2016 DeVos Medical Ethics Colloquy: The Medicalization of Society

Thank you Dr. Tomatis. It is an honor and a privilege to be here. I was connected with Dr. Tomatis and he asked
me if I would be the moderator for this event. At first I wasn’t sure exactly why he chose
me, but then we talked about the topic — the medicalization of society — and how that
may interface with not only medicine but psychiatry in general. So welcome to the 24th DeVos Medical Ethics
Colloquy. Think about those words for a second – ethics
and colloquy. I’m going to circle back to that phrase. This colloquy is hosted by Grand Valley State
University, so thank you Grand Valley State University for hosting this. My nephew is currently living in my basement
and going to the Grand Valley State University Honors College, so I thank you Grand Valley
State University. My nephew wakes me up at five o’clock every
morning to work out, so I don’t know how I feel about that right now. Regardless, we’re extremely happy and excited
to have you joining us today. Just to introduce myself, my name is Bill
Sanders. I am a psychiatrist, and I work at Pine Rest
Christian Mental Health Services in town here. I did my general psychiatry residency training
at Michigan State University and then after I finished my general adult psychiatry residency
training, I went down to the University of Florida and did a fellowship in forensic psychiatry
for one year. I had the privilege of working in the prison
system, working on death row, and kind of with the medicalization of society sometimes
I think about that in terms of the medicalization of criminal behavior. That too is a topic that we talk about in
forensic psychiatry quite a bit. In terms of thinking about ethics, at Pine
Rest we started a psychiatry residency training program, and as we were developing that training
program and thinking about our roles as psychiatrists and as physicians, I felt that ethics is one
of the most important things we have to deal with. Just to be able to take a step back when we’re
training our psychiatrists. So much of their focus is on the day to day
standardized medicine and the care of patients that sometimes you need to take a step back
and really kind of think about what we’re doing. So I insisted that we have ethics in the first
year of the curriculum of that training program. When we talk about the definition of ethics
with the residents, the definition I like and that’s easy for them to remember is
ethics is knowing the difference between what you have the right to do and what is right
to do. So, we’re trying to help them distinguish
between knowing the rules in practicing medicine and doing the right thing in medicine. I was just kind of reviewing that concept
with the residents today. It’s not always clear what is the right
thing to do, especially with the medicalization of society and thinking about the different
things, and I’m sure our speakers are going to touch on this and I don’t want to get
too much into the definition. But thinking about things that may have been
medicalized like obesity, depression, anxiety, child birth, and things like that. I’m always a little bit taken aback that
male pattern baldness is one of those as well. So I half wonder if that’s why Dr. Tomatis
wanted me to do the moderating today. Regardless, I think that we have an interesting
topic to review today. In the real world sense of things, just today
there was an article that was sent to me by a resident titled “Does Psychiatry Worsen
Mental Illness Stigma?” It stimulated a really thoughtful discussion
by board certified psychiatrists who were sending emails back and forth within a couple
hours. So just briefly, one of the comments was,
“The brain, as we know, is more than the sum of its anatomic parts. It is Grand Central Station for all the other
organs to communicate with one another. The brain is the organ that controls feelings,
thoughts, and behaviors of the organism. When we feel sick because of physical or emotional
pain, it is our brain telling us we feel sick. It is our brain thinking of ways to feel better. It is also our brain controlling our sickness
behavior. It’s okay for us to be the people who name
what we do instead of letting others name it for us. We are psychiatrists, the first physicians
to specialize in the treatment of brain disorders. Just as Pinel freed women from chains in the
1800’s, let us physicians and knowledge sharers free the minds of others and embrace
our brains in sickness and health.” One more comment and then I will get to our
speakers. In a reply it said – this is the end of the
next statement, which brings me to the point brought up by the previous doctor – stating
that “it is a biological fact that the brain is the organ that controls feelings, emotions,
thoughts, and behaviors. I personally refuse to reduce my entire humanity
and that of others to a collection of synapses, action potentials, and neurotransmitters. Our feelings and thoughts, which control our
behavior and clearly abstract notions, are immaterial whereas the brain is very tangible,
concrete, and physical. Does the brain actually have a localization
for our sense of beauty, compassion, love, poetry, hope, peace, and justice? The cerebral cortex is nothing but layers
of neurons, dendrites, and glial cells communicating and sending electrical impulses to subcortical
areas and other organs in the body. But who/what is giving others these neurons
in the first place? I think psychiatrists and other scientists
should free themselves from the reductionist views of the brain as the master organ and
start embracing the existence of higher controlling and pervasive power.” That just happened today. That’s why we’re getting today to kind
of figure out, what is this all about? What is the medicalization of society? I’m not going to talk much more because
we have two very distinguished presenters who are going to answer that very question
for us today. Speaking first will be Dr. Jerome Wakefield. Dr. Wakefield is university professor of social
work and professor of the conceptual foundations of psychiatry in the school of medicine, as
well as affiliate faculty and advisory board member of the Center of Bioethics, at New
York University. After Dr. Wakefield speaks, we’ll have Dr.
Michael First, who is a professor of clinical psychiatry at Columbia University, a research
psychiatrist at the Biometrics Department of the New York State Psychiatric Institute
and maintains schematherapy and psychopharmacology practice in Manhattan. So without further ado, I’m going to let
these two very capable and distinguished speakers get started. Dr. Wakefield, you’re up first. First of all, I’m honored and delighted
to be here. There are so many people to thank. This is just a few of them – Bill, and others
on the organizing committee, and so I thank you all for the efforts you put in to create
this wonderful occasion. I think it’s particularly wonderful because
there is such an interdisciplinary group here and that, to me, is very, very important. Philosophy, clinical theory, these are interwoven
in a way and they need to meet and this is one place where they are meeting, which I
really, really like to see. No conflicts of interest that I know of and
as an ethical issue, I just say right away, I’m going to be talking about what is and
is not a disorder. Now in this group I probably don’t have
to say this, but in a lot of groups I need to say: Don’t take anything I say as sufficient
to diagnose your cousin or your spouse or something like that. That requires assessment by an expert. I wasn’t officially involved in the DSM
effort so I’m not bound by any confidentiality agreements, and a lot of the stuff I’ll
be talking about is copyrighted by the APA and they have no particular involvement in
this presentation. Look, the topic we’re talking about here
is a really important one. It’s just the beginnings of it. The question is to what degree is our medical
knowledge, especially in psychiatry as we enter on this new era of exploration of the
brain, going to change our ability to regulate all manner of our behavior? We have people talking about regulating the
degree of affection, regulating all sorts of feelings, emotions, attitudes, and we actually
have some initial knowledge about how to do that. We have initial knowledge about triggers of
sexual interest and of aggression, and guess what? There’s a little section of neurons that
if you fire those it’s both sexual interest and aggression simultaneously. We’re learning a lot of stuff that is going
to challenge how we think about ourselves, give us powers to manipulate behavior. We’ve got to be thinking about these ethical
issues and their conceptual underpinnings. There is a fear that just as we see with globalization
and technology advancing, that this new knowledge of the brain and its effects on behavior and
our ability to manipulate it with new neuron level manipulations that we’re now capable
of for the first time — the science fiction fantasy is it could lead to a world that doesn’t
tolerate deviants, doesn’t tolerate difference, that insists on efficiency, efficiency, efficiency. You know, I work a lot on grief and the pathologization
of grief, and the way that young people say when I finish these talks they come up and
say if something happens and I’m grieving and I’m out of work for more than a day
people say go get some medication and come back. We need you. The efficiency motive and a kind of totalitarianism
in a psychiatric sense is a kind of nightmare people have. Also there are these questions everybody is
starting to ask. If you fall in love with somebody who is on
antidepressants, have you fallen in love with them or have you fallen in love with some
version of them that’s on the antidepressants, and what happens when they go off the antidepressants,
are you still committed to that person? And so on. There are a lot of interesting questions that
are arising. Who is the real you? Peter Kramer argued some time back that if
you’re feeling depressed and you take antidepressants, the real you is the person that emerges when
you’re taking the antidepressants. Other people say no, that’s not right. Antidepressants are perturbing you from the
real you. All these issues about who we are being raised
by these new capacities we have for manipulating ourselves. And it all also reflects a very deep issue. We’ve never been able to resolve since Descartes
the mind-body problem, and that sounds like a trite statement for a philosopher, but in
psychiatry it has an impact every single day that’s a very immediate impact. We don’t really understand how to put together
our folk concepts of belief, desire, emotion, meaning, with the simultaneous understanding
we’re getting of the brain going on and determining what we’re doing. There are two levels here that have to be
put together, understood together, and yet nobody has a satisfying, or at least has evoked,
a consensual attitude towards how to resolve this. And as a result, we have a kind of split in
the field between people who want to focus on meaning and people who think maybe meaning
is an epiphenomenon that we’ll get rid of and all we’re going to know is about the
brain. Maybe beliefs and desires are a prescientific
notion and we’ll get rid of that eventually as we come to understand the brain. So, these very deep issues and the philosophy
of mind that go back several hundred years, are actually right now intersecting with where
we are in the knowledge we’re developing in psychiatry. It’s an amazingly interesting time to be
dealing with these issues. At a more personal level, I know there are
a lot of clinicians here. I call this the clinician’s dilemma. Psychiatry has expanded so rapidly. I think there is no doubt, as I’ll argue
a little later, that we are in fact overdiagnosing disorders, especially mental disorder, at
enormous rates in many instances. If you agree with that, then you’re faced
with the fact that, as a clinician, if the diagnostic criteria that are put forward officially
are too broad, and I have somebody come in and I think they need and deserve help, but
on the other hand I truly don’t believe that they actually have a disorder. What do I do? This is a dilemma. This isn’t a theoretical dilemma. My friends who are in clinical practice face
