Transcript The Emperor's New Diagnosis

The Emperor's
New Diagnosis
Human Suffering and the DSM
Do I Have a Disorder?
When Do We Use Diagnoses?
1. Reimbursement.
2. Communicating with
colleagues.
3. Communicating with clients.
1. Reimbursement
Insurance companies and
government agencies want to
ensure that people only receive a
treatment if they need it and that
they are being given the most
appropriate treatment for their
problems.
2. Communicating with Colleagues
We are trying to convey the most
pertinent information about the
client and give our colleagues the
highest quality understanding of
the client's situation.
3. Communicating with Clients
We are trying to help the client
understand what they are
experiencing and why.
Is the Medical Model the Best Way
to Accomplish These Aims?
We will explore the ideas of "mental illness" or
"mental disorder" and psychiatric diagnosis
with the aim of answering two questions
1.Are "mental illnesses" real?
2.Is thinking in terms of "mental illness" and
diagnosis the most helpful to our clients?
Defining the Medical Model
1. There is such thing as “true mental illness”
or “chemical imbalance” in which
psychological symptoms cannot be
understood in terms of the person’s
psychology.
2. "Mental illness" can be divided up into a
finite number of discrete diseases, such as
schizophrenia, bipolar disorder and major
depression.
Emil Kraepelin
Robert Spitzer
Where Did the Medical Model Come
From?
Emil Kraepelin's optimism.
The German psychiatrist and contemporary
to Freud proposed the existence of
psychological diseases.
It was just after Louis Pasteur proposed the
Germ Theory of Disease.
The shift from imbalances and humours to
looking for germs and diseases led to cures
and vaccines.
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Medical Breakthroughs of the Early
20th Century
What Did Kraepelin Believe About
Mental Diseases?
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Any real disease must share common
symptoms, etiology and treatment.
Since so little was known about etiology and
treatment, Kraepelin sought to group
symptoms.
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He believed that if he could group them correctly,
they would also share an etiology and treatment.
An Example of a Real Psychiatric
Disease
• Wilson’s Disease is caused by mutations in
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the Wilson’s Disease Protein Gene (ATP7B)
which causes copper accumulation.
Wilson’s Disease causes depression, anxiety
and psychosis in addition to tremors and
jaundice due to liver and nervous system
damage.
Removing copper from the system (through
chelation) prevents further damage.
100 Years After Kraepelin
• After grouping and regrouping symptoms for
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100 years, discovery of psychological
diseases with symptoms, etiology and
treatment response that properly cohere has
been extremely rare.
Over 90% of mental health complaints are
not caused by a known psychiatric disease.
What Would Kraepelin Think?
• His ideas unequivocally did not lead to the
type of advances he had hoped. After 100
years, I think he would tell us to stop looking
and find another paradigm.
Why is the Medical Model Popular?
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If "mental diseases" were real, we might be
able to discover a cure (like antibiotics) or
even a vaccine (like polio).
Some people believe that if psychology were
more like medicine, it would make it a more
legitimate profession.
The pharmaceutical industry makes over a
trillion dollars each year with drugs that
aren't very effective. They want people
thinking in terms of medicine for "illnesses."
What Did Spitzer Do?
• Robert Spitzer was the creator of the DSM-III
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and chiefly responsible for taking Kraepelin’s
ideas from relative obscurity to being the
dominant paradigm in the mental health field.
The adoption of DSM-III in 1980 was the
most decisive move in the history of mental
health away from thinking in terms of
personal experience and the uniqueness
of the individual in his social context, and
toward the medical model.
How Big Was Spitzer’s Influence on
the Field?
• DSM-I and DSM-II both represented the view
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of psychological problems as being
expressions of inner-conflict and difficult life
experiences that were only able to be
properly understood by understanding the
individual or family.
Spitzer’s DSM-III was the decisive break to a
view of psychological problems as being best
understood as specific disorders. There is no
longer a need to understand the context.
The Crisis in the 1970’s and the
Need for a New Paradigm
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A broad antipsychiatry sentiment from Thomas Szasz and
Michel Foucault to One Flew Over the Cuckoo's Nest.
Third-party payers demanding that psychiatry demonstrate
the efficacy of their practices as they wanted to be paid to
treat people with increasingly mild distress.
Pressure from the emerging field of psychopharmaceuticals to be able to market their drugs for
specific diseases and newly deinstitutionalized patients.
Conflicts between various theoretical camps, and those
who viewed psychological theories as too subjective.
Psychiatrists feeling threatened by other professionals
delivering psychotherapy (Resnick vs. Blue Shields, 1980).
Who Did We Choose As Our
Savior? Robert Spitzer and Charts
Spitzer quote: "When I was 10, 11 or 12 I went
to summer camp and my bed was against the
wall and on the wall I made a graph of my
feelings towards 5 or 6 ladies and over time
went up and down. That's a strange thing for
somebody to do but that's the kind of person
that I guess that ends up doing what I did, in
other words translating feelings into some kind
of a system." NPR interview, 2003.
The Creation of DSM-III
• In 1974, diagnosis was an unpopular
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specialty. Spitzer was able to appoint himself
to head all 25 committees.
Findings were not based on any research,
but on the consensus that emerged from
small rooms of psychiatrists arguing with
each other.
Columbia Professor David Shaffer explains…
The Height of Subjectivity
• In those small room discussions, they
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concluded that racism was not a disorder, but
that PMS was. Spitzer favored viewing
homosexuality as a disorder, but bowed to
pressure from activists.
Spitzer says that the DSM-III (created with no
research) made psychiatry “feel” more
scientific when it was adopted in 1980 in the
same 2003 NPR interview.
Robert Spitzer and Human Emotion
• Spitzer does not view himself as
understanding very much about human
emotion. Instead he views his talent as being
able fitting puzzle pieces into a system, as he
relates in the 2003 NPR interview.
After the DSM
• After being denied the position of directing
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the DSM-IV, Spitzer did not continue to
pursue an interest in human emotion. He
pursued his interest in categorizing things.
He created an elaborate system for
categorizing ballroom dancing, as explained
in the 2003 NPR interview.
The ballroom dancing community has been
less willing to adopt Spitzer’s ideas than
psychiatry has.
Why Did the Rest of the Field
Follow Psychiatry
• Private insurance companies had usually
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required a diagnosis. They became stricter.
There was a growing shift from out-of-pocket
payment for therapy to increasing reliance on
third-party payers.
Government funders increasingly required
diagnosis.
This was all largely due to the most influential
mental health professionals in government
and private insurance being psychiatrists.
Does Diagnosis Increase
Therapeutic Efficacy??
• While a fair amount of research has been put
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into trying to prove the DSM’s diagnoses are
reliable, there has not been a single study
aimed at testing whether using diagnoses
increases therapeutic outcome.
All evidence shows that mental health
treatment as a whole has not improved since
diagnosis has become ubiquitous.
If Not Disease, Then What?
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Symptom-oriented descriptions
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List of symptoms and severity.
Complaint-oriented descriptions
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Describe patient/client’s own reason for seeking
treatment.
Terms like "serious mental instability" or
“multiple psychotic breaks” rather than
"serious mental illness” or “schizophrenia”.
Does It Matter If We Believe in
Mental Illness?
• Communicating with clients: Diagnosis vs.
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their unique experience and symptoms to
help them understand themselves.
Communicating with colleagues: Diagnosis
vs. one sentence describing symptoms and
one or two describing history to convey
clinical relevance.
Third-party payers: Diagnosis vs. list of
symptoms and severity to unsure
appropriateness and necessity of treatment.