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.
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 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.
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.
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.
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.
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.
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.
Christopher Lane responds:
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.