this every day. I have people who, let’s say, do only ADHD
work. And I say to them, well of your hundred percent
of practice, what’s the percentage of people that truly have a disorder and which are the
kids that just are too fidgety for school? And you figure they’re in normal range but
they need something to help them do well, and their parents want it, so you go along
with that? And this has been discussed in the New York
Times, this practice. It’s not a shocker or a radical critique. Of course, it’s going on in massive scale
and my friends tell me 50 to 75 percent are probably not disordered and the other 25 percent
there is really something wrong with their attentional mechanisms. This is a dilemma. People that come in who are sad, who have
life circumstances that are terrible. It comes up all the time in clinical training. So the clinician’s dilemma is a real one
and it is an ethical dilemma that I’m not going to try to solve today. I’m going to try to understand what’s
behind it and the intellectual underpinnings of some of these issues, but it’s something
that needs to be addressed more. We are living in a reimbursement system that
is self-defeating, I think often cruel and unjust; but it is the reimbursement system
that allows us to gain support to help people. How do you deal with it when people need and
deserve help but they don’t technically fall under the requirement of medical necessity
in a literal sense? I’m going to get to some examples of this. Medicalization is really a huge domain these
days of discussion and I’m going to quickly go through a couple of other senses of it
before I get to the sense it’s going to occupy me today. I’m going to just be focusing on one sense
of medicalization. But, the first sense is just the professional
domain, the shift of authority to the medical profession. Things that have been generally treated by
other groups as being non-medical issues then get treated by doctors. This can include an enormous number of things. They don’t have to be disorders at all. Childbirth versus natural delivery or delivery
at home with a midwife … but now it’s monitored by a physician, takes place in the
hospital, and so on and so forth. That’s one sense of medicalization – something
coming gradually under the authority of medicine and having its monitoring over it. Menopause is often mentioned here. Cosmetic surgery related to beauty. Alcoholism used to be more of a moral problem,
now it’s considered a medical problem. ADHD used to be rambunctious children, a discipline
problem, now it’s a disorder. So these are all things that have moved under
medical authority. I’m not saying all of them are nondisorders. Some of them may be disorders, but they’ve
all moved under medical authority. A lot of this discussion goes back to Ivan
Illich in Medical Nemesis where he talked about the medicalization of death and how
what was considered to be the natural process of death has become anything but, with people
in the hospital and fighting every step of the way, even when it makes no sense. This actually gave rise to some degree to
the hospice movement and palliative care. It was a very influential book. I won’t be covering everything in the slides. I’ve got too many slides. Please forgive me. I will be using them to trigger what I want
to say and later on this will all be on YouTube or somewhere if you want to catch up on the
details that you missed on the slides. The second sense is biologicalization that
is coming to see things in terms of the biology underlining whatever the phenomenon was, when
it wasn’t initially thought of that way. So addiction isn’t intense desire and bad
choices but it’s a brain disease, as we are told endlessly by the government, and
generally we use talk of the biology now to just dismiss something. These are actual conversations I’ve had. Why did X commit suicide? Because he was bipolar. There’s no meaning content to it at all. It’s just a disorder that’s presumably
biologically based. A concern here is that biologicalization has
no morality to it. There’s a question of whether it undermines
our moral discourse to be talking about each other this way below the meaning system level
in terms of the biology. On the good side it may relieve us of stigma,
that’s the argument. On the bad side, it seems to undermine moral
commitments. Now actually, just as a matter of philosophy
here for a moment and not a matter of describing the field, the argument that going to a biological
level somehow relieves us of moral censure is actually fallacious in my mind. I mean, people who believe this generally
argue that everything mental is biological; therefore we might just as well describe everything
in biological terms. That’s their general attitude. Everything mental is really biological so
let’s just go to the biological level. But if that’s true, then moral weakness
is biological and the biological level trait that you’re picking out may well be the
trait that corresponds to moral weakness. And so it may well be that in talking about
biology, although you’re not directly talking about it, you are indeed actually still talking
about moral traits and they can then be brought back up into the conversation if indeed they
are what this biological process is a substrate for. Now very often, actually, morality and disorder
go together. People have blamed people for getting PTSD
or War Neurosis in the old days because they considered it a byproduct of being a coward,
that you weren’t brave enough, therefore that’s why you weakly fell prey to this
disorder. There are other examples of this. It’s not a clean cut break between the biological
level and then getting rid of the moral level, but it is true that this is one of the things
that bothers people the most. What about the reduction of stigma argument? This is one of the main arguments used by
people who want to go to the biological level of discourse. We’ll get rid of stigma because then we’re
not talking morality anymore. We’re not talking about meaning. We’re not talking about the person’s personality. We’re talking about their brain. Therefore there will not be moral stigma,
as in “oh you’re a weak person” or “you’re a person who is a coward” and so on and
so forth. Leaving philosophy aside here and going to
the empirical literature, it turns out that if you’re worried about stigmatization of
people with mental disorders, it’s just empirically not true. There have been a lot of studies of this. It’s just empirically not true that biologicalizing
it, suggesting it’s due to biogenetic underpinnings, is going to relieve the person of stigma as
it’s usually measured. Stigma is measured in a variety of ways, not
only moral blame but, for instance, would you be willing to live near this person or
next to this person? Would that bother you? Would you keep your kids away from this person? There are many measures of stigma. Do you think this person has the possibility
of getting better? Turns out if you actually study this in detail,
you find that people are very subtle philosophers about this, and depending on the specific
nature of the disorder, and the specific biological theory of it, they come to all sorts of varying
conclusions. In a major review recently what they found
was that in the conditions they studied, it did reduce moral blame to say that something
was biological, it was in the brain, but on the other hand it increased pessimism about
the person ever changing and it did not constitute a major criterion. It did not change desire to be distant from
the person and to avoid them. So, there’s no simple cure as far as the
empirical studies go, there is no simple fix for stigma in biologicalization, contrary
to what you hear. Now I’m getting to what I’m going to discuss
for the remainder of my time, which is conceptual medicalization. Another word for it is pathologiza-tion, which
is labeling something as a disorder, and I’m going to focus on mental disorders, when it
is not in truth a disorder. When you do that, you get what I generally
call a false positive diagnosis. It’s a diagnosis of disorder of some condition
that is not really a disorder. So that’s what we’re going to be talking
about now. Thomas Szasz really started this conversation
off in its modern form with his claim in The Myth of Mental Illness that there is no such
thing as a mental disorder and that psychiatry is just about social control. We use medical jargon to justify psychiatric
intervention and using medical techniques to control the behavior that we find irritating
or undesirable. Michel Foucault helped it along with a historical
perspective on the transformation of nonmedical problems into medical problems of psychiatric
disorder. Medicalization is often used as a negative
term, but I’m using it neutrally here to describe something. Yes, it’s got something against it right
out of the gate because I’ve said I’m using medicalization in the sense of conceptual
medicalization of cases where you are not correctly diagnosing. So that’s negative. You are actually telling an untruth about
the condition. You’re saying it’s a disorder when it’s
not. But it could well be that in some cases that’s
morally justifiable, as I indicated before in talking about the clinician’s dilemma. So it’s not necessarily always bad to do
that and I think the question that I want to address is would it be okay and why are
we so open to doing this? You would think if there is massive overdiagnosis
and there are protests against it, that it would be easy to just extirpate it from the
manual because everybody would agree. But we don’t agree. And I think there are reasons beyond conceptual
confusion for why we don’t agree. I think there are moral reasons. To say what I’m about to say I have to have
a concept of disorder and unfortunately this could take us the whole time, so the concept
of disorder itself is highly controversial. I have staked out a position. What’s clear is that psychiatry does much
more than treat disorders. DSM itself lists “Z Codes” that are not
disorders that are often seen by mental health professionals . . . We help people to enhance
their potential. We help people to cope with stress and all
sorts of other things – marital problems, and so on. But mental disorder is at the core of our
profession, mental health professions in general, because we are health professions. Otherwise we would not be health professions. We would not have the privileges and responsibilities
that the health professions have. More or less everybody understands that this
is a necessary criterion, that we must address this, and then all these other things are
kind of add-ons to some degree. If we confuse disorder with other conditions,
lots of problems arise. If you want to do research to find cures for
disorders and you have a mixed sample of people. Let’s just take my area of grief and sadness. Because the criterion is so broad you’ve
gone out and used the criteria to select the sample. The sample actually consists of a bunch of
people who are having normal reactions to life vicissitudes making them sad or grieve,
and then some people have something genuinely wrong with their sadness generating emotional
systems or whatever that is. Your results are not going to be interpretable. You won’t know down the line if it actually
helps. Your results are going to be muddied by this
mixture of people. In fact, you might not even be able to tell
that an agent, let’s say a pharmacological agent, helps when it does help disorder because
the results may be muted by the inclusion of a lot of people that are going to naturally
be getting better because they have transient conditions abnormality. In other words, it poses basic challenges
to the entire research enterprise, and yet this is the kind of thing that’s going on. A gigantic research enterprise based on definitions
that in my mind are often dubious. Of course, at a more immediate level informed
consent is problematic. And then there’s prognosis: is this a transient
normal reaction or a disorder that’s going to go on and on? Should I be doing heroic things to prevent
recurrence or not worrying about recurrence at all? All of these things, as well as policy formation,
all of this depends on some accuracy in picking out what is a disorder and what is not. Plus there are lots of practical issues involved
