Introduction
I have mentioned what I have referred to as the ‘sorcerers manual’ in previous articles. Psychiatrists know this manual as the DSM (Diagnostic and Statistical Manual of Mental Disorders). This is man’s attempt to write a manual on how to fix the brain when its ‘wheels fall off”. Or is it just a compendium of 5 digit codes associated with mental conditions that mental health professionals reference when filling out insurance forms for reimbursement. Let us discuss a little to try and understand how psychiatrists diagnose their patients using this manual, and a little experiment that uncovered a lot of significant information.
Diagnostic and Statistical Manual of Mental Disorders (DSM)
There is huge difference between diagnosing a condition and treating it successfully. For both actions to blend together to heal the afflicted, the treatment must in no way cause harm or exacerbate the condition and cause more suffering and misery. In current mental health treatment is this what is occurring ?. If this manual is worth its salt, and when referenced by psychiatrists then we should go a long way to satisfy these conditions. So why are there 3.5 million children in the US alone prescribed with mind altering drugs and some 79 million American people overall diagnosed with mental dysfunction ?. Who diagnoses these conditions and what manual do they reference ?..if they reference anything it would probably be the DSM. Most psychiatric problems contained in this manual such as Mood disorders, Feeding disorders etc, and for each disorder will be qualified with a ‘laundry list’ of criteria. For example for Major depressive disorder (MDD)will be diagnosed, if your condition correlates with at least 5 of the following 9 criteria:
- Depressed mood or irritable most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful).
- Decreased interest or pleasure in most activities, most of each day
- Significant weight change (5%) or change in appetite
- Change in sleep: Insomnia or hypersomnia
- Change in activity: Psychomotor agitation or retardation
- Fatigue or loss of energy
- Guilt/worthlessness: Feelings of worthlessness or excessive or inappropriate guilt
- Concentration: diminished ability to think or concentrate, or more indecisiveness
- Suicidality: Thoughts of death or suicide, or has suicide plan
DSM IV contains about 300 disorders categorized in its nearly 1000 pages. There was a time when around 1968, doctors in the UK were more likely to diagnose manic depression than schizophrenia. While in the US the opposite was true. Then Thomas Szasz a New York doctor ( with some sense I might add) said “enough is enough” and wrote in his `1961 book ‘The myth of Madness’ that psychiatrists were diagnosing normal problems of living for medical illness. Erving Goffman ( 1922-1982) a Canadian Sociologist ( Symbolic interaction *) who wrote about asylums, and Michel Foucault (1926-1984) a French Philosopher ( he also held a degree in Psychology) whose theories addressed the relationship between power and knowledge and their use for societal control. Foucault wrote ‘The history of madness’ in 1961, and both viewed mental illness as more sociological than medical. They went on to state that psychiatrists were pathologizing deviancy rather than uncovering real illness, that only existed where PHYSIOLOGICAL PATHOLOGY could be identified as the source of trouble. Interesting turn of phrase, in other words the source of mental illness was more physiological than anything…what did Phillippe Pinel say ?..”the primary seat of insanity is generally within the region of the stomach and intestines” as I have stated more than once in previous articles.
*Symbolic Interaction concern 3 assumptions
- Individuals construct meaning via the communication process.
- Self concept is a motivation for behavior.
- A unique relationship exists between the individual and society
and is important in Social psychology and microsociology ( everyday human social contact )
Being sane in insane places : an experiment
Establishing the experiment
A very neat experiment was conducted in 1973 by a David Rosenhan (1929-2012), an American psychologist who decided in 1973 that he would test the legitamcy and efficiency of various psychiatric hospitals as a premise of ‘ Can the sane be distinguished from the insane?’. At the time, the growing viewpoint was that psychological categorization of mental illness was useless at best, and downright harmful, misleading and pejorative at worst. Furthermore, psychiatric diagnoses were in the minds of the observer, and invalid, in terms of characteristics displayed by the observed. His experiment involved 8 ‘pseudopatients’ ( individuals who were normal with no history of mental disorder). Three women and 5 men who were psychologists ( 3), a pediatrician, a psychiatrist, a painter, housewife, and a 20 year old psychology graduate student. One of the psychologists was Rosenhan himself. The hospitals that were chosen were in 5 different states on the East/West coasts and varied in staffing; some understaffed, some had appropriate staff-patient ratios, and one was a private hospital.
