Dr. Greenwood tapped his fingers on the counter three times before stopping and crossing his arms. The nurse looked at him and smiled. “Nervous about your first shift in the ER?” Dr. Greenwood nodded and smiled slightly. The nurse chuckled and said, “I’ve been doing this for 17 years, and we haven’t lost a new doctor on the first day of residency.” Dr. Greenwood did not have to respond to this old joke, as the doors swung open and ambulance attendants pushed a stretcher through. He walked over briskly and met Dr. Diastam at the stretcher. She was the senior physician on duty that night.
Dr. Diastam asked, “What do you see?” Dr. Greenwood responded, “Patient is breathing and conscious. Temperature is high, pupils are dilated, and pulse is rapid.” Dr. Diastam nodded, and said, “Sounds like Fedilrap syndrome to me.” Dr. Greenwood looked puzzled as he had never heard the term before. The senior doctor explained “Fever, dilation, rapid heartbeat syndrome. Get ice packs around the patient to bring that temperature down. Give IV morphine to reduce the dilation of the eyes. Give beta-blockers to slow that pulse.”
Dr. Greenwood stared at Dr. Diastam and swallowed. She had not asked about the patient’s history at all. She had no idea what the patient was doing an hour before they were put on a stretcher. No lab tests were run, no X-rays were completed, nothing. Dr. Diastam had also made up a syndrome, based on some symptoms. The intervention was just as weird. The patient was feverish, and she wanted ice-packs tossed on the stretcher to cool the patient down? How would that cure the patient?
Challenging the senior physician on the first day of residency is not a good career move. Yet he blurted out, “Shouldn’t we find out why the patient is sick?” Dr. Diastam looked puzzled. Dr. Greenwood continued, “We are just reducing this patient’s symptoms of fever and rapid heartbeat for a while. But we do not know why they are sick in the first place. We know nothing of their history. We don’t know if this is caused by malaria, or a drug overdose, or something else.” Dr. Diastam gave him a stern look. “Listen” she snapped, “around here we don’t waste our time looking for why people are sick. We focus on that they are sick, and we address the symptoms.”
You have watched enough episodes of “House” and “Grey’s Anatomy” to conclude that this scenario is absurd, that it never could happen. But you would be wrong. Life is not like TV. Sure, you have spent hours watching Dr. Gregory House ask questions, order lab tests, and pore through medical books to find the cause of the problem. After several missed tries, the doctor’s diagnostic brilliance shines through a crack in his spiky, scabrous personality, and he announces the obscure, correct reason why the patient is really sick. He discovers the cause, the right treatment is given, and the patient makes a nice recovery.
You may have even been in a hospital and experienced something similar. The physician comes in, asks about your history, runs tests, and then explains why you are ill. They tell you that because you were in Kenya recently, you were infected with a parasitic flatworm, and they found the eggs in your stool. They give you a pill to swallow, and you are treated. You now believe that any medical professional follows the same process. Ask about history. Gather data to check. Find out why you are sick. Once the cause is discovered, then move to treatment.
Who Is the Real Dr. Diastam?
If only our beliefs matched reality. Dr. Diastam is not a fantasy, but the embodiment of an entire branch of medicine, that of psychiatry. Consider the Diagnostic and Statistical Manual of Mental Disorders (DSM). It was created by the American Psychiatric Association, and version 5 came out in 2013. It is the definitive statement of how modern psychiatry should conceptualize the people it interacts with, and how to think about their emotional pain, odd thoughts, and experiences.
The astonishing fact about the DSM is that the clinician who follows it is under no particular obligation to ask the person about their history. For example, they do not have to ask the interviewee whether or not they ever were sexually abused. The clinician can ignore this very troublesome topic. They will never be charged with malpractice if they turn a blind eye to the question of whether the person sobbing in front of them was severely neglected in childhood.