in getting diagnosed when you don’t have a disorder, from life insurance to custody
trials and so on. Slapping down a bunch of criteria to show
something is irritating and bad isn’t enough to make it a disorder. Here’s Jordan Smoller, who is now a psychiatric
geneticist at Harvard, when he was a medical student. The etiology and treatment of childhood. He tried to make fun of DSM, so he put down
a bunch of criteria, you know: Well, this is a serious condition we’ve been ignoring. Childhood. Look at the disadvantages. Your social role impairment is enormous. You can’t really do anything. You’ve got congenital onset, which obviously
makes it suspicious. It’s genetic. You’ve got severe dwarfism relative to normal
people. You’ve got emotional liability and immaturity
that’s comparable only to severe personality disorder, and so on. Like my favorite, of course, being legume
anorexia – the inability to eat vegetables that are good for you, like spinach and broccoli
and so on. So slapping down a bunch of criteria that
look like something that’s problematic is not enough to make it a disorder, which is
a problem here. Now I propose that a mental disorder or a
disorder is a harmful dysfunction. It’s got to cause harm. There is a value component. Harm has to come out of a dysfunction, something
going wrong with some internal mechanism. By going wrong I mean that it’s not doing
something it was biologically designed to do, which I relate ultimately to evolutionary
theory. Every statement I just made is highly controversial
and has been controverted and I can’t go into it more or that would be the remainder
of my time. This is somewhat parallel except that it expands
on the DSM’s definition of disorder. But the point is, it’s got to be something
going wrong. It can’t just be something that we don’t
like. That eliminates social deviance. That eliminates other forms of things that
we just want to get rid of. It’s got to be an objective fact of something
going wrong. Even if we don’t know that it’s there,
we’re inferring it. We don’t know what’s going wrong in most
mental disorders, but we infer circumstantially that something is going wrong from the way
human beings are biologically designed to operate. Their anxiety systems are going off helter
skelter all the time, not when there’s danger or any threat. They can’t think in a rational way. Whatever it is, we judge that something is
going wrong with some system, even if we don’t know much about it. We’re at a primitive level here still. Medicalization, labeling something a disorder
that’s not a disorder, has a lot of problems and has some benefits. It may remove social stigma, there is still
that argument; it may relieve guilt like a parent with an ADHD child who feels relief
when the child is diagnosed and so on. But it also has a lot of disadvantages: it
encourages reliance on experts, undermines existing institutions like the church and
other institutions that have traditionally dealt with people’s suffering and ways of
coping. Especially in our brain disease era, I want
to make this point. Right now we’re going through an era … you
know thirty years ago it was all psychoanalysis, now it’s every mental disorder is a brain
disease. In this era what that means is that whether
you as a clinician do it or not, further down the road with that disorder diagnosis in the
file, the person is quite conceivably going to get medication or some pharmacological
intervention, and the side effects may not be warranted in that case. So there are a lot of these problems. Another problem is that according to the Supreme
Court in two different times when they were evaluating sexual predator laws, having a
disorder justifies the possibility of a civil proceeding that suspends . . . It doesn’t
suspend because it’s not applicable to civil proceedings, but it means that all the protections
of criminal proceedings are not applicable; so you can have civil proceedings for incarceration
in a mental institution even if you already served time in jail for your crime and have
been released. If the civil proceeding says you have a mental
disorder that might likely cause you to do the crime again, you can be put into an institution. That’s not double jeopardy. If you told your therapist in jail about things
you did, that can be brought up. Self-incrimination does not apply, and so
on and so forth. Preventive detention, something I thought
we fought the British over, does not apply. You can be put into an institution because
it’s thought with a certain percentage — and these percentages get pretty low — that you
might be a recidivising person. This matters. Constitutionally it matters. And the sick role. Of course we talk about constantly the relief
of the sick role, the good things about the sick role. You’re relieved of responsibility. People don’t morally blame you. What we don’t talk about is the other side
of the sick role. Once you’re in the sick role it’s assumed
you’re going to try to get better. It’s assumed that what you have is a disorder
that’s perturbing you from your normal state and that if you have a way back to normality
you will take it. The problem here is that it does mean that
as things get medicalized we create a narrow range of acceptability of emotions and behavior
for our children and our grandchildren. We have to think about what kind of world
we want to give them in terms of acceptable ranges of human emotions and human behavior. Now I promised to say something about why
we do this that’s on the positive side. I think there are several different reasons
for why the expansion of diagnosis so acceptable. I think one of the reasons I call psychological
justice. The fact of the matter is that normal variation
… not disorder … normal variation has portions of it that are disadvantageous in
any given culture. In our culture we make certain demands on
people to get good jobs, and so we make certain demands on people; and I think we recognize
that it’s not abnormal, but it is disadvantageous to the degree of perhaps unjustly depriving
people of opportunity in our system to have certain normal traits. If you’re a person who normally within normal
range doesn’t like getting up in front of an audience, seeing a large number of unsmiling
faces looking at you and probably evaluating what you’re saying at that very moment,
and a lot of people don’t like that, and you have various symptoms of anxiety that
keep you from doing that, that’s not very helpful in modern society because we are a
mass society, mass communication society, where many of the best positions require that
people get up in front of audiences that evaluate them and look at them. A lot of people are incredibly uncomfortable
with that. There’s pretty good evidence that it’s
not abnormal to feel that. If we’re going to treat people, whose only
problem is this performance anxiety, for so called social phobia, that may be more helping
them to access our social goods than it is to treat a disorder, and yet would we not
want to do that? It seems absolutely right because our system,
which we’re all benefitting from, as a matter of justice, owes them something for actually
creating a system that works well but makes them severely disadvantaged. Psychiatry, to the degree it can help make
up for things like that, is quite justified, and I think the clinician is justified, in
helping people. It’s clear the DSM includes lots of these
justice-related categories that have nothing to do with disorder. To take an obvious one, circadian rhythm disorder,
shift work type. This is the disorder that afflicts you if
you cannot adapt to having your sleep cycle shifted around constantly by shift work. Now it’s absolutely normal to be pinned
to a reasonable circadian rhythm sleep cycle and a lot of people have trouble adapting
out of it. It’s not an abnormality, but a large proportion,
a surprisingly large proportion of jobs in our culture, require your ability to sleep
at odd hours and changing hours, and so we have this diagnosis to help people. I think this is a matter of justice, not disorder. ADHD. I’ll just say this about ADHD. It’s one of the clearest cases there are
of wild overdiagnosis. I’m not saying at all that this disorder
does not exist. I’m not antipsychiatric. I’m not denying that there are children
who have disorders of their attentional or impulse control mechanisms. There are five different lines of research
that suggest that this is actually being overdiagnosed. I’ll just tell you one right now because
it’s particularly amusingly obvious and yet nobody has done anything about it. You take all the kids in a given grade in
school. By the way, the study I’m describing has
been done over and over and replicated. You take all the kids in a given grade in
school. In most cities it’s birth date that determines
it so the kids in a given grade have up to one year difference in their birth date. You look at the rates in a given year that
cohort going through, take a given year, 6th grade, 7th grade, whatever, and look at who
has been diagnosed along the way with ADHD. The biggest risk factor, other than the symptoms,
the biggest risk factor — we’re talking risk factors that are unknown in psychology
usually, like 50 percent or 100 percent greater chance — the biggest risk factor being diagnosed
is being one of the youngest in the class, being in those two or three months that make
you one of the youngest. Now, this has been out there for more than
a decade. There are replications across school systems
and guess what? There is no other explanation than we are
massively confusing disruption of class due to developmental immaturity because these
kids are younger with a disorder. Somebody should do something about this. The DSM-5 had a chance; they did nothing about
it. Instead they expanded ADHD to adults in a
way that I won’t go into now because of time considerations, but I think it’s simply
extending the wild overdiagnosis to the general population from children where it’s already
been evident. They did give new examples, so for instance
instead of your pencils and books for school, now it’s your tools, wallets, keys, paperwork,
eyeglasses, and mobile telephones. If you misplace them that suggests you have
a symptom of ADHD. If you hate reviewing lengthy papers or completing
forms or reports, this now is an adult form of a child symptom, and so on and so forth. Oh, I forgot to tell you a very, very important
one. Having trouble finding it here is, yes there
it is: difficulty remaining focused during lectures, conversations, or lengthy reading. So wake up now. Okay? So again the DSM has put social impairment
as a major criterion for a disorder all through the book. This confuses again, not that it’s not necessary
sometimes, but it confuses again our cultural pressures, the demands of our society, with
actual medical disorder. One more example just for fun here is sexual
dysfunction. All the sexual dysfunctions have a situational
specifier. That means you don’t have to have a general
dysfunction, you can just have this dysfunction when you’re with your partner. Now, is it necessarily a medical disorder
to only have a problem with your partner but be able to function perfectly well with other
partners? Most people historically … there was a big
argument in the 19th century about this … most people feel no, that just shows that you’re
uninterested in your partner or that you have a problem with your partner. That’s not in itself a medical disorder. So we have a lot of more or less subtle problems
here. Now, I didn’t get to the one I have talked
about in most of my own work, the bereavement exclusion and the diagnosis of depression. I will try to talk about that or I’ll answer
questions if you want to talk about that during the question period. But, it’s probably the most egregious area
next to ADHD where my own research actually has shown quite clearly that we are wildly
over-diagnosing depression. So, I will leave you there and stop at this
point. Thank you. Dr. Wakefield, thank you very much. You gave us a lot to think about. Just remember, the next part of the presentation
we’re going to be taking your questions and using them to ask our distinguished professors