Conducting the experiment
Each pseudopatient, having made an appointment, arrived at the admissions office complaining that they were hearing voices saying “empty”, “hollow”, “Thud”. They all gave details of their family ties conveying an overall message of stable and happy surroundings ( this was important since it would bias the results in favor of detecting sanity ). Once each was admitted, they ceased feigning any abnormal symptoms and acted normally, talking to staff and existing patients. When the staff asked how they were feeling, they said fine and the symptoms had gone. During their stay they complied with instructions from attendants and accepted their medication ( not specified ) but did not take it. They would all document their observations, initially, in secret, but then they realised nobody cared, so they openly updated their journals in public view, even the other patients became suspicious of their normal behaviour saying “ You’re not crazy…you’re a journalist or a professor checking up on the hospital”. What Rosenhan suggested was that the staff did notice the note taking, but thought nothing of it, since they assumed it a behavioural manifestation of his/her disturbance, maybe part of a compulsive disorder associated with schizophrenia.
Further observations
What was disconcerting was that the staff did not spot the deception, since, as Rosenhan explained after the experiment, there was little staff/patient interaction spending no more than 6 minutes/day/patient. Furthermore, it cannot be concluded that failure to recognize the pseudopatients sanity was due to them behaving abnormally because they did not, rather the conclusion drawn, was that once labelled Schizophrenic you were stuck with it, sane or not. The average ‘incarceration’ was 19 days. Physicians are more inclined to call a healthy person sick than a sick person healthy simply because they are trained to track down sickness and symptoms then concentrate on restoring health. It is better to err on the side of caution and suspect illness among the healthy, since it is more dangerous to misdiagnose illness than health which is political decision, not a scientific or medical one. Another observation was that behaviour stimulated by the environment ( situational attribution – Attribution theory Article 15) was commonly misattributed to the patients disorder. For example, in one instance, one of the pseudopatients was pacing the corridor and a nurse asked “Nervous” to which the reply was “No I’m bored”. One of pseudopatients witnessed one ‘in-mate’ going ‘berserk’ who had been mistreated by one of the attendants, and an attending nurse said nothing but to presumably assume that this outburst was part of his condition, not once asking what was wrong. One psychiatrist commented, upon seeing a group of patients sitting outside the cafeteria, that this behaviour was indicative of the oral acquisitive nature of their syndrome, ignoring the fact that there was little in the hospital to occupy them or indeed anticipate, besides eating.
The dark side of the psychiatric hospital as observed by the pseudopatients
I believe it was David Rosenhan’s original intent to simply prove that the mentally impaired were very often misdiagnosed, but once they had received a diagnosis, it was an indelible label almost like the labels that were sewn on the clothes of jewish people in pre-war Germany. This diagnostic label slewed the attitude of the psychiatric staff into thinking that all behavior displayed by the patients were dispositional attributes ( personality causing), and not due to situational attribution ( environmental causation). This had an emotional numbing effect on behalf of the staff toward the well-being of their charges ( the patients). However, what the pseudopatients witnessed during the experiment was in some cases total contempt for the patient, in a similar way the guards behaved toward the prisoners during the Stanford Prison experiment. Rosenhan’s words were “ The data I have presented do not do justice to the rich daily encounters that grew up around matters of depersonalization and avoidance”. Patients were beaten by staff just because they tried to initiate verbal contact; one example included a patient who was beaten in front of the other patients when he approached an attendant and told him “ I like you”. On several occasions beatings were administered for misdemeanors that even children would not be scolded for. Tempers were short, and any patient who did not respond to the call for medication would be excoriated, and often patients would be woken by the cry “ Come on you m*****f*****s out of bed.
No words can convey the overwhelming sense of powerlessness these patients felt when continually depersonalised in this way; the patient had no credibility, by virtue of his psychiatric label, their freedom of movement was severely restricted, they were forbidden to initiate contact with the staff, personal privacy was minimal, their rooms could be invaded and examined without reason, without permission, and their personal hygiene and waste elimination were often monitored through doorless toilets. The pseudopatients themselves felt invisible from this level of depersonalization or at least unworthy of account. On the ward, attendants would ‘dish out’ verbal and sometimes serious physical abuse. Pseudopatients would find other patients medication discarded in the toilet. So modern psychiatry ( maybe the situation has changed in psychiatric hospitals since this experiment was implemented) is not only become a pseudo pharmacological profession, prescribing poisons that cure nothing but harm many, but they are running psychiatric wards that are no better than the asylums of the 18th century during Pinel’s day. This depersonalisation witnessed during this experiment parallels the horrors of the Nazi concentration camps but without the showers and the crematory. Listen to Rosenhan talk about the experiment and his experiences on the following Utube link :
https://www.youtube.com/watch?v=j6bmZ8cVB4o
In conclusion, all pseudopatients were released from their respective psychiatric hospitals as Schizophrenics in remission.