Instead of considering the life story of the person, the DSM only obligates the clinician to ask about recent emotions or behaviors. How often have you felt tearful in the last two weeks? Do you harm yourself through cutting or burning? The manual then clusters those symptoms into a group and attaches a label to them. Adjustment disorder, bipolar disorder, these are the words that are written in the person’s file. The backstory, the real reason why the person has cried 11 of the last 14 days, need not be noted, according to the DSM. Just record if they have this symptom or not. Clump the symptoms together and if they have two of five, then give them this diagnosis. If not, give them another.
This ignoring of history, this indifference to the cause of the person’s severe difficulties, is the opposite approach taken by the rest of medicine. Oncologists hunt for causes and study cancer cells under microscopes. They analyze genetic mutations. Findings are discussed and presented at conferences, and diagnostic criteria are changed accordingly. The difference between breast cancers with BCRA1 and BCRA2 mutations are noted, and intervention plans are changed, depending on which mutation is present.
Why Is a Person’s History Ignored?
A question may be forming at the back of your mind. Wait a minute, isn’t this what psychiatrists do, too? Are they not looking for the genes for depression or anorexia? You may remember reading a news story about the topic. Surely, they are seeking out all the causes for mental health issues and revising the diagnosis as the research comes in? The answer, like a Zen koan, is both yes and no.
Yes, psychiatrists earnestly seek the genetic basis for anorexia and depression and a whole host of other maladies. Blood is analyzed, and SPECT scans are carried out on people’s brains. Dozens of billions of dollars have been spent by the National Institutes of Mental Health (NIMH) and research labs around the world. Psychiatry is gripped with the concept that people cry uncontrollably at times or refuse to eat even when they are dangerously skinny because they suffer from a biological disorder.
The former head of the NIMH, Dr. Thomas Insel, proclaimed that “Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion or behavior.”1 This motif is repeated when the NIMH instructs us that, “Eating disorders are not a lifestyle choice. They are biologically-influenced medical illnesses.”2 Many psychiatrists have told the public that chemical imbalances cause their strong negative emotions or odd thoughts. Ninety-nine percent of British psychiatrists believe bad biology is the primary cause, or a major cause, of schizophrenia.3
The search for biological markers is essential for the whole DSM enterprise. The psychiatrists whose work eventuated in the DSM III hoped that each clinical syndrome would be distinct from the others, with its own genetic profile and laboratory tests for precise classification.4 This was a real leap of faith because they admitted at the time that “consistent and reliable laboratory findings have not been demonstrated among the more common psychiatric disorders.”5 The leap fell flat because 47 years later, there still is not a single laboratory test that reliably identifies a particular syndrome listed in the DSM. No single gene has ever been found to be associated with a DSM syndrome, despite dozens of studies and billions of dollars spent.
Nor will there ever be a laboratory test, or gene found. Drs. Regier and Narrow, who wrote of the conceptual basis for DSM, admit the comorbidity of disorders is rampant. They mention that more than half the people with serious levels of anxiety, depression, or somatization had one or both of the other two conditions. Thus, if most people have two or more conditions, you will never find a test or a gene that reliably identifies a single condition. You cannot find the gene for depression if most people have depression and somatization, or depression and anxiety.
Although the sound and furious energy to find a biological basis for mental disorders has come to nothing, there is an odd silence on the other side. Psychiatry ignores what it does know about the cause of a great deal of emotional distress. It excludes this knowledge from the DSM, rather than revising and updating the manual to include it. It continues to rule out the history of the person, what happened to them, as an important factor in understanding why they are in emotional pain. As a result, critically important information is lost, and effective treatments are sidelined. An excellent example of this comes from one of the largest studies ever done in American psychiatry.
The Research: The Virginia Adult Twin Study
The researchers who ran the Virginia Adult Twin study followed 4,856 people, for up to 12 years.6 They interviewed them repeatedly, up to four times each. During each interview, they were questioned about 12 different depressive symptoms they experienced in the previous year. They were asked, “During this period, did something happen to make you feel that way or did the feeling just come on you ‘out of the blue’?” If participants could think of a cause, they were asked to describe it. So far, so good. What came next was astounding.