their thoughts about the various topics that you’re hearing today. So make sure, the more clearly you write the
more thankful I will be. So clear and concise please. Without further ado, Dr. First, you are second,
so go for it. Well thank you very much. So, I’m much more of a practical person. My career has been involved in creating this
book that Dr. Wakefield has been making fun of a little bit. So I’m going to talk about is the DSM’s
role in the Medicalization of Normality. I guess I agree that there’s no question
that for a lot of the reasons that Dr. Wakefield talked about there is this trend. I guess I’m going to be very focused on
this issue about what’s the DSM’s contribution to that one way or another. One quick disclosure: I do get royalties from
books related to the DSM. One of the problems — in fact, Dr. Wakefield
illustrated it — is confusion about what it means when something is in the DSM. (The DSM is the Diagnostic and Statistical
Manual of Mental Disorders.) That title suggests perhaps that everything
included in the DSM is a mental disorder, and the thing that I noticed that Dr. Wakefield
included is circadian rhythm sleep disorder, shift work type. There’s also another one, that I’m surprised
Dr. Wakefield didn’t pick on: jet lag type. That was in there for a while. So having jet lag could be a disorder. Well, you know, it’s not a disorder. Circadian rhythm sleep disorder is not a disorder. It’s in the DSM for one reason: people come
see doctors with this complaint. There are people who are in bad shift work
situations where they keep changing the shift, you know, week to week, and these people are
unable to function because of that. They’ll go in for an evaluation, maybe not
to a psychiatrist but to a sleep specialist, sometimes a psychiatrist, sometimes a general
practitioner, and that person needs to get a code to explain what was the reason for
the interaction. The treatment may simply be quit your job
or whatever, whatever it might be, but you need to have … this is a real problem. There is nothing that says that that’s a
mental disorder. It happens to be in the DSM because the DSM
includes a section for sleep disorders and it includes lots of things in there like narcolepsy
and sleep apnea. Nobody says that these are mental disorders
but they’re there because the DSM is fundamentally a book to help mental health professionals
practice on a day to day basis. That’s what it was there for when it got
started. The DSM goes all the way back to 1952. DSM-III in 1980 was the one that became popular. Somehow, because this book has become so popular,
people like to look at it as the authoritative guide to what’s normal and not normal, and
that’s a problem. So being in the DSM does not necessarily means
it’s a mental disorder. As I just was saying, there are lots of non-mental
disorders, such as the sleep disorders, and there are things that Dr. Wakefield mentioned
that people come in to see a mental health professional for, things that aren’t disorders,
like grief. People come in for counseling because their
spouse died. The counselor seeing that person needs to
have a code to write down in the chart and do the treatment. So there’s a whole section recognizing the
fact that mental health professionals and counselors and other people see people who
don’t necessarily qualify for a medical condition. There’s a whole chapter called “Other
Conditions That May Be a Focus of Clinical Attention,” and in that section it defines
conditions and problems that may be a focus of clinical attention or that may otherwise
affect the diagnosis, course, prognosis or treatment of a patient’s mental disorder. These are the kinds of things included in
that chapter, all kinds of things like bereavement, relationship problems, physical, sexual, and
psychological abuse and neglect, religious or spiritual problems, child or adolescent
asocial behavior, phase of life problems, and on and on. These are things that you could imagine somebody
might walk into a mental health professional’s or a GP’s office with these complaints,
and that person might need to deal with them, and nobody is saying that simply because the
person walked in that they’re going to be getting a disorder. Now, what sometimes happens that I think Dr.
Wakefield was indicating is that the insurance companies and the government in their wisdom
have drawn a line about what they want to pay for. Historically, medical insurance exists to
treat medical problems. So that has sort of driven the whole industry. Anything that is a medical condition, insurance
companies will cover. Because these things are explicitly labeled
as not being conditions, the insurance companies are off the hook in having to cover them. Now if we lived in a perfect world and in
parts of the world where they don’t need a diagnosis for payment, these things would
be covered by the healthcare system. I don’t think people in Scandinavia are
not getting treatment for grief because it’s not a disorder. They’re getting treatment nonetheless, but
in the United States and some other countries this line is drawn. So what do clinicians do? As Dr. Wakefield talked about in the clinician’s
dilemma, people will sometimes make a disorder diagnosis simply to allow the person to get
paid, even though in their heart of hearts they know that that person doesn’t really
have a disorder. These codes and this section of the book are
rarely used code-wise because nobody gets paid. So there is an unfortunate tendency to pull
codes from the rest of the book. So one aspect of the DSM that I think makes
people feel like things are being medicalized is the fact that it includes things that are
actually not explicitly psychiatric conditions, but people get confused about what that means. But in fact there is a real problem here,
and Dr. Wakefield talks about false positives. I have been in agreement with Dr. Wakefield
for years that this is a serious potential problem with the DSM, which is basically labeling
something that is not a disorder as a disorder. This is true in all of medicine, but it’s
even worse in psychiatry. Our disorders are defined by signs and symptoms
that are not inherently evidence of psychopathology. So if you go through the DSM, as Dr. Wakefield
did with ADHD, pulled out a couple of lines of symptoms, of course those things occur
in normal people all the time. The building blocks of the DSM categories
are common normal things: anxiety, depression, dissociation, somatic concerns, euphoria,
irritability, fixed beliefs, perceptual disturbances. Those are the building blocks of the DSM disorders. But each one of those in isolation is not
inherently evidence of psychopathology. What makes something a disorder in the DSM
is usually two things. Forget the concept that Dr. Wakefield referred
to as harmful dysfunction; that’s sort of conceptual, how you think of something as
a disorder. The way the DSM is put together is lists of
symptoms that usually have to have a bunch together, so they group together not just
an isolated symptom. Several symptoms must occur together, but
most importantly, following what Dr. Wakefield referred to as the requirement for harm, usually
most of the disorders of the DSM have a requirement that they’ve got to cause clinically significant
distress or impairment. The problem, of course, is it’s entirely
clinical judgment. There’s this phrase over and over again
in the DSM that it requires clinically significant distress or impairment. People ask what “clinically significant”
means, and unfortunately it’s up to the clinician making the diagnosis to decide what
it means to be clinically significant. So it’s a very fuzzy line, which means that
it can be bent and stretched. So you could have somebody who has an attention
problem, they come in, their parent drags them into the doctor’s office and the doctor
thinks, well it must be clinically significant — the parent is dragging the kid in for help. It’s clinically significant, therefore end
of story: it’s a disorder. The built-in judgment here is …it goes both
ways. Theoretically, in the case that Dr. Wakefield
was talking about, which is this issue about kids who are younger in the grade are getting
diagnosed with ADHD — that’s not a DSM problem, that’s a clinician problem. People are making the wrong diagnosis because
they’re not using common sense. If you think about the idea of attentional
capacity as something that’s developmental, you have a certain capacity. Younger kids, of course, normally will have
less capacity for maintaining attention. The clinician is supposed to take that into
account when applying the diagnosis of ADHD. Unfortunately, more often than not that doesn’t
happen. So this clinical judgment goes both ways. It can sometimes cause cases to be put in
that shouldn’t be there, but it also helps keep cases out. Another predisposing quality of the DSM is
the fact the DSM … by the way, Dr. Wakefield and I keep talking about the DSM. How many people have ever seen the DSM? Are most people familiar with it? The DSM is maybe the #1 or #2 bestselling
medical book ever. Each edition of the DSM sells over a million
copies, which is astonishing if you think about the fact that there are only 400,000
mental health professionals in the United States. Who is buying the book? Nobody quite knows. It’s patients, families, students. It’s all over the place. But you can see it’s really out there, so
a lot of people, even if they’re not mental health professionals, may be familiar with
it. The thing that makes it very appealing is
the operationalized criteria. It boils the mystery of psychiatry and psychology
into these check lists, which is both its strength and its serious disadvantage. A lot of people have criticized the DSM rightly
by the fact that it makes pretend you can boil the field down, but this makes it prone
to the idea that you can develop self-report instruments, computerized interviews, things
that leave out the clinical judgment so the possibility of false positives from a screening
test is huge. Another reason why the DSM will promote medicalization
is the whole … when the DSM was created in 1983 there was a big push at that point
for psychiatry to be like the rest of medicine. Psychiatry was marginalized. It was heavily dominated by psychoanalysts. We want to be like the rest of the doctors. So the DSM really filled that role. When you opened up the DSM it looked pretty
scientific to have these lists. Looks like it came from some wonderful compendium
of data, but in fact it was built by experts doing their best to define these conditions. But the actual science behind it was pretty
weak in the beginning. Still, it looked pretty good, therefore it
looks like other medical sourcebooks, so that’s another thing that made the DSM promote medicalization. Now that I’ve talked about why it is that
the DSM has promoted the possibility of medicalization of false positives, I’m now going to go
to the other side and say we recognize that. This has always been a problem that has been
through different people working on the DSM and looked at more or less carefully, but
when I was working on it we took this very, very seriously, the false positive problem. The problem is, unfortunately, that the DSM
can be used by anybody, you can buy it off the book shelf, you can diagnose your friends. The idea is that to really use it well you
need clinical judgment. So we had to figure out what we could do to
the DSM and the definitions to prevent it from being misused for medicalization. These are some of the mechanisms that we came
up with. The first one is that phrase I kept talking
to you about, which is this requirement that the disturbance must cause clinically significant
distress or impairment. Again, the reason we do this is most … Let
me give you a couple of examples, why something like shyness is a good example, and social
anxiety, or ADHD for that matter, or autism. Take virtually any disorder like autism, social
anxiety disorder, depression. They occur on a continuum. There’s no bright line separating shyness
from social anxiety disorder or geeky kid from autism spectrum disorder. What we use for that is some decision that
when it crosses a certain point, there’s enough harm that we’re going to call it
a disorder. So this criterion has a huge sort of job within
