Editor’s Note: Over the next several months, Mad in America is publishing a serialized version of Peter Gøtzsche’s book, Critical Psychiatry Textbook. In this blog, he discusses the poor reliability of psychiatric diagnoses and diagnostic criteria expansion. Each Monday, a new section of the book is published, and all chapters are archived here.
“People are unlikely to question the underlying premises of their occupations, in which they often have a large financial and emotional stake.”
—Judi Chamberlin, former mental patient102
In the protocol for my study of psychiatric textbooks, I noted that they should mention that psychiatric diagnoses are based on arbitrary criteria; that there is large interobserver variation when several psychiatrists assess the same patients independently; that psychiatric disorders can disappear again, without treatment; that psychiatrists are willing to change their diagnoses; and that patients can get their diagnoses removed based on a second opinion or longer follow-up.
I also noted that clinicians should not come up with additional diagnoses in people who receive psychoactive drugs because their adverse effects may mimic the criteria used for other diagnoses. It is therefore often impossible to say which is which, e.g. if a patient in treatment for depression or ADHD also come to suffer from bipolar disorder or if the observed symptoms are merely adverse effects of the drugs.7,8
Psychiatrists usually ignore this fundamental problem and may even say that the drug treatment has “unmasked” the new disorder, which is one of the reasons why contact with the psychiatric system often leads to several diagnoses and polypharmacy and why temporary problems with mental health often become chronic.
There was very little in the textbooks that even just hinted at any of these essential issues. One book noted that the psychiatrists had tried to make the diagnoses reliable and to ensure that the doctors agreed on how to use them.18:24 But it did not explain that psychiatric diagnoses are highly unreliable and did not quote any studies on observer variability.
On the same page, this textbook noted that the diagnosis is affirmed or rejected based on the course of the disease and treatment results.18:24 There are two obvious problems with this statement. First, the reality is that it is not possible to have an erroneous diagnosis removed. Numerous patients have tried and have been rejected. Second, it is circular evidence. If we give everyone a diagnosis of schizophrenia, and some become better when treated with psychosis pills, the diagnosis is confirmed for these patients and rejected for the rest. If we say it might rain tomorrow and it might not, and then let the “course of the weather” decide what was right, this doesn’t prove anything about our capabilities as a meteorologist.
Further ahead, this textbook noted about the diagnostic criteria for depression that they are symptoms most people experience now and then: sadness, difficulty concentrating, sleep problems, etc., but that the important thing is, firstly, that the symptoms must exceed a certain clinical threshold before they can be considered a disorder, which requires clinical experience to determine; and secondly, that they must have been present for more than 14 days.18:119
This boils down to psychiatrists’ best friend, clinical experience, which is not reassuring for the patients they label and stigmatise for life with their diagnoses, which are often wrong.7 If you are a patient, how do you object to a psychiatrist’s clinical experience? You are bound to lose, with three arguments: You are not a psychiatrist; you do not have clinical experience; and since you have a mental health disorder, you might not be able to think clearly about yourself.
It is problematic to use a diagnosis like depression to explain an experience.10:14 If I was asked why someone is feeling low and I answered that this is because she has depression, then a legitimate question to ask is: “How do you know that this feeling low is caused by depression?” The only answer I can give is that I know it is depression because she is feeling low. If we try to use a classification that can only describe in order to explain, we end up with a tautology or circular thinking. A description cannot explain itself. Low mood and depression are synonymous; we cannot use one to explain the other.
The American Psychiatric Association (APA) proclaimed in 2021 that major depressive disorder is a common and serious medical illness that negatively affects how you feel, the way you think and how you act.96 This is wrong. The APA has blown life into something that is just a name and therefore cannot cause anything. This is a very common error in psychiatry.
As the diagnostic criteria have been lowered, it is not surprising that studies have shown that more people are overdiagnosed than underdiagnosed for depression.103 The term “major depressive disorder” has become contradictory in terms, as it now includes cases of mild depression even though such cases are neither major, nor depression, not even a disorder.103
One textbook described agitated depression, with hand-twisting restlessness, inner turmoil or persistent pacing around, and said that as the patients are unable to find rest, they are often highly suicidal.18:119 What the authors described are the key symptoms of akathisia, one of the most dangerous harms of psychosis and depression pills. Akathisia is a state of extreme restlessness and inner turmoil. It literally means that you can’t sit still. You may have the urge to tap your fingers, fidget, or jiggle your legs.
