The anti-shrink case

kw: book reviews, nonfiction, psychiatry, history, polemics

In my prior review, of a book about psychiatry written by psychiatrists, I wrote (perhaps more than I should have) of my experience with psychiatrists. To sum up my takeaway: of at least ten shrinks that I have worked with, all of whom accepted ComPsych "insurance", I consider only two to be "normal", and only these two were of genuine help. Furthermore, when I asked family doctors to recommend psychiatrists whom they thought weren't crazy themselves, in each case, the ones recommended wouldn't accept ComPsych referrals, and their fees were extremely high, in the $400/hour range or more.

Side note: Do you know that guy who goes in with a screwdriver and needle-nose pliers to defuse a bomb? His work is worth $400/hour, and perhaps even more. Anybody else on the planet, no matter who, should not be paid more than half that. Period.

The last one I saw, I was pretty impressed with, at first. At our first visit he reviewed my case in detail, and we talked for a half hour. Then, thinking out loud, he ran through a differential diagnosis to reach the conclusion Dr. Valentine had reached several years earlier, of Bipolar II (the milder type, but still distressing enough). He suggested Abilify, an "atypical antipsychotic", which is also useful for reducing the distress of depression, but doesn't much affect mild mania. As he put it, "We'll let you have your fun," because hypomania is a happy state, while full-blown mania is torment (as I've been told by two friends so afflicted). The main side effects of Abilify for me were a little weight gain and the need for a daily nap. Otherwise, it was pretty good. However, after a year, going in for a third visit, I was planning to ask if there might be something better. He was gone. Vanished. No trace. No sign or note on the office door. Other doctors I've had who moved away or left the business at least had the grace to inform their patients. At that point, I decided I had learned enough about mood management to live without psychoactive medications, and I have done so ever since, for almost 15 years.

Reading Psychiatry and its Discontents, by Andrew Scull, I find that the differential diagnosis used by this doctor may have sounded good, but whether it was scientific or even medically accurate is not so certain. Based on my experiences over the years, for at least this condition (Bipolar II), I think the basic criteria the doctor (and Dr. Valentine) used are useful. In other cases, perhaps not so much.

Professor Scull's book mainly consists of prior articles and book reviews, edited for coherence, and it is a historical review of the various incarnations of psychiatry. Prior to the late 1800's those who worked with the insane were called Alienists, because the older meaning of "alien" was "insane". Once the word "alien" picked up the meaning "foreign", the ambiguity gradually led some to seek a new term. The Greek word "psyche" refers to the soul or mind, so that was a good prefix, and on it went.

Whatever one calls them, those who treat the insane (and the "sorta insane" like me), have always been sort of stepchildren of the medical profession. Apparently, after decades of working empirically (at best!), in the mid-1900's psychiatrists felt the need to establish their work on a more scientific basis. The process is dealt with, over the space of several chapters, and is a sad history at best. The result was a total of eight editions of a guidebook called the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The current edition is DSM-5, a thousand-page tome. In the view of our author, the first "official" version, DSM-III, released in 1980, was "an anti-intellectual collection of categories jammed between two covers". Later editions only compounded its errors, and much greater errors were gathered to comprise DSM-5.

It is a rather difficult for a layman to consult DSM-5 to see for themselves what is going on. Firstly, it is enormous, 947 pages, covering 297 named "disorders"; it is expensive at $199, or $149 for the paperback. There is a little bit of information available without cost. I took a look at some of the Fact Sheets found at this page. One of them is titled Personality Disorder, though the sheet itself is titled Personality Disorders, and lists ten items in the first paragraph. Look at this list, mentally appending the term "personality disorder" to each item:

• paranoid
• schizoid
• schizotypal
• antisocial
• borderline
• histrionic
• narcissistic
• avoidant
• dependent
• obsessive-compulsive

If you dig into the characteristics and criteria used to "diagnose" any of these, they are nearly all rather mild extensions of ordinary tendencies we all pick up over time. In the discussion on the Fact Sheet, four of these are somewhat deprecated—frankly, they are redundant, being covered by other items dealt with elsewhere—leaving the six I have highlighted to be dealt with in the body of DSM-5. Prof. Scull states several times that most of the 297 categories in DSM-5 are inventions of the drug companies that effectively "pathologize" common behaviors so drugs can be sold to the "anxious well", people who are quite sane, but easily convinced to worry about their mental health.

Why is DSM-5 important? The insurance companies have adopted it as the "standard" upon which they are willing to pay. Shrinks everywhere have to put a diagnostic number on a prescription or treatment schedule or they won't be paid by the insurance company, and in most cases, the patient can't afford to pay. Sadly, most of the categories are, in my view (developed years ago), bogus.

The Autism Spectrum was invented, practically out of whole cloth, during the production of DSM-5, which was released in 2013, but "the spectrum" was being bandied about earlier. Before the 1990's about one child in 500 was counted as autistic. A much smaller number, formerly called "high functioning autistic" were later said to have Asperger's Syndrome. "The spectrum" produced millions of new "victims", such that one person in 90 is now "on the spectrum". I have several friends or acquaintances who are considered "on the spectrum." Actually, with one exception, they are just shy and a little withdrawn. Big deal. So was I. I suppose I could, even now, go get diagnosed and get some kid of Federal "help". I'd be mortally ashamed to do so.

My grandmother, using an old term for "mildly crazy", would say, "Everybody's pixilated except you and me. Sometimes I wonder about you." Extend that to the psychiatric profession. Most (not all!) of the psychiatrists I've known are earnest and honest, but it is certain that a significant number are just cynical enough to be willing to profit if the entire population were to be brought under their "care."

I won't get into the horrors that "mental care" entailed in the past, nor many other aspects of the book. Psychiatry has the lowest rate of "true help" of all the medical and fringe-medical professions. It did help me, even though I eventually learned how to do better without any more "help".

I don't agree with some who say there are no mental illnesses (neither does the author). There can be organic problems with the brain, which is physical, after all. Some afflictions such as schizophrenia and bipolar and chronic depression may be organically-based. Also, there are stresses, particularly if they are severe enough or chronic, that require some people to develop defense mechanisms, and defensive habits are hard to break, even though their cause is no longer present. This is how most neuroses arise. We still don't know enough to go beyond that with any pretension of scientific credibility.

The book is, then, a history of a failed profession, and a polemic against its present incarnation as a practice enslaved to DSM-5, and a polemic against DSM-5 itself. I happen to agree. The two psychiatrists that I respect had a human dimension to their practice that went far beyond totting up a checklist of my symptoms to get me in the right pigeonhole. They did their best, with both hands tied, to treat the whole person that I am. The current state of psychiatry, as seen in this book and in the prior one, is well described as a tiny candle in a dark forest. Nobody yet knows how to bring any more light on the subject. Our brain and mind are still almost total mysteries.