the DSM in trying to set this boundary between disorder and nondisorder. And this is in contrast to medicine. People have picked on this as something which
makes psychiatry a little bit ludicrous. For example, you would not make a diagnosis
of tuberculosis and require the patient to be in pain or having some harm to make the
diagnosis. If you have the infection it is called tuberculosis. This requirement of some kind of role impairment
is something which is unique to psychiatry. We all recognize that that’s a weakness
of the DSM and psychiatry, but there’s no other way right now to be able to differentiate
normal from a disorder. Now the other mechanism that the DSM has used
to try to help differentiate normal from disorder is the idea considering context. The idea is that so we’re taking things
like anxiety. We all know that anxiety is normal. Everybody experiences anxiety at one time
or another. But if the anxiety occurs in a situation where
it doesn’t make sense, then we consider it a disorder. So something like generalized anxiety disorder,
the person is anxious all the time no matter what, and they’re anxious and worried about
insignificant unrealistic things. Somehow in that person their anxiety has become
untethered from their context. So that’s a marker in general for when a
symptom smells like it’s a disorder rather than just being something normal. So the way the DSM deals with that, what’s
really going on here and you can see in the example I gave you, is that you have to look
for when the symptom is untethered from its context. So there are several examples. Here are three examples from the DSM that
show you that. When you have the concept of hallucination,
it’s normal to have a perception, but if you’re having a perception without an actual
stimulus to trigger it, then we have the perception untethered from the context of the stimulus. Extreme fear in the absence of danger is the
core idea of how you diagnose a panic attack or a phobia. And separation anxiety, when it occurs in
the absence of a bond disruption, that’s again a marker of a disorder. So DSM tries hard to sort of institutionalize
common sense to try to differentiate disorder from nondisorder. So there are lots of conditions. Kleptomania is an example of a condition. Obviously stealing is not evidence of a mental
disorder. It can be but not necessarily. So in the definition of kleptomania we know
we don’t want to be labeling people with kleptomania if the person is stealing to express
anger or vengeance. Sometimes some of our disorders have phrases
in there … If we have something that we know is clearly evidence of a nondisorder,
we’ll explicitly put it in there. Some disorders — two disorders in particular
… There’s a disorder in the DSM called intermittent explosive disorder, which is
recurrent outbursts of verbal or physical aggression. Again, lots of people do that under all different
contexts — too much alcohol, just being irritated. But to make this a disorder from the DSM perspective,
a requirement is that the aggressiveness has to be grossly out of proportion to the provocation. So this is the person driving, you cut them
off, they get out of the car and they start smashing your car because that little provocation
triggers this out of proportion reaction. A specific phobia by definition, if you’re
faced with a tiger in front of you and you’re feeling frightened, that’s normal. If you’re feeling frightened of a little
mouse that’s on the other side of the room and you’re out of control with fear, there’s
an example where the fear that that person has experienced is out of proportion to the
actual danger, so that’s why we would consider that a disorder. Another important thing is many of our symptoms
are normal depending upon the age. Separation anxiety is normal in a two year
old. You would never on its own call a two year
old having separation anxiety disorder if it’s within what you normally see in a two
year old. So the definition of separation anxiety disorder
in the DSM specifically requires that it be developmentally inappropriate for that person’s
age. This is also true for ADHD. ADHD — there’s a clause in there as well
saying it’s normal for kids at a certain age to have trouble sitting still. You have to make a judgment. This is out of proportion to what you’d
expect. Enuresis, which is bed wetting, is another
good example. It would be ridiculous to label a four year
old as having bed wetting because the capacity to hold your urine overnight isn’t developed
until age five, so you wouldn’t make the diagnosis if it’s developmentally inappropriate
to do so. Another strategy that the DSM uses is to require
a symptom to occur in multiple contexts. So ADHD requires the symptoms to occur in
two or more settings. The reason that’s important here is that
if it’s really a problem and it’s really from the individual you wouldn’t expect
this to be in one setting. If it’s at school and not at home, it makes
you wonder whether the real problem is the school. There’s something about that schooling that’s
really not stimulating enough. You like to see it in multiple settings. That’s a marker of validity that it’s
not a false positive. Another example is requirement for a degree
of discrepancy between the patient’s belief system and external reality. What I mean by that is there is a condition
called body dysmorphic disorder where a person is preoccupied by what they believe to be
a defect in their appearance. If somebody has a birth defect that makes
them deformed and they’re embarrassed and preoccupied about it we wouldn’t consider
that a disorder, because you’d expect that. The requirement of body dysmorphic disorder
is if somebody walks into your office saying that I’m horribly embarrassed by this defect
and you look at them and you can’t see it at all, they look fine to you, that’s the
marker that is this disorder. I’m sure people here are somewhat aware
of the DSM-5 saga of development. There were lots of criticisms about the possibility
that the DSM was expanding false positives rather than contracting. I just gave you a whole bunch of strategies
to try to keep the false positives under control, but at least some of the criticism that was
proposed for DSM-5 was changes that might have expanded false positives. Any time you add a new category to the DSM,
those are the biggest risks of false positives. Basically what it does is . . . The idea is
that when you add a new category to the DSM in cases that were previously undiagnosed,
they will now be diagnosed and labeled as a new disorder. So obviously if those cases were normal in
the first place, then you’re going to have a disorder. The other thing is I mentioned before that
one of the ways the DSM makes diagnoses is we have you count up the number of symptoms
that are present and if you lower the requirement you’re going to potentially increase false
positives. So let me give you a couple of examples in
DSM-5. There is a new disorder that was added called
social communication disorder. This is the definition: persistent difficulties
in the social use of verbal and nonverbal communication in nonliteral or ambiguous meaning
of language. So somebody that’s unable to understand
jokes, inferences . . . so you can see right off the bat lots of people may not have trouble
picking up on jokes. People who are socially awkward, that’s
what I call a geeky child here; the normal case is the geeky child where we have this
disorder in the DSM called social communication disorder. The thing that helps make this a disorder
is the requirement that it results in functional limitations. Another new disorder that was added to DSM-5,
which is a real focus of concern, is something called disruptive mood dysregulation disorder,
and the normal variant of that is what we called bratty kid. The definition is severe, recurrent temper
outbursts with persistently irritable or angry mood in between the outbursts. So that’s the basic definition. What they tried to do to elevate it above
just a bratty kid, is the requirements of the outbursts are grossly out of proportion
or inconsistent with developmental level and occur in two out of three settings. Also the number of outbursts required for
this is actually pretty high. Hoarding disorder is another new disorder
in the DSM. Again, whenever you have a new disorder there’s
the potential for false positives, especially something like this. Lots of people collect all kinds of things
and fill their houses with them. As soon as this disorder is added, there’s
the risk that people who are just simply collectors might be labeled as having a disorder. The actual definition is difficulty . . . now
it turns out that even though we think of hoarders as collectors, the actual definition
of hoarding disorder focuses not on the collecting, which is inherently normal, but this difficulty
discarding or parting with possessions. I’m not saying that’s necessarily not
that normal too, but the focus is on this because what makes it a disorder is this combination:
difficulty discarding or parting with possessions that results in an accumulation of stuff that
clutters the living area so much so that they compromise their intended use. So this is the person who fills their house
with stuff so they can barely get around. It’s not just the person who has trouble
throwing things out. Here’s my final example of a disorder that
was criticized: binge eating disorder. Binge eating disorder is like bulimia nervosa
without the purging and excessive exercise. So it’s just the binging. So you get into this blurry thing here about
what’s the boundary between overeating and being obese and having binge eating disorder,
and it was partly criticized because the threshold that was set in the DSM was actually pretty
low. Basically a binge once a week for three months
was enough to call it binge eating disorder. Even though they do have the requirement that
causes marked distress, but in this case it’s probably not that helpful in keeping normal
people out of that. Now I did mention about the lowering the threshold? There are two examples where DSM-5 lowered
the number of symptoms required. Dr. Wakefield already talked a little bit
about adult ADHD. So ADHD you usually think of as a childhood
disorder, and it is a childhood disorder, but when you’re a child with ADHD and you
grow up to be an adult you can be an adult with ADHD. The reason for this new category called adult
ADHD is that there are people who weren’t recognized as having ADHD in childhood. Even though now ADHD is all the rage, twenty,
thirty, forty years ago ADHD was much less recognized; so there really are a number of
people out there who suffered through their childhood with undiagnosed ADHD. They’re only being diagnosed now that they’re
adults. So that’s the concept of adult ADHD. But DSM decided in a very controversial way
to reduce the number of symptoms required for adult ADHD from six out of nine to five
out of nine. So clearly when the DSM does stuff like that,
they are flirting with the possibility of increasing the risk of false positives. In substance use disorder, there was also
pretty big change. It went from three out of seven to two out
of eleven. That’s a pretty big drop. A lot of people have wondered about this and
there is some evidence suggesting that substance use disorder in DSM-5 may have a significant
number of false positives. The last thing I’m going to talk about is
the issue of epidemics in psychiatry. People are talking about an epidemic of ADHD
and an epidemic of autism. One of the problems is it’s very hard to
know when the actual incidence is increasing versus whether people are coming into treatment. Autism is a good example. The whole vaccine thing. Lots of these other environmental suspicions
about causes of autism come from the fact that all of a sudden out of nowhere the rate
of autism has exploded. How much of that is due to the fact that autism
is becoming more prevalent versus parents bringing their kids in to treatment with that
label because they’re more familiar with it? So getting into treatment and all the factors
that bring people to treatment make it very difficult to know what is a real epidemic
in the sense of an actual increase of prevalence versus an apparent epidemic simply because