To begin with, 88% of the time the participants identified a specific event that triggered their depression. They mentioned romantic losses, the death of a loved one, perceived failure, or a conflict with a loved one. They talked about chronic stress, poor health, and fears about the future as events that kicked off an episode of negative mood, or major depression.
This finding alone refutes the idea that biological factors, such as chemical imbalances, cause depression. Nine times out of 10, it is a psychological injury of relationship loss, grief, or significant fear that pushes a person into depression. If it were biological, then it would occur fairly randomly. Instead, depression is enormously influenced by interpersonal conflict, failure, and other painful events in the matrix of relationships.
Another important revelation was that each type of psychological injury was associated with a distinct pattern of symptoms. People who reported that a romantic loss triggered their depression experienced more sadness, appetite loss, and loss of concentration than the rest of the sample. They had less fatigue, slowed movements, restlessness, oversleeping, and appetite gain than everyone else. People who were depressed as a result of chronic stress had essentially the opposite pattern of symptoms. Meanwhile, the people whose health problems kicked off their depression had quite a different pattern of symptoms. Each psychological injury resulted in a pattern of symptoms that was markedly different from the others.
Across time, these symptom patterns were remarkably stable. Because the researchers interviewed the same people four times, some people were depressed twice over the dozen years. If the same person had two different psychological injuries during the 12 years of the study, they did not have the same symptoms as before. Instead, they had the symptoms specific to the new psychological injury. If Elizabeth was depressed in the second year of the study because her boyfriend dumped her, she had the classic “romantic loss” symptom pattern. Eight years later, when she was chronically stressed for a while, she displayed the standard “chronic stress” symptom pattern. There is no single entity of “depression.” There is “romantic loss” sadness, “chronic stress” low mood, and then there is “grief” as a form of emotional pain.
This finding also demolishes the chemical imbalance theory of depression. If it were low serotonin, then the pattern of symptoms would be the same for the person, time after time. There should only be one pattern of symptoms, “low-serotonin depression.” We see that for physical diseases; malaria produces a fever, no matter how often you get it. But each psychological injury is distinct. Each has a unique pattern of painful emotions, disturbing thoughts, and changes in behavior. “Romantic loss” sadness looks quite different from “grief.”
We see that uniqueness when we look at wounds on the skin. A cut, a burn, and a chemical spill all damage the skin. But the type of pain, the appearance of the wound, the speed of recovery, and the appearance of the scar vary distinctly between the three types of physical injury. That is why medicine does not have a diagnosis of “skin damage disorder.” It pushes deeper, and asks what was the underlying injury that caused the damage to the skin. Once a physician understands she is dealing with an abrasion, rather than a burn, she diagnoses it and treats it accordingly.
The DSM-5: Ignoring the Research
Psychiatry had the opportunity to push deeper, to ask about and understand the actual psychological injury that shows up on the surface as depression. Instead, it whiffed it. This was a massive, sophisticated longitudinal study done in the US, published in the American Journal of Psychiatry in 2007. It gave excellent evidence that nearly all “depressions” were from psychological injuries, and each had characteristic patterns of symptoms. This is a major advance in understanding what we call “depression” and how to address it. Now, clinicians could ask people about the psychological injury that they had recently. They could point out how the pattern of symptoms they reported was very similar to other people who had the same emotional wound. The clinician could explain that grief is a normal reaction to losing somebody you love deeply. If the person was chronically stressed, the clinician could discuss ways to reduce the stress and help the person recover.
None of this happened. When the DSM-5 came out six years after the study was published, it ignored the evidence that psychological injuries caused 88% of “depression” in adulthood. It wasn’t just this study that was sidelined. All the research that linked childhood trauma to later episodes of “depression” was ignored as well. I discussed this research in an earlier post on MIA available here.