But the authors did not tell their readers about this or say how one may distinguish between the two conditions, which seems close to impossible. Is this also a matter of clinical experience?
I am not joking. In 2015, I was invited to lecture at a hospital in Denmark by the psychiatric organisation in that region.8-18 Rasmus Licht, professor of psychiatry and a specialist in bipolar disorder, also lectured. I asked him how he could know, when he made the diagnosis of bipolar in a patient who received a drug for ADHD, that it was not just the drug harms he saw because they are very similar to the symptoms doctors use when diagnosing bipolar.
I was flabbergasted when he said that a psychiatrist was able to distinguish between these two possibilities.
Rasmus said a lot else that wasn’t correct, which illustrated what psychiatry does to its own people. When I first met him, he was a bright young man who impressed me. I was one of the examiners when he defended his PhD about mania 17 years earlier and hadn’t seen him in all those years. It was shocking to watch how he had assimilated psychiatry’s wrong ideas. We corresponded a little afterwards, but I could not convince him he was wrong.
One of the things Rasmus wrote was that “it is mentioned in ICD-10 [ICD is WHO’s International Classification of Diseases] and DSM-IV [APA’s Diagnostic and Statistical Manual of Mental Disorders] that if the mania only occurs when the patient has received an antidepressant at the same time, it speaks against bipolar disorder, as it is understood it could be drug induced mania. However, in contrast, the DSM-5 has taken the consequences of recent epidemiological studies and written that, even though a mania occurs during treatment with an antidepressant, this should be perceived as a true, i.e. primary, bipolar disorder. So, in this case, you speak against better knowledge.”
I wondered how it was possible for Rasmus to believe in such nonsense. It is total baloney to postulate that a mania that occurs during treatment with a depression pill is a new disorder when it might as well be a drug harm. It is a smart trick psychiatrists use to distance themselves from the harms they cause and from their accountability. It is always the patient who is to blame, never them or their drugs, is the message they send, also in their textbooks.
It should be forbidden to make new diagnoses while the patient is in treatment with psychotropic drugs, and if psychiatrists cannot resist the temptation, they should tentatively call it a drug-induced disorder.
In one of my books, I describe a patient, Stine Toft, who has never been manic, apart from the time when she received a depression pill, but she also got the diagnosis bipolar.8:5 What psychiatry did to her was devastating, yet so typical, that I published her story on the Mad in America web-site.104
Stine was seriously harmed. She was told her condition would definitely last for the rest of her life; she was treated with depression pills, antiepileptics, and a psychosis pill; put on 50 kg; lost about 14 years of her life to psychiatry; lost her husband; came close to suicide; and came on disability pension.
Stine’s next husband saved her. He asked quite quickly “what the sickness was all about,” because he couldn’t see it. After a year and a half, she surrendered and agreed to withdraw the medication. She suffered an excruciating withdrawal phase because she did not receive the necessary guidance. It took two and a half years. This was when she came to know two of my books7,46 and found out that everything she had experienced was well known and perfectly normal. It was shocking to her to read about how it is normal practice to be exposed to the hell she had been through, but also liberating to discover that she wasn’t sick and that there was nothing wrong with her.
Stine is doing well today. She became a coach and a psychotherapist and has helped many patients taper off their depression pills, with great success. She no longer sees her family. They maintained the claim that she was ill and just needed to take her medication. Stine lectures but finds it difficult to get the message out. She had previously lectured about being bipolar, which was easy. People like to see a sick person and hear her story. But a psychiatric survivor’s success story that calls the whole system into question is not considered interesting.