people are brought in. Let me just jump to ADHD. There was a study that was done between 2003
and 2011 ADHD that showed cases went up 42% in diagnoses in children ages four to seven. That’s a significant increase. It’s hard to say that and feel that that’s
a real increase in prevalence. It’s almost certainly due to the fact that
parents are bringing in their kids more often for help. The point of this slide is to ask if that
so, what’s the role of the DSM? Well, it turns out that from that period of
time, from 2003 to 2011, the DSM criteria for ADHD hadn’t changed. It was stable. So from 1994 to 2013, the criteria were unchanged
because that was a very big gap between versions of the DSM. My point here is that while the DSM may have
something to do with some of this, clearly something else is going on. If the definition is unchanged. It really argues that other factors are involved,
like parents wanting their kids to get medicated because it’s easier to throw medicine at
them to get them to behave, or whether they want to give them an edge in testing, or any
of a number of other possible reasons why somebody might want to get a diagnosis. So the whole general issue about what the
role of the DSM is in medicalization is complicated because the users of the DSM, whether it’s
the doctors or the family members or the patients themselves, are often a big driver on coming
in for treatment. So I will stop here and we will open it up
now for general discussion. Thank you very much for your attention. While Dr. Wakefield and Dr. First get situated,
I just wanted to remind you to mark your calendars for the next colloquy: March 27, 2017, The
Ethics of Physician-Assisted Death. This is a new topic that not only is an issue
in the United States but worldwide as well, and it actually impacts psychiatric care. We’re seeing countries, especially over
in Europe and Eastern Europe, where they have psychiatric panels for people who have severe
depression or severe mental health disorders being evaluated if they are able to consent
for physician-assisted death. So this is a very interesting topic especially
in the state of Michigan, where we had to go through the process with Dr. Jack Kevorkian. So, March 27, 2017. The speakers will be Dr. Robert Arnold from
the University of Pittsburgh and Dr. Timothy Quill, University of Rochester School of Medicine. Now let’s get started and we’ll ask some
questions. For the next thirty-five to forty minutes
we’re going to go through some written questions, and after that we’re going to have some
live questions and we’ll have the mics open for questions. So first question, and this is probably a
good question for both but we’ll start with Dr. Wakefield. Does the healthcare system of the United States
make us more inclined to medicalize everyday problems so that providers can assure getting
paid for their work? That’s easy to answer. The answer is obviously yes. In many other healthcare systems in developed
countries you don’t have this kind of parsing of the diagnosis. In fact, in some countries you don’t even
have to give a diagnosis for most cases that you treat if you’re a psychiatrist, for
instance. Or there might be like in France, there are
certain special categories which are more expensive which you have to specify, but it’s
much more open. Because we are so focused on medical necessity
and on keeping a certain threshold in place, I think clinicians have overwhelming pressures
to diagnose and overdiagnose in order to justify helping people that need help. Look, I will bet that many of you in this
room have had relationship problems where you have gone to somebody. Relationship problems are not covered under
most reimbursement systems in this country; yet that’s self-defeating, right? You want to keep a relationship together,
that relationship might have children involved. Isn’t it self-defeating and foolish? The clinician wants to help, so maybe stretching
it a little or interpreting the symptoms so they fit — this partner might have generalized
anxiety disorder as a result of the partners arguing all the time. This one looks like they might have major
depression and so on. So you will get these kinds of diagnoses that
are out of a pressure for reimbursement all the time. My only comment is that unfortunately we know
that there is huge pressure in the United States to control healthcare costs, which
are exploding, and somehow, unfortunately, for a long time the insurance industry has
used this blunt instrument, which is deciding what’s a disorder and not a disorder, making
it clear what that is and basically forcing clinicians to have to shape things around
that. So I think there’s no question that our
system has helped create this problem. This question kind of goes along with the
last one. Discuss how health insurance has contributed
to medicalization. For example, increased treatment with medications
rather than more evidence-based treatments that require longer treatment sessions and
treatment trajectories to be successful. Dr. First, I’ll give you first shot at that
one. That’s a general issue, the push towards
medication. Part of it is the insurance companies are
favoring it. It’s very difficult to get coverage for
psychotherapy. It’s not so hard to get your GP covered
to give you Prozac. That fundamental bias in the insurance system
is clearly going to put pressure on people seeing these or wanting to see these things
as things that can be treated with medication rather than with talk therapy. So, you’re right. This insurance system is clearly pushing treatment
into a certain direction. It’s inherently more medical. You can see psychotherapy works for the disorder
depression, but it also works for grief and sadness. It’s a much broader thing. You don’t give pills to somebody who is
not disordered. By making pills the only option for many people,
of course you’re going to be pushing people into being given a medicalized label. I would just add that I agree with everything
that Dr. First said, but I would add to that that the pressure for evidence-based practice,
which is a reasonable one in some regards, also leads to the conclusion that — at one
point it led to the conclusion that pharmacological interventions had been studied better, could
be administered in a more research anchored way, in a more clear-cut way, and the idea
was out there that we have to bring psychotherapy around to that level of precision. How many sessions for how long fit this particular
case? You’ve got to titrate the psychotherapy
like you would titrate a medication. This is a little unrealistic, but we’ve
heard it even within the last year from one of the heads of the NIMH. So I think that has been pressuring things,
but the reality is that in almost every area psychotherapies, multiple psychotherapies,
have been shown to be just as effective as medication. The reality is this is a kind of stranglehold
that the pharmacological producers and the system have on clinicians pressuring them
in a certain direction, when in fact the efficacy of treatment is known to be equal to, or in
some instances better than, psychotherapy. I think it’s . . . At this point, where
evidence isn’t all in, you can argue it, but it seems to me an unjust bias of the system
at this point. Next question. I’m going to add a little bit on to this
question, so my apologies to the writer. Do you anticipate better tools for diagnosis
in the near future, e.g. MRI with enhanced uptake in specific areas of the brain? And in terms of biomarkers, psychogenomics,
and other strategies for diagnosis and treatment, how much do you see that influence in the
near future or distant future? I can’t tell you how much I wish I could
give you an answer that we are just around the corner. We are unfortunately very, very far away. It’s a little counterintuitive. You see brain scans and you think, for example,
that we know that patients with schizophrenia on average have certain brain findings compared
to normals. It doesn’t help you when you’re diagnosing
an individual. There are people who are pushing for the use
of neuroimaging claiming it helps, but right now, unfortunately, all the things you mentioned
– brain imaging, biomarkers . . . they were desperate during the development of DSM-5
to get a biomarker in the DSM. There’s only one biomarker in the DSM and
the diagnosis that has it is narcolepsy, which is not a mental disorder. Actually, in the criteria for narcolepsy there
is a cerebrospinal fluid assay hypocretin that’s low in narcolepsy. We want that for everything. Unfortunately, it doesn’t exist. I very reluctantly predict when that will
happen. The hope is that in my lifetime we’ll have
that, but we’re still very far away. That would change things. I think that the reliance on subjective symptom
reporting, I mean some of the concern about the overdiagnosis . . . if we had really good
biomarkers to help us know what’s disorder versus nondisorder; not that that solves the
problem, but that would help a lot. It’s the lack of that kind of hard biologically
based data that would . . . and in regard to Dr. Wakefield’s perspective, if you look
at harmful dysfunction, that’s the marker for dysfunction. If you actually had an objective marker that
would be really helpful, but we don’t have that. I think that would help with this problem,
but the lack of the tools keeps us there. I agree that there’s no biomarker information
that isn’t so fuzzy that it does more harm than good when you use it for diagnosis as
of now. Some day we may have that, but keep in mind
that that is . . . Mike was absolutely right that the biomarker will help tell us perhaps
if there is a dysfunction inside. But you’re still going to need the clinical
criteria to tell you if it is a harmful dysfunction. We know of many biomarkers in physical medicine
for which there is something wrong with something, but only 1% of all those cases have any clinical
disorder. So you can’t . . . there’s no magic here. You’re going to always be looking at the
meaning of the biomarker in that individual’s life to make your final, to draw your final
conclusion about whether there is a disorder. I guess the harm component is whether it actually
has an impact on the person’s life. We may actually have to still talk to our
patients? This question is directed to Dr. Wakefield. Could you say more about psychological justice
and why this justifies intervention of the kind you described and does not merely explain
it? I didn’t have time to say it all, but you
can see where I’m going. I said that I find our current reimbursement
system to be self-defeating and somewhat cruel. How could it ever be expanded? What would be the argument by which it might
be expanded? And if you look around at arguments . . . I
mean there are various possible arguments but one has been successful. There is one argument out there for extending
medical treatment beyond medical necessity that has been unbelievably powerfully successful,
and that is injustice in terms of our economic system. If you look at Supreme Court rulings — I’m
going by the discussions of the justices, and in this case, interestingly, especially
the female Supreme Court justices where they discuss why it is that it is essential for
the medical system to provide contraceptive technology to women, for instance, and other
reproductive benefits that have to do with regulating reproduction that has nothing to
do with disorder. Contraception is not about disorder. So why is that? And if you look at the various opinions that
they’ve put forward, the reason, it turns out, that’s given is in terms of justice. And I’m not going to go on a riff here about
John Rawls and how it fits with medicine and so on. I think it’s very interesting, but how theories
of justice could fit in here. I’ve written something about that, but the
point is, the rationale is, that if our system is such that we construct it in a way that
opportunity, the opportunity to partake and to advance yourself, is foreclosed under a
wide variety of circumstances that we can help you out of, then we owe it to individuals
to help them. And women in particular, in a system like
ours where there is equal involvement in occupational careers and equal interest in success, equal
benefit of the system to having everybody involved, the argument has been by these justices