There are hundreds of articles linking sexual abuse, nay, all types of abuse, neglect, and dysfunction in the household to depression and suicide later in life. None of these studies made a whisker of difference to the committee tasked with diagnosing depression in the DSM-5. They ignored every single one of them. Like Dr. Diastam (they actually are the embodiment of Dr. Diastam), they did not query what caused strong negative mood. They just clumped some symptoms together, and if you had 5 of 9, you had depression. If you had 4 of 9, you did not.
This was in complete contradiction to the rest of medicine, which puts forth huge effort to find the cause of the problem by taking a careful history and adding in blood tests and X-rays. Instead, psychiatry ignored all the research on the largest cause of depression and stuck with clusters of symptoms.
DSM—You Get What You Pay For
The more cynical and well-informed would tell us not to be too surprised. You get what you pay for, they would tell us. And they are right. Dr. Allen Frances, who headed up the whole DSM-IV revision, received hundreds of thousands of dollars from Big Pharma to promote Risperdal.7 Every single psychiatrist on the DSM-IV Committee for Mood Disorders had financial ties to the drug companies.8 Every one. For the DSM-5, that was 67% of the psychiatrists on the committee. These people had strong interests in expanding the market share of Big Pharma.
The number of diagnoses expands wildly with each edition of the DSM, from 128 in the first to 541 in the last. They even said that grief was depression, refuting all of human experience that people get very sad when someone they love dies. The psychiatrists on the drug companies’ payrolls had zero interest in telling the truth from the research that episodes of strong sad mood are very much due to psychological injuries, such as finding out your spouse is cheating on you. What would that gain them? Certainly not another lucrative promotional contract from a giant corporation.
The public might think it would be better to talk to a therapist about their feelings of betrayal, anger, and sadness than to swallow a pill. The public actually wants to get to the root of the problem, not just numb out the pain for a while and take a pill that causes weight gain.
But the public was not paying the psychiatrists on the various DSM committees. Therefore, the public did not get anything useful from them. What would have been useful was an approach like the rest of medicine. An inquiry as to the actual cause of their problems. An explanation that linked the cause to their symptoms. An intervention that flowed from the cause and helped heal the damage.
Nor did the public get anything reliable. Because the psychiatrists ignored the research that different psychological injuries produce different clusters of symptoms. They just shoved together all the symptoms associated with sad mood into a single cluster and the result was a mess.
The reliability of diagnosis is measured with a metric (kappa coefficient) that ranges from 0 to 1. If the kappa is 1, it means that two clinicians agree each time whether the person has the disease or not. If the kappa is 0, then the two clinicians never agree, and the system of diagnosis is completely unreliable. A kappa of 0.7 is considered to be good.9 The kappa for Major Depression 10 in the DSM-5 is 0.28. For Generalized Anxiety Disorder it is 0.20. For Alcohol Use Disorder it is 0.40.
That is a shocking disgrace to psychiatry. They cannot even diagnose depression with any reliability. One psychiatrist might say it is depression, another might say it is bipolar disorder. Or adjustment disorder, or schizoaffective disorder. Who is right? No one knows. Both are equally qualified, yet both come up with different labels for the same person.
If you went to a hospital, and one physician said you had Crohn’s disease, and another said pancreatitis, and another said stomach cancer, you would be utterly confused. And if all of them came to this conclusion without doing any lab tests or blood samples or scans at all, you would think they were quacks and run away.
Yet psychiatry has no X-rays or blood samples. The labels they come up with are not grounded in reality. With stomach cancer, you can see the tumor on an ultrasound and the cells on a microscope slide. Psychiatry has no link to lab tests at all. The entire DSM is invalid. Disconnected from anything empirical. It is a bunch of unreliable labels made up by people paid vast sums by drug companies to expand their market share. That is all it is.
