with good reason — but some doctors are prescribing the drug off label to toddlers in the mistaken belief that early intervention will nip the bipolar trait in the bud and avoid its blossoming into an adult disorder. Among large numbers of psychiatrists, however, it’s widely accepted that the rationale for early pharmaceutical intervention is a medical fallacy: there’s no proven link between a childhood trait and an adult disorder, and many behavioral issues are simply part of childhood development.
A great deal more investigation needs to be made into the causes of bipolar disorder. In Mania: A Short History of Bipolar Disorder, psychiatrist David Healy is highly skeptical of claims that bipolar is a juvenile and childhood disorder, documenting at length the controversy surrounding arguments that children with attention-deficit hyperactivity disorder should instead be classified as bipolar. As the PBS Frontline documentary “The Medicated Child” also underscores, the evidence for bipolar in children is still highly ambiguous and questionable.
I would also want to examine what is going into children’s diets, including their consumption of vast amounts of sugar and caffeinated drinks. How can those not be considered a factor in determining their behavior and ability to concentrate? We also need to consider how much time they’re spending in front of the TV and playing video games. I’m not saying there’s a simple causal relationship between such activities and behavioral problems. I’m also not saying there aren’t children who are seriously ill and need treatment. But children represent a huge market for the drug companies, and their medical problems are easily hyped. We need to remember that there are other, nonmedical remedies available and that medications can often greatly compound a problem.
Cooper: What about cognitive-behavioral therapy? It seems to have faded away.
Lane: It’s still, to my mind, a successful treatment for some patients with very specific sources of anxiety. It helps people adjust their cognitive responses to, for example, fear of elevators or spiders or flying. It’s far less effective, however, when the cause of the anxiety is less specific.
Cooper: What about talk therapy? Has it been replaced by drugs?
Lane: Among many clinicians it has been, but in the vanguard of research there’s a renewed interest in talk therapy, both in combination with medication and separate from it. In fact, psychotherapeutic work has received a bad rap. It’s far more effective than people realize, as Jonathan Shedler was able to document in American Psychologist, in his scrupulous 2010 essay “The Efficacy of Psychodynamic Psychotherapy.” Other researchers are revisiting talk therapy and finding that its results have been unfairly maligned.
Cooper: Trace levels of antidepressants have inadvertently ended up in our drinking water. This seems alarming, yet a study published in 2009 in The British Journal of Psychiatry found that low levels of naturally occurring lithium in Japanese water supplies led to fewer suicides. An accompanying editorial suggested adding lithium to drinking water intentionally. If a low dose of the stuff saves lives, why not?
Lane: [Laughter.] I think the editorial was slightly more cautious than that. Evidence of a correlation between lithium in drinking water and lower suicide rates in Japan is slim, and the original study is highly speculative. The editorial fails to ask what lithium in the drinking water could do to the vast majority of people who are not suicidal and don’t need an anti-depressant. It fails to ask the big question of whether such mass tranquilizing would be ethically acceptable, much less a net plus for the population. Obviously the researchers are talking about only trace amounts of the drug, but lithium’s side effects include severe allergic reactions, blurred vision, involuntary twitching, vomiting and persistent nausea, seizures, slurred speech, and irregular heartbeat. There’s a reason Americans’ love affair with lithium more or less ended in the seventies. SSRIs were considered a welcome replacement. That the editorial staff of The British Journal of Psychiatry didn’t even mention lithium’s side effects is very troubling. That they might presume that medicating an entire population is the way to go strikes me as completely unbalanced.
Cooper: Peter Kramer says low doses of lithium encourage cell growth in the brain, allowing for new connections among existing cells and preventing stress-induced deterioration, even helping delay the onset of dementia and depression.
Lane: I think Kramer is conveniently ignoring the possibility of unforeseen, unintended consequences. He says the price of adding lithium to the water supply is a “change in the array of temperaments within the population” and asks if that is a “bargain” we can accept. But is that really a bargain or something closer to a Faustian pact? Kramer obviously doesn’t know conclusively what those secondary effects are, including on people who neither want nor need the medication. And why should we trust his speculations, since he was so wrong about Prozac and other antidepressants? Giving lithium to the entire population is far more radical than putting fluoride in the water to enhance dental health. We’re talking about possibly irrevocable personality changes.