that that justifies on nonmedical grounds the essential nature that medical insurance
must cover these kinds of provisions for women. Now, just taking that without going into it
further, I mean I see that as an analogous argument to the one I’m mounting for mental
health. I see psychological properties that are normal
variants that are extremely disadvantageous. I try to give a couple of examples, such as
inability to engage in mass communication in our mass communication society which we’re
not evolved in, and so on. But you can see many of them – ADHD, inability
to gain an unnatural level of stillness in school and focus beyond what children are
probably evolved for, but some are talented at it and some aren’t. All these things have become crucial to our
culture’s demands on people in terms of economic involvement and success, ultimately
including the education, of course. But they’re not medical problems because
what they are is they are part of the normal curve that we have to some degree excluded. So they’re not medical necessity strictly
speaking. What I see is an analogous argument for extending
a reimbursement at least to those areas where as a society we make it difficult for people
to succeed. So I hope that answers the question in the
way that it was asked in terms of what my rationale is and expanding on the notion of
psychological justice. Psychological justice is providing the opportunity
to develop those psychological properties that we demand of people to have opportunity
in the society we’ve constructed. Dr. First, the next question is directed to
you. Thank you for your thought-provoking talk. If over diagnosis is not an issue rooted in
the DSM, but a misuse or misunderstanding of the text by clinicians, why is there so
much misuse, understanding especially given the DSM’s role in making psychiatry more
medical? Well, the problem with the DSM is that it’s
a book that you buy and you use. There’s a limit to what the DSM can do to
make sure it’s used well. Everything I talked about were our attempts
to build into at least the definitions to try to make people do less stupid things,
smarter things. But the bereavement exclusion, which unfortunately
was eliminated to Dr. Wakefield’s and my chagrin, but that was there to put it bluntly
keep your spouse… person comes in, spouse died, they seem depressed, stupid thing would
be to say oh, they have major depression give them the medication. The smart thing is to say wait a minute, this
is normal grief. Putting it in as a criterion is a way to put
a red flag. Do the right thing and think smartly. The problem is people still do what they want. ADHD is a good example, you know. People will write down a diagnosis because
that’s what they think they want to do, they need to do, and they don’t read it
that carefully. I’m not saying the DSM has nothing in there. Every time you add a new diagnosis . . . I’m
not saying everything in there is perfect and could be leading to overdiagnosis including
the getting rid of the bereavement exclusion. So there were things that were done that still
could be improved in the DSM to help. I still believe that the bigger problem is
some kind of educational effort. I’m not sure exactly. It could be educational. Unfortunately, you don’t have to take a
test to use the DSM. You use it because you want to use it. If there was maybe some kind of educational
effort in residency programs and training about false positives. I mean there are things that could be done
to take this more seriously. But it’s got to be done on the user level,
not the book level. There is a limit to what the book can do to
get people to behave better. I think there is a slight point of disagreement
here. I do agree with Dr. First’s account of how
DSM tries to prevent false positives because these are smart folks who are clinicians. They can see certain obvious objections. The people who write out these definitions
are not philosophers. They’re not conceptual analysts. They haven’t been trained in the notion
of necessary and sufficient conditions. It’s much easier, of course, to come up
with necessary conditions. Well, to have an anxiety disorder you have
to have intense anxiety. What about all the conditions that make it
sufficient that distinguish it from all the range of circumstances where you have intense
anxiety but it’s not a disorder? Well, that’s not so easy. Yes, it’s true, that if it’s out of proportion
to the actual danger, that helps. But guess what? Your smoke detector goes off when the fish
is frying in the oven. It goes off out of proportion to the actual
fire in your apartment and that’s good. There are some areas of life where we biologically
have been selected to be overresponsive. We are anxious, vigilant creatures. I was once in a pool at my mom’s house in
Boca and a snake jumped into the pool with me. I could see right away that it was a garter
snake. It’s harmless. I discovered I could fly. It was amazing. I was like out of the pool straight up in
the air off to the side. So, that fear response to snakes doesn’t
stop for a moment and say uh, is this a dangerous thing? How proportionate is my fear to the snake? In other words, this is an Aristotelian vision,
that reason regulates all of our other emotions and so on. There’s a certain truth to that in a way,
but on the other hand when it comes to psychiatry you’ve got to look beyond that. It seems to me that Michael has made very
good points about this, but saying that there are some good things in DSM doesn’t, I think,
undermine the many objections one can bring. There are still many, many, many serious problems
there. I wish I could go through his slides and give
you the other side of these various disorders, the things that they didn’t do that were
left that are stupid. Also there’s another kind of point to be
made. The fact that the diagnostic criteria stayed
constant during a certain period and diagnosis went up does not mean the DSM is not part
of the fault. That’s just a fallacy. What it means is that DSM diagnosis as written
on the page interacted with something else. The fact that it could happen was made possible
by the DSM criteria. The fact that pharmacological, that direct-to-consumer
advertising exploited that over that period, the fact that parents came in and physicians
could exploit that easily during that period. There are a lot of factors which interact
with these criteria. If the criteria are broad enough, yes you
can interact with them in a way that gives rise to this huge false positives problem
even while the criteria stayed the same. It does take time also for the possibility
of exploiting criteria to become known, understood by clinicians and percolated out, and for
the motivation to be there, such as support of alternative education, special education,
and so on. Dr. Wakefield, you beat me to it: “direct-to-consumer.” And I have one more question, one of the more
popular questions we had. I want to talk about the direct consumer prescribing
and you brought that up and that was one of the questions. Dr. First, what are your thoughts on that? Do you think that had an effect as well? Direct-to-consumer advertising by the pharmaceutical
industry? I think the direct-to-consumer advertising
is a disaster. We’re one of the only countries in the world
that allow that. If I were president — I’m not debating
tonight — I would roll that back in a second. I think one of the big problems direct -to-consumer,
though, is the healthcare cost problem keeping people away from using generic drugs for the
most expensive stuff. It does have some impact here because, like
Dr. Wakefield kind of hinted about this, what is bringing the parents and people into their
doctors to ask for treatment? Like social anxiety disorder. Social anxiety disorder — several SSRIs like
Prozac got approved for social anxiety disorder. It wasn’t Prozac, it was Zoloft I think. That drug company went to town running ads,
putting ads of a checklist based on the DSM definition. Do you have this? If so, see your doctor. People come into the doctor and doctors are
busy, especially if you’re a GP. They just write the prescription. There’s no question that the pharmaceutical
industry for their own financial reasons has definitely had a huge negative impact on the
medicalization by manipulating the consumers to see this in a way that is medical for their
own benefit. So I agree. I think that’s only part of the problem. Advantages of direct-to-consumer advertising
are minimal. I mean it does potentially uncover unrecognized
cases. This is a good example where DSM interacts. I don’t think Dr. First would disagree with
this. So the DSM, as he pointed out, creates a set
of criteria; like with depression it’s nine symptoms and you have to have five out of
those nine symptoms. So that’s a pretty good threshold. But the symptoms differ in their severity,
or what I call pathosuggestiveness. They differ in how much they suggest a pathology
versus a normal reaction of sadness and they just consider them all equal. Then big pharma comes in and says well look,
we can present ads with the five most nonpathosuggestive symptoms and that’s going to suggest to
all the people out there that when they’re sad they should come in and see their physician. Look, if you’re feeling sad, you’ve lost
interest in stuff, you’re having some insomnia, your appetite is less, you’re having trouble
concentrating — those are all general distress symptoms when things go wrong in your life. They’re not suicidal ideation. They’re not psychomotor retardation. They’re not marked role impairment where
you’re lying in bed unable to function. But you can orient ads, and this is what the
pharmaceutical industry does and they don’t think they’re doing anything wrong. They’re saying the psychiatrist told us
this is a disorder, so we’re just trying to use that to help people. If DSM were more careful about that, it seems
to me, there wouldn’t be that ease of use where you could create ads out of weak symptoms
that then have this very broad kind of encompassing quality. So here’s a case that illustrates the interaction
of maybe insufficiently incisive criteria with other actors that can use that. It’s exploitation, but it’s using what’s
there. So you would suggest that the pharmaceutical
companies know how to market and they know that medications with the letters PQXY and
Z sell better than some more scientific terms and that medications in purple packages sell
better. That might be true. This was a popular question. I think because we ran out of time in your
lecture and presentation . . . Give us more information about –there were several questions
of this kind — about the overdiagnosis of depression. How do you differentiate appropriate sadness
due to a life circumstance from clinical depression? Isn’t this a huge gray area? I think we just didn’t have time to get
to that in your presentation. I’m going to let both of you comment on
that and then we’re going to go to a live mic after that. It follows on what I just said in a way. It’s too huge to go into all. It is a gray area. But here’s what we do know. We do know from many, many studies that with
normal grief, people weren’t clinically coming in or anything. They were relatives of people who had just
been lost, studying that sequelae, that it includes many of the weaker symptoms I was
just distinguishing. I call them the general distress symptoms
of depression as distinct from the pathosuggestive or serious symptoms of depression. So as it turns out, those general distress
symptoms are extremely common in reactions to loss, reactions to stress. Now, you can do research on this. And I’ve done research on this. I’ve probably done more studies on this
than any other person alive. It turns out if you have people that only
have those weaker symptoms, they are not anything like all the rest of the people that come
under major depression that have one or more of those stronger pathosuggestive symptoms. For instance, the classic quality of depression,
of major depression, is recurrence. You’re likely to have recurrences. Another quality is likely a much higher rate
of suicide attempts. There are others. Development of generalized anxiety, there
are a lot of other markers, predictive markers, the most powerful kind. You can study the people who have only the