A special case of erroneous diagnoses is post-mortem diagnoses. Two textbooks claimed that 50% of suicides occur in people who are depressed,17:358,18:129 and a third that by far most people who killed themselves had a psychiatric disorder demanding treatment.16:534 However, a post-mortem diagnosis is highly bias-prone. Social acceptability bias threatens the validity of such retrospective diagnosis-making. Relatives often seek socially acceptable explanations and may be unaware of or unwilling to disclose certain problems, particularly those that generate shame or put some of the blame on themselves. Furthermore, a depression diagnosis is made by questioning the patient, and one cannot talk to a dead person.
One textbook, which had a psychologist as one of its two editors, was markedly different to the others. It quoted the Canadian physician William Osler (who died in 1919): “It is much more important to know what sort of a patient that has a disease then what sort of a disease a patient has.”17:34 It also noted that to put the human being at the centre is to organise mental health with respect for the individual’s integrity and self-determination, and that, in an evidence-based clinical practice, treatment must be adapted to the individual’s and the relatives’ personal perceptions, feelings, and expectations and not only to the diagnosis and the often meagre evidence associated with it.
The authors wrote that, “In the book we will see the person behind the diagnosis.”17:35 Later, the book repeated that it is the patient’s perception of himself and his world that is at the centre.17:136 This view is radically different to that in the other textbooks where the patient is the passive receiver of drugs and is reprimanded if he doesn’t want to take the drugs by being called non-compliant or treatment resistant, or as lacking insight into his disease.
This book noted that there are strong economic interests behind the diagnosis of new conditions, e.g. the use of ADHD medication has increased dramatically, and the ADHD diagnosis is being used increasingly, also about things that are not deviant or constitute a disorder, e.g. difficulty concentrating, restlessness, motor restlessness, and impulsivity in children.17:51
This is correct. ADHD is an American construct, and with each revision of the DSM, a larger number of children are found to be above the threshold for diagnosis.10:33 ADHD is the product of vested commercial, political, and institutional interests. Nowhere in the story of this diagnosis has there been any significant scientific discovery.10:35 It is the emperor’s new clothes.
The book mentioned that studies show that the youngest boy in the class has about a 30% greater risk of getting an ADHD diagnosis than the other children.17:51 It is actually worse than 30%. As noted above, 50% more of children born in December were in drug treatment for ADHD than those born in January in the same class.51
The book noted that psychiatric diagnoses have poor validity and do not tell us much about the nature, course, and treatment of the diseases.17:212 The reliability of the diagnoses was also questioned: Will clinicians reach the same diagnosis? Both yes and no.17:214 The diagnostic criteria are arbitrary, and there is great aversion in the population against psychiatry´s use of diagnoses, which are more stigmatising than they are a help for the doctor.17:215
This scepticism was repeated 703 pages later, in a chapter about psychiatry’s history:17:918 Can we trust the diagnoses, and what do they really tell us about the patients’ diseases? The anti-psychiatry movement after 1968 was in particular directed against the diagnoses, which were considered unreliable, stigmatising, and alienating: “Who is it that are mad?”
Much of the book was traditional and full of errors. But the chapter about the history of psychiatry in Denmark was so bold that I suspected that the authors must be retired psychiatrists or close to retiring, or from another profession. I was right. Only one of the three authors was a psychiatrist, born in 1949. The other two were a psychologist and a medical historian.
The authors explained that slogans such as “the patient is an expert in his own life” have challenged psychiatry’s traditional paternalistic attitude, and that the recovery movement—with the basic attitude that patients can recover and return to life outside the treatment system, like patients who are treated for non-psychiatric diseases—has been particularly important in social psychiatry.17:910
The authors even noted that there is no relation between the available evidence, national clinical guidelines, and the content of treatment packages, and that psychiatry’s image remains under pressure due to cases of overmedication and too much coercion.17:919
They ended their chapter by saying that one of the biggest problems is the high mortality among psychiatric patients.17:920 This was not discussed in the other books or mentioned in the main text of this book, but by the end of a huge book, under the heading The history of psychiatry in Denmark, starting on page 910. Students are very results oriented and prioritise what they read. Few students will ever read these 23 pages, even though they are among the most important ones in all five textbooks.
To see the list of all references cited, click here.
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