Map of life expectancy at birth from Global Education Project.

Friday, June 07, 2013

Onward to the murky swamps of the DSM

Since it turns out that Eric Holder and James Clapper already know all about my pathetic social life (and BTW, Glenn Greenwald says there is more to come), I might as well fess up here. I was bummed out a while back by a relationship that didn't work out, and I'm still kinda bummed out. I don't happen to want to talk to a professional counselor about it, but somebody else might. Do I have a disease? What if I stay sad for a really long time? Do I have a disease after six weeks, or six months? Do I have to be more than a certain amount sad? What difference does it make what you call it?

As you may recall, drug companies used to run ads claiming that depression was caused by a deficit of a specific neurotransmitter, serotonin; and that their pills fixed it by increasing the amount of serotonin in your brain. One of them even had a little cartoon showing serotonin ostensibly flowing between brain cells and their pill keeping it from being reabsorbed, whereupon the person got happy.

This was total, unmitigated bullshit. People diagnosed with depression have the same amount of serotonin in their cerebrospinal fluid as everybody else; and most people with depression don't respond to anti-depressants at all. (Absolutely true. At best 15% of people show a clinically meaningful response. The rest just get the side effects.)

The brain is not a bag of chemicals, and our moods, thoughts and feelings do not correspond to some overall level of one or any combination of chemicals. The brain generates the mind in all its states through highly complex processes -- networks of excitation flowing among millions of neurons to produce each and every phenomenon of consciousness. Once we have ruled out the gross abnormalities of structure or biology I discussed earlier, we are left with states that are only arbitrarily classifiable and which nobody understands very much about.

It would be nice to have a pill that could stop us from being sad. Actually, they used to prescribe amphetamines, which do work. You could ask Lenny Bruce but, uh, he's dead. It would also be nice if we could take pills so we wouldn't be shy, wouldn't be anxious, wouldn't get angry. Well, there are pills that have these effects to some extent, but it's usually a very bad idea to take them for very long. The reason is that our shyness and anxiety and anger are not caused by a deficiency of a chemical, and if you do pump in a lot of some chemical that changes how your brain works, the effects are going to be a whole lot more than the specific one you're looking for.

In fact, there are occasions on which it is very wise to be anxious, or shy, or angry. Evolution has equipped us with these states because they sometimes can save our lives, or benefit our kin. And people's personalities and capacities vary enormously, which is also a good thing for society and makes life more interesting.

Alas, we sometimes make unwise choices, or get locked into emotional states that are unpleasant or counterproductive. Some people behave in a self-defeating way consistently, or are frequently obnoxious to others. It can get so bad sometimes that we want to get help. Here's where psychiatrists come in. They want to be thought of as real doctors, so they need to be treating diseases, and they need to have pills to do it with. And so we get official names for mood disorders and personality disorders. But these are not real entities. They are pareidoilia, an "illusion or misperception involving a vague or obscure stimulus being perceived as something clear and distinct," like Jesus appearing on toast.


kathy a. said...

it seems to me that you are mixing a couple of concepts here. one, which you discussed in an earlier post, is that unlike organic brain dysfuntions, we cannot really "see" psychiatric disorders, and their mechanisms are poorly understood; a corollary is that they are hard to treat effectively. another point, i think, is that mild deviations in functioning (feeling sad or anxious, for example) are pretty normal.

i have a concern that your discussion in this post minimizes the severe disruptions that can occur, e.g., with major mental illnesses. feeling weepy after a breakup is not in the same league as chronic suicidal ideation. getting angry in an argument is not in the same league as being unable to refrain from a physical attack. for that matter, wishful thinking is not the same as delusional thinking.

that separation from reality and significant disruptions of normal functioning can be serious indeed -- devastating to the affected person, and often to those around that person as well. i worry that both over-medicalizing the small stuff, and a lack of diagnostic clarity about the big stuff, might lead people to dismiss these really disruptive disorders as "not real."

we see that all the time in criminal cases; prosecutors almost invariably argue that the person is "faking" or the doctors are wrong, and the defendant is just evil.

i think there is that tendency in civil life, too, to dismiss the seriousness of major mental disorders. it's easier to chalk behaviors up to eccentricity, or a mean spirit, or bad choices. it's easier to assume that the problems will be sorted if only family offers the right help.

love and patience are not always the answer, though, when somebody is operating in a different reality. medicine may only have fairly blunt instruments for dealing at this time, but it's a step above voodoo or burning at stake.

Cervantes said...

Oh yes, you are right. What I am saying is that you can't draw clear lines around these things. At some point, you know a person has a major problem that isn't just going to get better. But it's not a distinct entity, and even things that look similar may well have very different underlying causes.

Anonymous said...

Big Pharma.

Right now about 50% or so of USA citizens are diagnosed with some psych. diagnosis, or are undiagnosed (officially, mostly because they don’t have heath insurance) but family and others apply categories like those in the DSM. A husband is a sociopath, a girl friend is a narcissist, a mother ‘has bi-polar’ and so on. They need treatment! Their brain chemicals and / or their ‘nasty characters’ or ‘deviant personalities‘ or ‘sociopathic tendencies’ require immediate action. > Medication, forcible therapy, etc. Not to mention ‘addicts’, alcohol, heroin, or just marijuana. And so it goes, new reasons to demean, punish, send to the medicos who make their living off it, imprison, reject, etc.

DSM like categories (which I don’t agree with as for one reason they mask serious psychiatric illness) are always a reflection of society in a way.

The example of homosexuality needn’t be mentioned. Now pedophiles are the subject of with hunts...

Attention deficit disorder is a newbie on the scene, and simply reflects the fact that many children and young people cannot perform properly in militaristic / controlling type educational environments, not to mention family, because, in their eyes, and this is crucial, nothing in that scenario makes sense, and is in fact contradictory to other messages (follow your dream, develop your talents, or as Apple said recently, break the rules..!) as they see they are being controlled for the sake of control and not for knowledge or performance, even if that is drill and skill which might be disagreeable in some ways.

So they tune out and become either lazy or aggressive or mix the two, lost in a contradictory landscape. Ritalin!, almost always with parent agreement or downright forcible pill prescription. Not good.