Just what is wrong with you?! – How we diagnose mental illness in America
July 8th, 2013 By Steven Knope, MD
For those of us who grew up in the Midwest, this was a question that virtually all children heard from their mothers at one time or another. Seemingly rhetorical, the question was meant to convey the message that there must be something seriously wrong with any young boy who would put his sister’s Barbie doll in the garbage disposal and then flip the switch. Of course, young boys exhibit such inexplicable behavior on a regular basis. Such behavior is quite normal among children, along with stuffing peanuts up their noses and jumping off the household appliances wearing a cape fashioned from a pillow case.
So who determines whether behavior is normal or pathological? What represents a real mental illness? Who decides on the criteria for mental disorders? Well, shrinks make up these rules. Psychiatrists are the legal and societal arbiters of what is considered normal and what is deemed mental illness. However, as it turns out, modern psychiatrists are often not much better than our mothers were in differentiating true mental illness from normal variants.
In the year 2013, psychiatry is – at best – a soft science. The field is still in the Dark Ages. The brain, the organ that is responsible for generating all human behavior, remains poorly understood. There is no simple test, like a CAT scan or MRI, to determine whether someone is depressed, suicidal, or sociopathic. Instead,psychiatrists make diagnoses of mental illness based upon a set of symptoms. Making a psychiatric diagnosis is like using a Chinese menu: If you have 2 symptoms from category A, and 3 from category B, you might have “depression” or a “borderline personality disorder.” Quite shockingly, there is no “gold standard” for making psychiatric diagnoses, as there is in most medical diagnoses. This is why if you put 2 psychiatrists in a room you can get 3 different opinions. Much of it is hocus pocus and conjecture. Much of it is subjective.
The State of the Art
So what is the definitive guide to making psychiatric diagnoses in 2013? It is something called the Diagnostic and Statistical Manual (DSM). The DSM has been the bible of psychiatry since 1952. The DSM has recently undergone its 5th revision, the first major revision in 20 years. And if you look closely at this new version, you will see that there is still precious little science underpinning modern psychiatry. Mental illness is defined by committee; a committee of shrinks. These so-called “experts” argue amongst themselves about what is normal and what might be a disease.
As was pointed out in the WSJ, this revised psychiatric manual, or what is called the DSM-V, is facing very mixed reviews. There is much controversy about changes that have been made in this latest version of the psychiatric bible. For example, some personality disorders have simply disappeared from the DSM-V, such as Paranoid, Schizoid, and Histrionic Personality Disorders. How did that happen? Are we to understand that people who were previously diagnosed with a Histrionic Personality Disorder – people who had profound social dysfunction from their histrionic behavior – no longer have a serious problem? Is it now normal to wear a cocktail dress with a plunging neckline to pick-up a few things at your local Safeway?
During the revisions, some committee members argued for the removal of the Narcissistic Personality Disorder from the DSM-V. Really? Perhaps our society has become so narcissistic – with the advent of Facebook, Twitter, and social media – that narcissism is now considered the new normal. (“Just ate a burger, LOL!”) However, after a long debate, the “experts” agreed that Narcissistic Personality Disorder will still be considered a mental illness as of 2013. For the layperson, this means that politicians should still be given some empathy for their condition.
An even more illustrative example of the “soft” and even political nature of psychiatry is the issue of homosexuality. In 1974, under a great deal of social pressure from the gay community, homosexuality was removed from DSM-II as a mental illness. Prior to this, to be gay was to be crazy. Interestingly, there was no new evidence introduced in 1974 to support this change. Being gay was a disease in 1973 and it was suddenly not-a-disease in 1974. Compare this arbitrary decision making to other disciplines in medicine: Is a urinary tract infection controversial? Do internists wake up one day and argue that UTIs don’t exist? Do cardiologists decide suddenly that suffering a heart attack is no longer a disease? Of course not! This is because we define infections, heart attacks, and other forms of physical illness based upon objective criteria – things that we can see on scans or examine under the microscope.
There is Hope
The good news is that neuroscientists are working hard to bring psychiatry out of the Dark Ages. Researchers are starting to understand how the brain works (and fails to work) in ways that will no doubt lead to a deeper understanding of mental illness and even bothersome behaviors that many of us would like to change. Many neuroscientists believe the key to understanding the brain is to examine the vast network of connections between our brain cells, as opposed to the size of the brain or the number of bumps on its surface.
What we now know about neuroanatomy is that each one of us has a brain that is composed of about 100 billion brain cells. Our brains all appear quite similar on CAT scans and MRI scans. However, at the microscopic level, each brain is completely different and unique from every other brain on the planet. Each of our 100 billion brain cells are connected to each other by 2 trillion tiny hair-like threads called axons. This network of connections is very different from person-to-person. It is our unique configuration of connections that makes us who we are. “Bad wiring,” if you will, is what creates sick behavior.
If you look at the brain under a microscope, you can see these tiny connections and begin to appreciate the complexity of the brain. This pattern of connections has been dubbed the “Connectome.”
The neuroscientist, Sebastian Seung, likens theConnectome to a vast forest, so dense that no light could begin to shine through to the forest floor. Even more interesting, this forest is not static. It continues to grow and change over our lifetime. Certain connections are reinforced over time by our experiences and our environment. New connections are made, in part, by our experiences and environment. Other connections are pruned back. New cells form in the brain over time, which add their own set of new connections.
In the future, it is hoped that by understanding the Connectome, using supercomputers and advance imaging, we well better understand how the brain functions. Equally important, we will learn how the brain malfunctions. We may begin to understand the neurological basis for the broken brain. When someone is depressed, we will understand the anatomy of depression, and we will be able to target our treatment to the individual. If someone has the destructive and persistent personality features of what we now call a Narcissistic Personality Disorder, we will know what that looks like in the brain. We will have a deeper, scientific understanding of why people with schizophrenia suffer from a familiar pattern of symptoms that clinicians recognize, but presently cannot cure. We will understand why sociopaths kill. We might even understand why politicians lie.
Until we better understand the brain, we will be left with the soft science of psychiatry and the new DSM-V. This is good news for Dr. Phil and other talk show hosts who make millions in peddling psychobabble on daytime television. However, our ignorance is bad news for the scores of young children who will continue to be placed on Ritalin for “ADD,” which will likely go down in the medical history books on the same page with bloodletting and treating hemorrhoids with hot irons.