Consider past euphemisms for these products: “aspirin for the soul,” “happiness pills,” “peace-of-mind drug,” and “bottled well-being.” Every one of them points exclusively to the upside of tranquilization rather than suggesting that we ask what it means to have a sedated population. Do we want our citizens to be so tranquilized that they can’t anticipate risk, including in the housing and stock markets? That they’re not sensitive to the risks of declaring war on another country? I’m still astonished, as a Brit, at how acquiescent the U.S. population was about the war in Iraq and the flimsy evidence invoked in support of it. We need well-informed skeptics and dissenters; the “official” line often masks an array of half-truths.
Personally I’m drawn to periods in British and European history — the Romantic era would be one — when people were prepared not to go with the flow, instead voicing principled objections to the consensus. Of course, dissent over psychiatric medications has to be based on good science. Let’s look at the hard data on antipsychotics, including their long-term health risks, before we start prescribing them to children or for mild complaints.
Cooper: Daniel Carlat, author of Unhinged: The Trouble with Psychiatry, says that the DSM isn’t pathologizing normal behavior, because psychiatrists don’t use it that way in real life: “People who exhibit normal behavior who come into our offices rarely leave with a medication. People without a pathology are typically not even going to be seen by a psychiatrist.”
Lane: He’s not looking at the broader picture there; and, as he acknowledged more recently in The New York Review of Books, whether a psychiatrist prescribes one or another medication to a patient depends on variables such as the doctor’s mood, influence of marketing, pushy pharmaceutical reps, and so on, which aren’t scientific in the least. Large numbers of people respond to pharmaceutical advertising by opening a conversation with their doctor as to whether their symptoms constitute a pathology. At the same time, as Carlat has written, many psychiatrists schedule multiple patients per working hour, to the point where one likened his waiting room to a bus station. Yet in each case some kind of outcome for the visit is expected. Only a certain amount of information can be exchanged in a short visit, however, and I join many others in thinking that it’s an insufficient amount of time to determine whether a person will benefit from drug treatment. Finally, we know from independent monitoring agents, which record how many prescriptions are issued for each drug, that at the height of Paxil’s advertising campaign the number of Americans taking it grew by five thousand every day. You don’t reach such numbers by drawing only on the chronically ill; you reach them, as every drug marketer knows, by capturing the concerns of the “worried well.”
I’d say that if some psychiatrists are turning away patients who don’t exhibit pathology, or refusing them free samples even when the patients are bludgeoned daily by ads to request them, they are in the minority. And don’t forget that general practitioners can prescribe these medications too. In fact, a study of the effects of the FDA’s black-box warnings on SSRIs in 2007 found that, rather than giving up on medication, most physicians simply switched patients from SSRIs to antipsychotics, which, if anything, are even more dangerous.
I unearthed a clinical trial that was testing Seroquel on people with public-speaking anxiety. Think about that: an anti-psychotic for fear of public speaking, one of the most common and widespread fears in our society.
I unearthed a clinical trial that was testing Seroquel on people with public-speaking anxiety. Think about that: an anti-psychotic for fear of public speaking, one of the most common and widespread fears in our society.
Cooper: Let’s talk about some disorders that have been proposed for the DSM-5. After golfer Tiger Woods’s adultery scandal, we began to hear about “hypersexual disorder.” It’s being considered for inclusion.
Lane: A number of articles have been written that tried to attribute promiscuity or adultery in men to a brain disorder. I find this questionable for a number of reasons.
First, it’s worrying to me that a group of psychiatrists is trying to determine how much sexual activity and how many encounters we can want or fantasize about before we’re considered “mentally ill.” Again, given the embarrassing history of the DSM revisions and all the shoddy science informing them, why should we trust the APA to dictate yet another norm to us, much less accept its judgment about something so personal and intimate? People have markedly different appetites for sexual experiences. I’m uncomfortable with the idea that the APA would determine implicit guidelines, even quotas, for sexual activity, with a view to pathologizing behavior that is, in its estimation, “excessive.”
