Map of life expectancy at birth from Global Education Project.

Friday, January 04, 2008

Such stuff as dreams are made on . . .

While Freud got psychiatrists out of the lunatic asylum and into cushy offices, nevertheless his work only increased the influence of dualism in psychiatric practice and the relationship between psychiatry and the rest of medicine. While the theory of "functional disorders" did forge a link between mind and body, the etiology of the disorders lay in psychodynamic processes, the still ethereal stuff of mind. A psychiatric diagnosis depends on ruling out "organic illness," and vice versa.

In the 1930s, psychiatrists tried to further advance their prestige within the medical profession by creating the field of psychosomatic medicine. In the functional disorders, patients experience physical symptoms but no organic referent for those symptoms can be found. Psychosomatic illnesses, in contrast, are "real" in that organic symptoms are observable.

In early theories of psychosomatic illness, organic syndromes were linked to psychodynamic processes with a crude narrative logic. For example, ulcers were caused by conflicts over the symbolic meaning of food stemming from the patient's relationship with his or her mother. Based on such theories, psychiatrists claimed they could cure various illnesses through psychoanalysis. Thanks to these treatment approaches, psychiatrists started to get jobs in general hospitals and medical schools. World War II brought further gains for the psychiatric profession as traumatized soldiers required treatment for their supposed psychosomatic illnesses. Alas, in the 1950s, the psychosomatic theories got their comeuppance as attempts to rigorously demonstrate the efficacy of psychoanalysis for physical diseases failed.

As psychodynamic theories began to lose the luster of scientific credibility, psychiatry reorganized its diagnostic schema. The Diagnostic and Statistical Manuals I and II, published in 1952 and 1968, based diagnoses largely on supposed underlying etiologies based on theories about repressed desires and frustrated fantasies and so on. But the DSM-III, first published in 1980 after a developmental process that began in 1974, based diagnoses on checklists of symptoms -- 2 from column A and 3 from column B and aha! You have Major Depression, or Boderline Personality Disorder. Little or no concept of etiology was provided. Since then we've had multiple revisions under the guise of various editions of the DSM-IV. (One of the most notable developments during this period was the elimination of homosexuality as a disease, after much political controversy.)

Since then, etiological theories have largely been driven by the interests of pharmaceutical companies that seek to have DSM disorders explained as chemical imbalances of one sort or another that can be corrected by drugs. For example, while the drug companies claim in their advertising that depression is actually a shortage of the neurotransmitter serotonin, there is no evidence for that whatsoever, in fact the evidence pretty much rules that out. In fact, the evidence rules out that there is such a "disease" as depression at all. People who qualify for a diagnosis of depression under the two from column A and three from column B criteria - or more commonly, in research, based on scores on a questionnaire of 20 or so items -- may or may not respond to antidepressants (usually not, in fact) and may or may not have various chemical signals or functional MRI patterns. One thing they do not have is a shortage of serotonin.

In fact, it is still true today that once an organic disease process is discovered which truly underlies a psychiatric diagnosis, the diagnosis ceases to be psychiatric. The only reason psychiatrists get to prescribe pills is because they don't have a clue what they're doing -- it's a purely empirical art, in other words, let's try this and see if it works. If it doesn't, let's try something else. If it does, great, but we don't know why it worked, or even if it really did -- maybe you just got better.

That is not to say that counseling can't help people. It definitely can, and that's something that psychiatrists still do, some well, some badly. But psychoanalytic or other kinds of psychodynamics based counseling have not been shown to be beneficial in trials. Rather, more pragmatic kinds of counseling -- teaching people to change bad habits, whether of thought or action -- are what works. And so, next time, on to bio-psycho-social concepts of health and the criticisms thereof.

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