Letters from MIA bloggers Sera Davidow and Laura Delano appear in the New York Times‘ Sunday Dialogue today, responding to Ronald Pies commentary about diagnosis and the DSM-5. A few letters from MIA readers and bloggers that the Times chose not to run appear below.
MIA readers, bloggers and others respond to Ronald Pies’ letter in the New York Times:
To the New York Times:
Dr. Pies’s letter is timely, coming just before the impending release of the Diagnostic and Statistical Manual 5 or DSM 5 in May. The new manual dangerously expands the pathological definition of behaviors once considered understandable parts of life. One of the most egregious expansions is the reclassification of grief exceeding two weeks as a depressive illness. This expansion of an illness model of life is a continuation of the medicalization of life processes and their primary treatment with medication.
Personally I am frightened by the prospect of more realms of life being described as pathological. As a person who was diagnosed with schizophrenia before becoming a psychiatrist, I can attest to the dehumanizing and discriminating effects of psychiatric diagnoses. For many years my diagnosis became my identity and was the reason I was denied life insurance, education, and hope. My recovery was promoted by psychotherapy that saw me as a person with a future not as a diagnosis. I would agree with what Dr. Pies himself wrote last year: “In my view, psychiatry needs to scrap the present diagnostic system and begin afresh, with its core ethical and clinical mission firmly in mind.”
We need to transform the world-view upon which the DSM is based. Instead of the present medical model of behavior, which reduces every manifestation of distress to a hypothetical set of chemical imbalances, we need to understand the human being who is suffering. In place of DSM’s checklist of symptoms, we need descriptions of the whole person in their world, authored as much by the person as the professional. We need to understand the subjective experience as well as the social context of distress. Such descriptions need to carry the hopes and dreams that make us human and motivated to live. We also need to value aspects of distress as attempts to solve problems and not symptoms of illness. I personally recovered when my psychiatrist invested trust in my capacity to describe and understand my world, rather than see me as a diagnostic category.
Daniel B. Fisher, MD, PhD
Commissioner, Presidential New Freedom Commission on Mental Health
The following comments are from a writer who wishes to remain anonymous because of the harm that could come back to her if she were to reveal her name. Her reaction to Dr. Pies is as follows:
‘Diagnosis?!’ I withdrew from a benzodiazepine which was to help me sleep after my mother died. I became jittery. It was benzodiazepine withdrawal syndrome. A psychiatrist gave me an antidepressant. I became agitated. I was diagnosed withAgitated Depression but it was akathisia – a drug effect of extreme torment and agitation.
More incorrect DSM-4 labels followed: Generalized Anxiety Disorder, Adjustment Disorder, Bipolar Disorder, Vegetative Depression, Psychotic Depression,Dementia, Dissociative Identity Disorder, Somatization Disorder, Paranoid Ideation. Drug effects equaled mental illnesses.
Within 8 months – 35 drugs, forcibly hospitalized for 2 ½ months, forcibly given 25 rounds of bilateral electroconvulsive therapy.
I had a ‘spontaneous recovery’ from all DSM labels when I tapered off all drugs.
My story has been widely circulated (print/electronic) as ‘An Open Letter to Doctors’ ‘You Call Yourselves Doctors’ and ‘Iatrogenic Insanity.’ Youtube: ‘The Stories of Harm that the APA Refused to Hear‘: http://www.youtube.com/watch?v=S83aAvWoJMk
Toronto, Ontario, Canada
NYT DSM Dialogue/Response:
I’ve worked in the traditional Mental Health system since the late 1970s. Starting my career in a research program called Soteria House, for “first breaks”, developed by a psychiatrist named Lauren Mosher who in the ’70s was the head of NIMH’s research unit on schizophrenia. Dr. Mosher realized that people were going through a life crisis and needed a safe place to sort through some overwhelming feelings. I became a licensed therapist in the mid 1980’s. I worked in a locked acute psychiatric hospital for 20 years. I did all the assessments on people (I was the “gatekeeper”) being brought in by law enforcement on 72 hour holds and those who came in voluntarily, in psychic distress, seeking help. In order to complete my paperwork I was required to give each person a diagnosis. I would read through the DSM attempting to match broad descriptions, labels to a human experience. They never quite captured the individual, but one could find some catch all label that might fit, close enough.