Even if you were in favor of creating such a disorder, should the parameters for young adults be the same as for retirees with, most likely, much lower sex drives? Would the standard for “excessive” sexual activity be identical for a newly formed relationship and one that’s lasted decades? Why should we see a man’s cheating on his wife with multiple women as a result of brain chemistry rather than, say, marital unhappiness or personal recklessness? Personally I think expecting lifelong fidelity to one partner may be asking too much of certain people who are ill-suited to it, or who simply don’t believe monogamy is the best way to achieve emotional and sexual happiness. That’s surely up to them, isn’t it? Yet there’s an expectation, even a kind of demand, in our culture that one person will meet all of our needs — emotional and sexual. That can happen, and it’s great when it satisfies both parties, but those choices don’t work for everyone, and an organization seeking to pathologize “excessive” sexual activity needs to recognize that. We need broader public discussion of this complex issue rather than the kind of psychiatric judgment and ritualized shaming that goes on right now for those who prefer to remain nonmonogamous. Good for them if that’s what they want.
Cooper: Another proposed disorder for DSM-5 is “post-traumatic embitterment disorder.”
Lane: Some psychiatrists want a reference in the psychiatric literature to situations in which people snap and vent their violent anger at co-workers or bosses. The research has been inconclusive. What concerns me about the proposed diagnosis is the inability to draw a conclusive line between people with regular grievances — which, let’s face it, many of us have — and that tiny percentage who snap under highly stressful conditions. In this bad economy, people who are bitter over termination of their jobs or repossession of their homes could find themselves also saddled with a mental diagnosis, adding insult to injury. You’ve lost your job and home, and you’re told that you’re mentally ill for feeling bitter about that. It’s absurd, almost grotesque.
I’m frankly quite bitter about the legacy of the Bush era, including $4 trillion wasted on a pointless, borderline-illegal war based almost entirely on trumped-up evidence. What happens if you label someone like me mentally ill for dissent? There are already diagnoses in the DSM for people who do snap. What’s different about the proposed addition is that it would pathologize people simply for experiencing extended periods of embitterment, just as another initiative by the APA would pathologize people experiencing extended periods of grief from bereavement. There’s something truly Orwellian about that. It’s new and disturbing territory, even for the APA.
Cooper: Isn’t it good sometimes that we get these new disorders on the books so people can get resources or help? Post-traumatic stress disorder [PTSD] was included in the DSM-III because of lobbying by veterans’ organizations. Without the PTSD diagnosis, many veterans would be worse off today.
Lane: You raise a couple of good points. First, war shock has been written about and analyzed for decades, and it is of course a serious psychological phenomenon. I understand entirely why veterans lobbied for its inclusion, because it’s important to formalize the mental distress caused by war. The problem that rapidly emerged, however, which both Allen Frances and Robert Spitzer have written about, is that the threshold for PTSD kept being lowered at the urging of other lobbyists who wanted the definition expanded, until the line between chronic and mild suffering became indistinguishable. This is true of many of the disorders that first appeared in the DSM-III. As recently as last year Spitzer was saying that we need to “save PTSD from itself,” because it’s become a mushy diagnosis. The good that it did has all but disappeared due to what’s called “diagnostic bracket creep” — when a category like PTSD can be applied to any form of trauma that someone undergoes, even mild trauma.
Cooper: When homosexuality was removed as a disorder from the DSM-IV, was it because of new evidence or again because of lobbying?