Exposing the intellectual bankruptcy of the DSM is necessary to help people with intense negative mood and distorted thoughts. Once they understand that the psychiatric labels pasted on them are unreliable and invalid constructs made up by drug company flunkies, they can rip them off. The stigma and helplessness inherent in the label of “schizoaffective disorder” or “borderline personality disorder” can be shed like a dolphin wriggling out of a fishing net. The fear of being denied health insurance or jobs, being shamed or bullied for the label, or being viewed as having a permanently broken brain can be left behind. Instead of being dismissed because “you’re a borderline” with the subtext that “you are a manipulator and can be ignored” these people can be listened to.
Which is not to say that these people do not have serious problems. Of course they do. They spent six hours crying yesterday and they want to kill themselves to end the pain. Their brain is whirling with vicious thoughts that they are utter failures. Just because “Fedilrap syndrome” is drivel does not mean that Dr. Greenwood should push the stretcher out the door of the emergency room and tell the person they should go home and get over it. When there is something very wrong it needs to be understood and treated accordingly.
So How Do We Treat It?
And that starts with taking a careful history. This is Diagnosis 101 and it is the step that the DSM makers skipped entirely, leading them far astray. Psychiatry can redeem itself by going back to the basics. It is breathtakingly simple. Ask the person what happened to them. When you were a child, were you ever abused in any way? Were you emotionally or physically neglected? Did your parents have substance abuse problems, violence, or other dysfunctions? Were you bullied or rejected by your peers? Did you experience trauma in adulthood? Are you working for a bully of a boss? Have you recently had a very stressful event in your life, such as a family member being diagnosed with a terminal illness?
These are the psychological injuries people commonly experience. Thousands of research articles (and untold clinical experience) show that these are the largest causes of intense negative mood, and problems with thinking and perceptions. The Psychological Injury Index is a framework for assessing these emotional wounds. It is free at https://psychologicalinjuryindex.com/. The PII is a guide to taking the person’s history, and it gives a much richer understanding of the person.
Understanding the person’s psychological injuries is so crucial because diagnosis guides treatment. The diagnosis of stomach cancer leads to surgery and chemotherapy as treatments. The diagnosis of ulcerative colitis leads to completely different treatments. Get the diagnosis wrong, and you get the treatment wrong and people stay ill or die. This is the dramatic tension that powered the TV show “House.”
Once you learn that the person’s psychological injury is four years of sexual abuse by her stepfather, you interact with her in a different way than if you learn that her psychological injury is having a bully of a manager. Both may present with frequent tears, a sad mood, and hopelessness. But what I say in a therapy session to the first client is radically different from what I say to the second. Different injuries require treatment that takes those injuries into account, rather than a cookie-cutter approach of “you have depression, so you must receive this pill or that intervention.”
Exploring the person’s psychological injuries also has an important consequence. It makes them into human beings. This seems to be an odd statement; are they not always human? Sadly, no. One of the terrible consequences of labels is that they dehumanize people. “She is a borderline” is a label I have heard all too often from professionals, pasted on to keep psychological distance from people who have mood swings and suicidal thinking. Once you listen for it, the reduction of humanity in phrases like “substance abuser” or “we had a bipolar come into the emergency room last night” comes into focus.
Talking about psychological injuries is very different. Saying “Stuart has five adverse childhood experiences” puts the person first. “Stuart” is the first word in the sentence. Their humanity, their personhood is the primary element. They are not a label. They are a person with a name. The fact that they have psychological injuries comes second. It also frames that these are people who are wounded. There is a clear difference between someone who is injured (and who can recover with various forms of therapy) and someone who is diseased. Such as Typhoid Mary. Or someone with a mental illness, a sickness of the brain that whispers of permanent malfunction and warped neurons.
After the emotional wounds are mapped out with the Psychological Injury Index, the next step is to explore how the person coped with them. Have they sought out therapy in the past? Was it helpful for them, or not? Who was supportive of them in their family? Do they use substances in excess to numb out their pain? Do they try to prove they are not a failure by working all the time and chasing promotions? Do they buy self-help books, or do they find acceptance (however unhealthy it is) by being part of a neo-Nazi group? This phase is meant to explore the coping mechanisms people have used and the degree to which these strategies have either healed or perpetuated their psychological injuries.