It was a challenge and sometimes just a game. When someone had a psychiatric history I would typically see 4, 5, 6 different diagnosis made by each psychiatrist both out patient and in patient who had met with the individual. Rarely did anyone have the same diagnosis.
Dr. Pies wrote: “‘Diagnosis’ means knowing the difference between one condition and another. For many patients, learning the name of their disorder may relieve years of anxious uncertainty. So long as diagnosis is carried out carefully and respectfully, it may be eminently humanizing. Indeed, diagnosis remains the gateway to psychiatry’s pre-eminent goal of relieving the patient’s suffering.”
I never once saw relief on a persons face when I told them the diagnosis they were given. This didnt bring relief from their suffering, instead it triggered deep distress and agony. I would need to walk them through the “decision tree”, attempting together to make sense of these labels, stereotypes that of course never really captured the uniqueness of each individual. Instead these labels or “diagnosis” only brought pain and suffering. I would reassure the person that these are only labels, or short cuts to communication that describe a set of symptoms, we used them to communicate with our colleagues, a shorthand, for telling their story.
Mental Health diagnosis are stigmatizing and only create more harm and pain as one struggles to find a way to come to terms with and live with the label. Alienation, the fear from others who know you are “mentally ill” is a unique reaction to these “diagnostic” terms. No one reacts with fear when someone is labeled diabetic.
Label someone Schizophrenic and there is an immediate fear reaction in our culture. Its a death sentence, the end of being “normal”. Furthermore, I would estimate that at least 75% if not more of the people who get diagnosed with a DSM label are actually misdiagnosed, this is quite evident in the stories you hear from people who manage to “survive” the psychiatric system and come forward to tell their story. Most people exhibit extreme emotional states as a result of trauma or the trials and tribulations of moving from childhood into adulthood. These people are brought to hospital for help. And they are told they have a disease and are given a nice neatly packaged diagnosis that describes all their symptoms…and medications that are linked to the diagnosis are then administered by force or coercion to take voluntarily. Without first informing the patient or explaining all the side effects and damages that the drugs will cause over years of taking them.
Now, years later people who are the lucky ones come out of the fog of their childhood trauma, stop taking the numbing medications that stop all feelings and begin to sort out their lives, and surprise! They are no longer schizophrenic or bi-polar! Then they spend years trying to undue the harm and damages of being told they are diseased, broken and must take mediations the rest of their life that they have a disability and can’t work, they often have spent years in supervised settings and never learn how to cook or shop and do the basic functions that we learn to do in adulthood.
So I must disagree with Dr. Pies, there is no applicable science in this field of mental health, no blood test that one can take to determine their “illness”. So lets stop the fallacy that the DSM is a bible that holds the truths.
But instead, lets learn to “be with” people when they are suffering and not hide behind the labels, but rather allow the intuitive compassionate ones who entered this “field” to assist in the discovery and wonderment of the vast human condition, to actually help others is to connect and be with.
Stop the labeling of people, and embrace the fact that no two human beings are alike. I celebrate our differences and learn from each connection I make.
San Cruz, CA
New York Times:
I am grateful for this invitation for public dialogue about psychiatric diagnoses as the APA moves out of its own contentious dialogue and into practice with a newly expanded set of diagnostic criteria that I fear will rob our children of their most precious right, the right to fail, to explore limits and make mistakes, to test the boundaries of their emotional capacities, not to mention our capacities as parents, caregivers and teachers. Growing up, by its very nature, can be a messy, uncertain and sometimes painful process for all involved, particularly in adolescence. This is a time-honored truth.