Lane: Both. Gay activists definitely opposed the diagnosis. Also the idea that being gay was a form of pathology relied on suspect research from the thirties, forties, and fifties that described homosexuality as a result of developmental immaturity. In fact, research has since shown otherwise. Spitzer wrote a paper attempting a compromise: he said that being gay is not a problem; the problem is if you are gay and don’t accept it. But conservative psychiatrists opposed his suggestion, so the need for compromise led to the creation of “gender dysphoric disorder,” a diagnosis that is hotly contested by transsexuals today, who say it pathologizes those who perceive themselves as differently sexed. In short the compromise has inadvertently created a fresh pathology that is now applied to anyone seeking sex-reassignment surgery. And the paradox is that people who want this surgery are forced to accept the DSM diagnosis in order to get it. They have to agree to call themselves “mentally ill” to undergo the operation, which I find completely crazy. It’s yet another indication of the DSM’s unintended consequences.
Cooper: You claim that some famous individuals, such as Emily Dickinson, Nathaniel Hawthorne, and Henry David Thoreau, would be diagnosed today as mentally ill.
Lane: Certainly I’m struck by the difference between nineteenth-century understandings of mood and the contemporary assumption that happiness is the default. This is something Barbara Ehrenreich discusses in her superb book Bright-Sided: how positive thinking and happiness have been taken as the measure for how well we’re doing in life. In the nineteenth century there wasn’t so much cultural pressure to eradicate or manage negative emotions. On the contrary, they were understood to be part of the human condition.
There is a beauty in Dickinson’s writing that comes from her working through great sadness. Her poetry represents those incredibly complicated moods in a way that I think surprises my students today.
I often teach Charlotte Brontë’s last novel, Villette, a philosophically complex and mature work. My students are astonished by the subtlety with which the novel examines states of sadness, depression, and disappointment.
Cooper: Can you think of some other people from the past who would be diagnosed with a disorder today?
Lane: I’ve been writing recently about nineteeth-century orator Robert Ingersoll, the “Great Agnostic,” who was angry about the intrusion of religious belief into civic life. Today he might easily be diagnosed with intermittent explosive disorder. Misanthropes like the poet Byron could be thought of as experiencing avoidant personality disorder and narcissistic personality disorder. In fact, every eccentric and iconoclast in the nineteenth century could easily reach the criteria for these disorders in the DSM.
I’m not suggesting that psychiatrists today should close their DSM and open their Brontë or Dickinson, but I am saying that most of them have a limited historical understanding of their field and of the emotions and behaviors they blithely pathologize. Their knowledge seems to extend back only five or ten years, and the profession’s capacity for amnesia is troubling; it endlessly updates the past by rewriting it with today’s favored terms. Psychiatry would benefit enormously from a reinvigorated discussion of emotion — including its history and effect on depression, anxiety, and sadness — in ways that are infinitely more subtle and nuanced than what we’re seeing in the psychiatric literature today.
Christopher Lane raises some legitimate concerns about tainted research by pharmaceutical companies and the misuse of some psychiatric medications. The overall picture he paints of “modern psychiatry,” however, is skewed and outdated. In addition to prescribing medications when necessary, most mental-health professionals promote exercise, sleep, nutrition, meditation, mindfulness, cognitive behavioral techniques, and many other nonpharmacological ways to encourage emotional wellness.
We need to dispel the fear of pharmaceutical treatments for psychiatric problems. What is wrong with naming and treating pathological functioning? Granted, some anxiety is adaptive, but a little shyness about making a speech is a far cry from paralyzing and debilitating social-anxiety symptoms that require professional treatment.
Like Christopher Lane, who was interviewed in your March issue [“Side Effects May Include,” by Arnie Cooper], I’ve been concerned about the “pathologizing of emotion,” the expansion of the list of diagnosable mental illnesses in each new edition of the Diagnostic and Statistical Manual of Mental Disorders, and the readiness of doctors and patients to turn to mood-enhancing pharmaceuticals. But I detect a note of dismissiveness on Lane’s part toward people’s desire to feel better emotionally.
I agree with him that complex emotions, including sadness, anger, and worry, are part of the human condition. More than fifteen years ago I happened to mention to a good friend who was also a therapist that I’d been feeling mildly depressed and didn’t know what to do about it. I found it incredibly freeing when she said to me that emotional ups and downs are a natural part of life’s rhythms, and that she’d learned to accept them to some extent rather than pathologize them and try to fix them. That bit of wisdom is a touchstone I’ve returned to many times since that day.
