Scull on psychiatry’s problems

Interesting book review by Andrew Scull in the Los Angeles Review of Books. The book is called All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders by A. V. Horwitz and J. C. Wakefield. The authors (and the reviewer) are critical of contemporary psychiatry for much the same reason that some of us philosophical types are skeptical of it—empirical evidence is sketchy and many of symptoms of psychopathology are amorphous enough to mean anything. This paragraph is a good synopsis of the review:

This reliance on symptoms, and on the simplistic approach of counting symptoms to make a diagnosis, creates a bogus confidence in psychiatric science. Such categories have an element of the arbitrary about them. When Robert Spitzer and his associates created DSM III, they liked to call themselves DOPs (data-oriented persons). In fact, DSM’s categories were assembled through political horse-trading and internal votes and compromise. The document they produced paid little heed to the question of validity, or to whether the new system of categorizing mental disorders corresponded to real diseases out there. And subsequent revisions have hewed to the same approach. With the single exception of Post Traumatic Stress Disorder (PTSD), which, as its name implies, is a diagnosis having its origins in trauma of an extreme sort, the various categories in the DSM, including the anxiety disorders that preoccupy Horwitz and Wakefield, are purely symptom-based. (The construction of the PTSD diagnosis, incidentally, as the authors show, was every bit as political as the creation of the other DSM categories.) Because so much depends on the wording that describes the symptoms to be looked for and on how many symptoms one needs to display to warrant a particular diagnosis (why do six symptoms make a schizophrenic, not five, or seven?), small shifts in terminology can have huge real-world effects. The problem is magnified in studies of the epidemiology of psychiatric disorders. As Horwitz and Wakefield point out, to make studies of this sort cheaper and allow those producing them to employ laypeople to administer the necessary instruments, the diagnostic process is simplified even further in these settings. They write that psychiatric epidemiologists make “no attempt to establish the context in which worries arise, endure, and disappear so as to separate contextually appropriate anxiety from disordered anxiety conditions [and thus they] can uncover as much seeming psycho-pathology as they desire.”

Scull noted earlier that the DSM was created specifically to standardize psychiatric diagnoses after some embarrassing events in the mid-twentieth century. But as with all standards for complicated and messy phenomena, simplification was necessary. And since simplification leads to abstraction, the symptomologies for various disorders became vague. Vaguely defined symptoms can be matched to any complaint. Are you feeling down? Or very down?

Anyway, a good read.


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