Clearly, this process is more in-depth than the DSM. It is not about asking tightly defined questions in order to funnel people into one label or another. It is completely different. It involves learning about the person who is sitting across from the clinician. Hearing their life story. Understanding their emotional wounds, their efforts to overcome them, their goals, their defeats and their victories. It is knowing who helped them, and how it was helpful, and who hindered or abused them further.
And from that knowledge, treatment emerges. It is the same process as in medicine: understand the history, map out the cause(s), look for complicating factors, and move on to treatment. Once the psychological injuries are mapped out, treatment can address them. And only psychotherapy is specifically designed to address emotional wounds. Only therapy is focused on uncovering and refuting the negative self-talk that scrolls through the minds of people who have been emotionally abused. Only therapy can heal the distorted images of self and body that people carry who have had their sexuality violated.
Pills may be helpful to modulate extreme distress (suicidality, active psychosis), but they can never heal the underlying psychological injury that caused the intense emotions in the first place. When people stop the pills, the underlying psychological injury causes a relapse. One only has to consider that the relapse rate after taking pills for depression is two to three times higher than with psychotherapy.11 Similar results are found for treating anxiety.12
And now the public has something that actually is helpful for them. Instead of a string of invalid and unreliable labels that seems to get longer each time they meet a doctor wielding a DSM, they get to tell their life story. They get understanding. And empathy. Once someone is seen as “Jennifer, with four childhood traumas” or “Dave, who was bullied by his boss,” they are seen as a human who is hurting, who can grow and heal. They are seen with hope.
- http://www.nimh.nih.gov/about/director/index.shtml ↩
- https://www.nimh.nih.gov/health/publications/eating-disorders/index.shtml ↩
- Kingdon D., Sharwa T., Hart. D., (2004). What attitudes do psychiatrists hold towards people with mental illness? Psychiatric Bulletin, vol. 28, 401-406 ↩
- Regier DA, Narrow WE, Kuhl EA, Kupfer DJ. (2009). The conceptual development of DSM-V. Am J Psychiatry. Jun;166(6):645-50. ↩
- Feighner JP, Robins E, Guze SB, Woodruff RA Jr, Winokur G, Munoz R. (1972) Diagnostic criteria for use in psychiatric research. Arch Gen Psychiatry. Jan;26(1):57-63. ↩
- Keller MC, Neale MC, Kendler KS. (2007) Association of different adverse life events with distinct patterns of depressive symptoms. Am J Psychiatry. Oct;164(10):1521-9. ↩
- Caplan, PJ. (2015) Diagnosisgate: Conflict of interest at the top of the psychiatric apparatus. Aporia. Vol 7. p. 30-41. ↩
- Cosgrove L, Krimsky S. (2012). A comparison of DSM-IV and DSM-5 panel members’ financial associations with industry: a pernicious problem persists. PLoS Med. 9(3):e1001190. doi: 10.1371/journal.pmed.1001190. Epub 2012 Mar 13.PMID: 22427747 ↩
- Spitzer, R., J. Williams. J. Endicott (2012) Standards for DSM-5 reliability. Amer J Psychiatry. 169: 537 ↩
- Regier DA, Narrow WE, Clarke DE, Kraemer HC, Kuramoto SJ, Kuhl EA, Kupfer DJ. (2013). DSM-5 field trials in the United States and Canada, Part II: test-retest reliability of selected categorical diagnoses. Am J Psychiatry. Jan;170(1):59-70. ↩
- Cuijpers P, Hollon SD, van Straten A, Bockting C, Berking M, Andersson G. (2013) Does cognitive behaviour therapy have an enduring effect that is superior to keeping patients on continuation pharmacotherapy? A meta-analysis. BMJ Open. Apr 26;3(4). ↩
- Barlow DH, Gorman JM, Shear MK, Woods SW. (2000). Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: A randomized controlled trial. JAMA. May 17;283(19):2529-36. ↩
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.