Yet, as the daughter of a man who was paranoid schizophrenic and committed suicide, my antennae were up from an early age for signs within myself of mental illness, including depression, anxiety, and rage. My “emotional ups and downs” seemed to span a wider range than others’: I felt unhappy much of the time, occasionally entertained suicidal fantasies, and had a problem with anger that was destructive to my romantic relationships.
Though my issues weren’t crippling — I held down a good job, maintained healthy relationships with family and friends, and hadn’t become addicted to drugs or alcohol — by the time I was in my midtwenties, I felt a need to get help. Looking for a permanent solution and wanting to avoid unpleasant side effects, I decided to commit to a path of healing that didn’t include pharmaceuticals. (I did promise my counselor that, if things got worse, I would consider an antidepressant.) I went to talk therapy, read self-help books, attended twelve-step meetings, developed a spiritual practice, and even spent thirty days in an inpatient treatment facility that rarely prescribed pharmaceuticals. Basic self-care was vital, too, including a balanced diet, regular exercise, and the occasional “news fast” when the world out there seemed too overwhelming. I felt improvement right away, but it was a slow process. I’ve experienced firsthand how brain chemistry, and therefore mood and emotional states, can be influenced by behavioral and cognitive patterns. More than twenty years later I can say that happiness — or, at least, contentment — is now my default. That was my goal, one that Lane seems to view critically. There are times, of course, when I still experience outrage over injustice, grieve deeply over loss, and worry about the problems facing our planet or my loved ones.
What if I hadn’t started feeling better after undertaking my program of recovery? Or what if I’d lacked the motivation to stick it out? Would I have considered a pharmaceutical remedy? Probably. I wasn’t content to live feeling bad most of the time. I tremendously value and appreciate the work of writers, artists, and musicians from centuries past who explored painful emotions in their art, but if they’d had access to modern psychotherapeutic tools that could have helped them feel better, including judicious use of pharmaceuticals, would I deny them that relief? No.
Reading the responses in the June 2012 Correspondence to Christopher Lane’s critique of psychiatry [“Side Effects May Include,” interview by Arnie Cooper, March 2012], I was prompted to make my own observation as a practicing psychiatrist.
It is certainly true that the Diagnostic and Statistical Manual of Mental Disorders [DSM] overpathologizes the human condition and that psychiatrists and other mental-health professionals may feel obligated to diagnose a patient with something. There is one diagnosis in the DSM, however, that is not given often enough, due to the biases of the clinicians, patients, and insurance and pharmaceutical companies. That diagnosis is alcohol abuse. Other diagnoses, such as depression, anxiety disorder, social phobia, or bipolar disorder, are often given to patients along with the message that they are abusing alcohol to “self-medicate” for their underlying condition. In my opinion the opposite is more often true: The real underlying condition is alcoholism, and the symptoms presented by the patients are largely a response to alcohol abuse — and, to a lesser extent, drug abuse.
I believe that this problem is more deeply entrenched in our society than we like to acknowledge, and it often ends up in the lap of mental-health professionals, masquerading as anything other than itself.
In your September 2012 Correspondence Kelley Blewster expresses appreciation for the works of writers, artists, and musicians from centuries past who explored painful emotions, yet she says she would not deny them modern psychotherapeutic tools that might have relieved their pain. I have a different view. I fear that “early detection” and the pathologizing of anything outside of what corporate medicine deems “normal” in our modern society could be robbing us of great future works. Perhaps some souls were meant to be tortured, mine included.
The juxtaposition of the Christopher Lane interview [“Side Effects May Include,” by Arnie Cooper, March 2012] about the pathologizing of emotions and the photo essay about our military servicemen raises the questions: Why is war still acceptable? And how can we still send our young people into battle and then so inefficiently heal their wounds afterward?