Growing up without labels isn’t easy. But the new DSM-5 makes labels and disability more available to ever-younger populations of “patients.” Parents and school systems, both overworked, are not only tempted, but encouraged to get diagnoses for their children to receive additional school supports. But at what cost to our children’s health, self-image and ability to develop resilience and coping skills in the face of adversity?
Diagnoses can make concrete processes that are fluid and rapidly changing (like growing up, for instance). They can create overarching identities when children should be trying on, discarding and discovering their many identities. Make no mistake. Growing up in our culture is not easy. And when violence invades our classrooms, we are demanding children grow up faster than ever before.
Well-meaning psychiatrists and general practitioners can’t easily fix our cultural and familial traumas, broken homes, one-size-fits-all underfunded school systems, or poverty, but they can prescribe diagnoses and the medications that all too often go with them. And, with the best of intentions, they often do — despite adequate research on the safety or efficacy of either labeling or medicating children under 18.
We can do better by our children than to label and medicate them. And we must. Please keep the DSMs (1 through 5) in the adult book section, and only check them out when absolutely necessary.
Parent of two school-aged children and managing director, Mother Bear CAN: Families for Mental Health, www.motherbearcan.org
New York Times:
Dr. Ronald Pies provides a compelling argument that psychiatric diagnoses are not stigmatizing, but, rather, the label is relieving to patients. More, he claims that psychiatry is much more like the other branches of medicine in which physicians diagnose based on symptom clusters and do not require the use of objective data (i.e., biomarkers) to support their diagnoses.
His argument about stigma vis-a-vis mental health diagnoses is not supported by the research. Researchers like Danny Lam, Paul Salkovskis, Hillary Warwick, John Read, and Niki Harre have consistently found a link between stigma and societies’ belief that psychiatric diagnoses are a “disease like any other.” In other words, the more we promote this unfounded notion that psychiatric diagnoses are caused by some genetic, biochemical or structural abnormality in the brain, the more likely patients will experience the effects of stigma. Conversely, when symptoms are explained psychologically, say as a function of a traumatic history, the more compassionate people feel towards those with these symptoms. An NIMH study found the same: clinicians who emphasized a psychological view of mental distress were more effective than those who viewed clients’ symptoms through a disease-model lens.
To his credit, there is limited data that support his observation of an improvement in self-perception immediately after receiving a diagnoses. However, this improvement is short-lived. Since most psychiatrists prescribe medications, many patients eventually must accept a belief of being dysfunctional, diseased, disordered or disabled in order to convince themselves of the rightness of swallowing the next pill.
After reading his piece, I imagine that Dr. Pies believes that science is about consensus–if the psychiatric community agrees that a diagnosis is valid and reliably measured, it must be right. However, science is not about consensus; it’s about the truth. Unfortunately, unlike other branches of medicine, virtually none of the DSM diagnoses can be independently verified by the presence of any biomarkers (despite repeated claims that such findings are “right around the corner”). Pseudoscience makes claims that cannot be discounted or verified. If a doctor claims that I have a broken leg, I can demonstrate through x-rays that I do not. This cannot be said about psychiatric diagnoses, claims can not be independently verified or nullified. Claims are 100% based on the subjective impression of the diagnostician. Once again, research finds that this process has proven ineffectual. Learning can only happen through the process of finding out that one is wrong, not by consistently believing that one is right.
Albeit, his article was an op-ed and not a scholarly work, but I become nervous when professionals tout opinion as scientific fact. Within the mental health field, there is no evidence that years of experience and credentials contribute to effectiveness. In fact, psychiatry is no more effective today in curing and preventing “diseases” than 50 years ago. (Some data seems to suggest that patients are worse off.) More, I am chagrined that he is unwilling to consider that the suppositions of biological psychiatry may, in fact, iatrogenically contribute to the very concerns he observes.
Thomas L. Murray, Jr., PhD, LMFT, LPC-S
Director, Counseling & Testing Services (IACS Accredited), UNCSA
Clinical Assistant Professor, Department of Psychiatry and
Behavioral Medicine, Wake Forest University