Experiment # 2: Diagnosing the sane insane
Rosenhan decided to reverse the experiment using a research and teaching hospital who were informed of experiment # 1 and categorically said that, this deception experiment could never happen here and agreed to participate in experiment # 2. Staff were informed during the next 3 months that one or more pseudopatients would attempt admission in their hospital, and to rate each pseudopatient if they were detected. Out of the 193 patients that were admitted during those 3 months, staff identified 43 high probability pseudopatients – One psychiatrist suspected 23, another psychiatrist suspected 20. As it turned out not one pseudopatient ever set foot in the door on this hospital.
The DSM Part II
In Gary Greenburg’s brilliant book ‘ The book of Woe’ he points out that psychiatrists acknowledge ‘the absence of blood tests or brain scans or any other technology that can anchor a real diagnosis beyond symptoms’ so they rely on their own experience, what Greenburg refers to as I-know-it-when-I-see-it definition. He refers to the 1990’s as the decade of the Brain, when vast amounts of money were spent trying to get the brain to give up its secrets. A great deal of expenditure went on the acquisition of expensive MRI machines and great minds like Eric Kandel were saying that “ all mental disorders involve disorders of brain function, which Thomas Insel head of the NIMH stated that, this means that psychiatry could one day be converted into ‘clinical neuroscience’ transforming psychiatry from simply observing signs and symptoms into something more credible. This was an example of psychiatry so desperately needing to be recognised as a legitimate science based profession, like conventional medicine that diagnosed symptoms, supported by something tangible like blood tests and CT scans etc. This same craving existed toward the use of pharmaceutical drugs that can be used, just like our conventional allopathic doctor colleagues…we can then be regarded as equals…Hurrah…we now have the credibility to poison, maim and kill our patients without receiving so much as a parking ticket…lol.
DSM-5
At least there are a few in my opinion, very bright and credible psychiatrists such as Allen Francis who was also involved in the DSM compilation, when he stated in his 2013 article ‘…psychiatric diagnosis, which still relies exclusively on fallible, subjective judgements rather than objective biological tests’. He also went on to infer that due to diagnostic inflation, psychiatric diagnosis is facing a renewed crisis of confidence. This is borne out when diagnosis definitions for conditions that were no more than severe versions of everyday living such as ‘being worried, a little anxious and sad’ and blown out of context into serious mental disorders. As he states DSM-5 defines ‘grief’ into a major depressive disorder, ‘a senior moment’ gets blown up as a mild neurocognitive disorder, and a normal ‘childhood temper tantrum’ becomes disruptive mood dysregulation disorder. Even Dr Francis effectively said that this will only lead to high false-positive rates and unnecessary treatment opening the floodgates to the predatory pharmaceutical companies. The DSM-5 ( as in all previous versions ) lacks sufficient scientific support ( because it has none) and defies clinical common sense, and concludes that all medical professionals should use this unofficial manual cautiously and if you need insurance reimbursement codes they are freely available on the internet. According to Greenberg, Dr Francis’s wife was diagnosed with a brain tumor in 1988, but she was also suffering with Parkinson’s disease. Her death in 2007 was not caused by the cancer ( when diagnosed in 1988 and given 1 year to live ), but by the treatment ( not specified) that was administered to her for Parkinson’s, according to Francis himself.
Psychiatry is institutionalized scientism: it is the systematic imitation, impersonation, counterfeiting, and deception. This is the formula: every adult smokes (drinks, engages in sexual activity, etc.); hence, to prove that he is an adult, the adolescent smokes (drinks, engages in sexual activity, etc). Mutatis mutandis: every science consists of classification, control, and prediction; hence to prove psychiatry is a science, the psychiatrist classifies, controls, predicts. The result is that he classifies people as mad; that he confines them as dangerous (to themselves or others); and that he predicts people’s behavior, robbing them of their free will and hence of their very humanity.
Quote Peter Szasz
References/Acknowledgments :
- Being sane in insane places 1973 D.L Rosenhan
- The Book of Woe Gary Greenberg 2013
- The new crisis of confidence in Psychiatric diagnosis 2013 Allen Francis MD Annals of Internal Medicine
- Oppositional Deficient Disorder (ODD) WebMD
- Quotes Peter Szasz Wikiquotes