Soldiers of my father’s generation received no acknowledgement of their psychic wounds, which may have spawned emotional distance from, or abuse of, their families. If our current soldiers are so horrified by what they’ve witnessed (and perhaps have done themselves), I hesitate to imagine what problems this may create after they get home and have to deaden their emotions as a way of coping.
We need to listen to our returning soldiers and to people who slip into the growing categories of “mental disorders.” Let’s begin by asking them, “What do you need, and how can we help you get it?”
I was diagnosed with attention-deficit disorder [ADD] as a kindergartner after I knocked out some poor boy’s front teeth with my lunch box. I spent the majority of my private-school years staring at the turtle figurines in Mother Francine’s office. The truth is I preferred the quiet order of the principal’s office to the overwhelming chaos of my classroom. I remember being unable to make any sense of it.
After extended testing and therapy, my parents bravely chose not to medicate me. I switched to another, more structured private school, and when that didn’t work, they chose to homeschool me, my mom teaching me phonics on two hours of sleep after working the graveyard shift. They put me on a restricted diet, limited my TV time, and encouraged my love of horseback riding. And it worked. My mom still recalls the first time she asked me to go put my pajamas on, and I actually came back wearing them. I was seven.
I have continued to struggle because my brain makes it difficult for me to function in mainstream society. And I have found it necessary to use medication when my coping skills are trumped by deadlines and fifteen-page papers. But my parents gave me the freedom to understand how my brain works and not just how it should work.
Christopher Lane’s arguments provide much needed ballast against an increasingly narrow definition of psychological health. I do believe that some people with serious psychological disorders have their lives improved by pharmaceuticals, but I believe at least as strongly that corporate greed, clinical laziness, and the obsession with quick fixes has led psychology to paint the population with far too broad a brush.
As perhaps one of the last big frontiers of profit for the drug companies, children are especially vulnerable. Lane points to the unsettling trend of entire generations being medicated for the convenience of parents, teachers, and caregivers. I can envision a day when psychiatric drugs will be required for some children to participate in school or sports.
Are we to engineer children’s character with drugs? Whom is this really benefiting?
I am grateful to the letter writers for their thoughtful replies. The field of mental health is too vast and complex to address comprehensively in one interview. My thoughts and claims were weighted toward what’s wrong with modern psychiatry, leaving less space to discuss what its practitioners are doing that’s working — including, as Carol Knieff-Wishnek puts it, promoting “nonpharmacological ways to encourage emotional wellness.”
The DSM is indeed full of “arbitrary and imperfect” diagnoses, as Russell Elmer notes, and, thankfully, a large number of clinicians treat it only as a guide. But many unfortunately do not, and proof of that is easy to find in the broader trends, including the medication of the very young.
Last October the Centers for Disease Control and Prevention released data showing that “about one in ten Americans aged twelve and over takes antidepressant medication.” The same month, the American Academy of Pediatrics [AAP] announced that it was releasing new guidelines lowering the age at which children could be diagnosed with attention-deficit hyperactivity disorder to four years old. Diagnoses of bipolar disorder in the very young have exploded by 4,000 percent in recent years, largely from off-label prescriptions, and the new AAP guidelines, which the DSM-5 is set to endorse next spring, guarantee the diagnosis and medication of hundreds of thousands more.
On the basis of existing DSM criteria, the American Psychiatric Association [APA] already considers 48 million Americans — almost one in six — eligible for a psychiatric diagnosis at some point; and National Comorbidity surveys, also following DSM criteria to the letter, put that figure even higher, asserting that “about half” the U.S. population will receive a DSM diagnosis during their lifetime.
At the same time, to cite just one survey of overmedication, researchers at the RAND Corporation determined in 2002 that more than 70 percent of Americans are medicated for conditions for which only a fraction of them meet the DSM’s already expansive criteria. Of those who reported receiving medication for depression, “just 20 percent tested positive when screened for the disease. Fewer than 30 percent of those receiving the medication had any depressive symptoms at all.”
How has this troubling situation come to pass? While my interview focused chiefly on the wholesale expansion of the DSM, in Shyness: How Normal Behavior Became a Sickness I noted several other factors, including the massive increase in direct-to-consumer advertising and cultural expectations that pills are better than other forms of treatment. To reach such astonishing figures, however, at least some psychiatrists must be using the DSM more literally than letter writer Lindsay Bowton does.
Christopher Lane is right that the profit motive that drives the pharmaceutical and medical industries has an adverse impact on efforts to treat mental illness, but he is incorrect to condemn the DSM-IV criteria. Although the categories of illness therein are arbitrary and imperfect, they are a vast improvement over the archaic Freudian concepts that were employed for years by the psychiatric community. Psychotropic medications can have terrible side effects, but they are far better than the straitjackets and padded cells once used to prevent psychotic patients from injuring themselves.
I worry that Lane’s criticisms will only reinforce some people’s belief that “I can handle this on my own,” which is often as absurd as a diabetic patient believing he can control his elevated blood sugar through force of will.
I was forced as a minor to take antipsychotics that made me so exhausted I had to sleep ten hours every night and almost developed tardive dyskinesia — repetitive involuntary spasms and twitches.
Though I am glad to be medication-free and am determined never to have another psychiatric drug in my body, I still struggle with my old symptoms: a depression that makes me never want to leave my bed, chronic guilt and shame, a persistent sense of worthlessness, unhealthy romantic attachments, and an overwhelming belief that life is too much for me. I often debate whether I am in fact mentally ill or if my suffering is justified by all the heartbreak in the world. I am afraid that I have only two options: emotional turmoil or drug-induced stupor. There is no easy answer. But reading your March issue made me glad to be alive and not to have any medications muddling my brain.
As a psychotherapist, I have railed for years against the Diagnostic and Statistical Manual of Mental Disorders, or DSM. Many clients who come to me after being in other forms of therapy want to get off their medications, which they say make them feel less like themselves. So I love the Christopher Lane interview [“Side Effects May Include,” by Arnie Cooper, March 2012], especially Lane’s comment about the American Psychiatric Association wanting to “pathologize people simply for experiencing extended periods of grief from bereavement.” Dark emotions are part of the human condition. If we could once again accept crying as our body’s natural way to heal and let go of pain, there would be less need for medications with unwanted side effects.
As a clinical social worker, I was disappointed and insulted by some of the assumptions Christopher Lane makes. Lane seems to assume that clinicians who use the DSM have no clinical judgment to rely on when making a diagnosis, and instead haphazardly fumble through the diagnostic “bible” to figure out what ails a patient. The DSM is used as a means of classifying and organizing symptoms and disorders. Yes, the typical mental-health patient will be given a diagnosis from the book, but this is mainly for insurance-billing purposes and does not mean that a clinician necessarily sees that patient as having a fixed, innate mental disorder.
Additionally Lane seems to disregard a large portion of the criteria needed to make these diagnoses. Almost every diagnosis in the DSM requires that the symptoms cause a person distress and impairment in daily functioning. Lane’s assertion that putting hypersexual disorder in the new DSM may pathologize the nonmonogamous is absurd. No one who is not significantly distressed by their own behaviors would be diagnosed with a disorder.
By overemphasizing the power of the DSM and deemphasizing clinical expertise and judgment, Lane fails to ask more important questions: Why are general practitioners able to prescribe powerful psychotropic drugs when they have a limited understanding of psychiatric illness? Why is it not a breach in ethics for a doctor to allow a patient to suggest his or her own prescription regimen? Why, as a society, would we rather medicate our children than alter their environment? These are the problems we should be addressing. What we don’t need is more unfounded wariness of mental-health professionals.
I agree with Christopher Lane that direct-to-consumer marketing by drug companies is overly aggressive and inappropriate, but these pills can still make a huge difference. As a nurse in a detention center for adolescents, I see the relief my patients get from the depression, impulsiveness, and anger that could otherwise land them in prison, and also from the learning disabilities that make school a nightmare for them. There isn’t always time to talk endlessly.