weaker symptoms that qualify under DSM, but they have only the weaker symptoms and guess
what? So far we’ve gotten it to a three. We did a one-year follow-up and a three-year
follow-up. On the three-year follow-up those with weaker
symptoms do not look different than the general population of those who never had major depression,
whereas the people with major depression look radically different. They have very high rates just as we believe
all along, they have very high rates of all of those markers follow-up outcomes. So the research is fairly clear. How do you distinguish? You look at the environmental context. Dr. First pointed that out. We both worked on that. It’s critical it’s left out of DSM in
many places. You look at the context. You look at the person’s history and you
look at the actual quality of the symptoms rather than counting the way the DSM suggests
you should. The quality of the symptoms matters and if
you email me I can send you some papers or research on this. So there is a lot of research supporting the
fact that there is an overdiagnosis going on here. Dr. First, any thoughts? Dr. Wakefield and I have had a little disagreement. It’s true that in epidemiologic samples
when you apply these criteria, you see the criteria overdiagnosed, according to Dr. Wakefield. Whether this actually means people are being
overdiagnosed with depression in the real world, coming to doctors, asking for help,
that’s unknown. I think you’ve got to be careful. I’m not saying there’s not a problem. From this statement, people are imagining
there are millions of people out there taking medicine they don’t need. That would be, I think, too much of a stretch
to know the answer to that question. I agree we don’t know the answer to that
question. It is true that clinically by far the most
people that are seen are classified under other scales not using that division I just
described as mild or moderate, not severe. We know that antidepressants don’t even
work all that well with that group or at least it seems that. So, if you do careful studies, not the kind
of cross sectional study remembering all your symptoms through your life, but you follow
people asking them every few years what happened this year so they’ve got fresh memories
and so on. The current criteria in DSM for major depression
apply to apparently more than half of the entire population at some point between about
ages 18 and 30. There’s nothing in the conceptualization
of this disorder that ever suggested that, it just looks like we are massively potentially
overdiagnosing. But Michael is absolutely right. We have not done the studies to show in terms
of who comes in clinically what percentage there are false positives and aren’t. We just don’t know any of that yet. We’re going to switch gears to some live
questions. If you have a question, please raise your
hand or come to the mic and please tell us your name so that we can reference you. Hi. Thank you very much. My name is Jeff Burns. This is directed toward Dr. First. So you gave us some very helpful clarifications
in a kind of rough defense of the DSM and the clarifications are something like look,
not everything listed is a disorder. Not everything is outlined concretely but
there is room for clinical interpretation, and even when criteria don’t change you
might see an uptick in people seeking help. But even if that works as a defense of the
text, I mean I wonder if that doesn’t provoke the cultural question. If people see a text that could play Linneaus
to all mental phenomena, it can encode everything, and that even in the interpretive work it
can only be done by a kind of priesthood of people who know about these things, it seems
like the text or the culture around the text could be feeding into this kind of problem. Well, I think you’re right. Let me just give you a little anecdote. I worked very heavily on DSM-IV, the one that
we were very caring about false positives. The next crew of people who took over the
DSM-5, interestingly enough they didn’t care that much about false positives. In fact, when these issues were raised to
them about false positives, several of them actually said, well, it’s not our job to
worry about how it could be misused. My response is the opposite. You’re right; we now created a tool which
is easily misused. The DSM and the APA have a responsibility
to do whatever they can to make the book as abuse-proof as possible, however difficult
that is. My point about the rates going up, you know
the point that there’s a limit to what we can do. That’s not the core of the problem. I’m not saying absolving, washing my hands
of it and saying we’re going to put it out there, it’s clinicians’ responsibility
to use it right. I think we do have a responsibility to not
put in stupid disorders, to not put in really low thresholds. Do the best we can. I sort of want it both ways. My name is Brian Lakey. Professor Wakefield, I admire your work on
bereavement and diagnosis of major depression; and Professor First, I admire the DSM as a
required textbook of my 300 level psych pathology class. The question that I have has to do with many
of the premises of the discussion assume that there is a clear criterion for mental disorders
to compare diagnoses with. And it seemed to me that Professor Wakefield,
you were arguing that in the DSM there’s a primary biological cause for all disorders. But in my reading the DSM doesn’t actually
say that. And in fact it lists stressful life events
as an etiological factor for more disorders than there is actually good evidence for. I wasn’t clear, actually, on what your opinion
was on this, Professor First. In some ways it seemed to me that you were
saying if we could find biomarkers then the problem would be solved. So here I’m ranting. The question is can either of you offer a
definition of a mental disorder that does not rely upon a primary biological dysfunction? I think actually the current definition says
biological or psychological, but the key word is dysfunction. It’s not required that only biological dysfunctions
count. There has to be a dysfunction of some sort. I think we commonly . . . and part of it does
have to do with this decade of the brain. There’s been a push, especially in psychiatry,
to see part of it is so we can be like the rest of medicine, to see things in biological
reductionistic terms. But I think that in the current . . . I don’t
know how many people here are familiar with RDoC. It’s the new NIMH replacement, so to speak,
for research for understanding the brain where they’ve broken down mental disorders into
psychological functions that by definition having neurobiological cause. Neurocircuitry based. That’s one way of looking at it. I think the DSM is open to both. I think it would be a mistake to say that
everything has a core biological cause. My comment on the biomarkers was more that
as a doctor we love biomarkers because people want blood tests to tell us things, so that
would help. I don’t want to imply that will solve all
the problems. I guess given the drought of biomarkers, any
biomarker that comes our way I think would be an improvement. First of all let me just say, and I’m not
sure but it may be that what you’re asking about is actually reflecting ambiguity in
the word biological. That is, I personally don’t believe that
every disorder must go back to a dysfunction that’s describable in reductionistic, if
you want to use that word, brain/physiological terms. So biological can have two meanings. Biological can mean oh, it’s got to be a
brain thing that’s gone wrong. Or, biological can mean evolutionary biological
which means simply something is going wrong at some level that is not doing what it’s
supposed to do by biological design — without getting into that whole discussion. To me, given my view, I know it’s often
confused, my view is that in principle there could be dysfunctions and therefore disorders
purely at the psychological level of how meanings interact, how people reason, and so on, that
don’t correspond to a brain physiological dysfunction. Now, of course we have Nobel Prize winners
like Kandel at Columbia saying, you know, parroting the argument that all mental events
are brain events, therefore all mental disorders are brain disorders. That’s a fallacious argument. The standard way of refuting it — at least
to get you started thinking about it — is the software-hardware analogy, which is that
all software runs in hardware, but that doesn’t mean that every software malfunction is a
hardware malfunction. In fact, most aren’t, as we know, and you
would waste your money getting somebody to look into your hardware when you have a software
malfunction. So if there is emotional belief, desire, programming
of some kind, it’s conceivable that its parameters could go wrong in such a way that
there could be a dysfunction at that level without a dysfunction in any brain physiological
process. That’s what I would hope. Now I will say anecdotally that I tried to
say this to the psychiatric residents at a nearby medical center in New York and I was
met with utter disbelief. I would say more than disbelief. It was incomprehension. That’s just simply impossible, they said. Every mental disorder must be a brain disorder. That’s what I meant when I said we’re
living in an era, the brain disease era, where it is assumed. Now how this will all play out, whether every
mental disorder is a brain disorder, that’s an empirical question, not a philosopher’s. As a philosopher you can’t just solve that. But I hope that clarifies the point that you
were asking about. Thank you both again for two thought provoking
talks. My name is Brian Pilkington and I teach philosophy
at Aquinas College. I want to push back a little bit on Dr. Wakefield’s
Rawlsian move. I hope Dr. Sanders will pull me back up the
rabbit hole if I go too far. I appreciate the equal opportunity move and
I think I know where you’re going with Rawls, but why is it that this medical response is
appropriate as opposed to social activism or making arguments in favor of acceptance? So why is it if someone falls within a normal
range — and I can see by the nod you know where I’m going — or is disadvantaged by
society, why must that person bear the burdens of acceptance as opposed to the rest of us? It’s an excellent question and it will vary. I think many of us would say that when it
comes to children, I mean this argument has actually kind of been made by people in the
field of ADHD. Well, you know, look, in our society kids
need to learn this is our educational system, better to give drugs so that they learn and
they have opportunity later on. People say this who study ADHD – psychologists
and psychiatrists. Many of us would argue that a better solution
is social change for God’s sake, and change in the school environment. So I’m not precluding that argument at all. I do believe, you know, a theory of the professions
would hold maybe that kind of Aristotelian theory that each profession has an essential
goal. I call it the organizing value of a profession,
so for medicine it’s health. So why should they do stuff having to do with
justice? And, that is, every profession also has what
I call derived tasks. Due to their skills, their skills define that
group as the best one to handle something society wants done. So cosmetic surgery for aesthetic reasons,
we all agree — most of us agree — has nothing to do with the ultimate goals of medicine,
of healthcare; but there’s nobody else that has those skills, so it’s given to medicine. So this is given to medicine, as is contraception
and other reproductive health issues that have nothing to do with real disorder. So the answer to your question is once it’s
established that this is something people are owed, then the medical professions do
it because they have the skills. Is it presumed that we will intervene and
train everybody? No. First of all, once it’s relabeled . . . That’s
the problem. Labeling it a disorder precludes this whole
discussion that you’re trying to open up. Should we have other options? What if you don’t like speaking in public? Should there be other ways? Should we develop ways of helping you that
don’t involve going through therapy or taking Paxil or whatever? So, I see all these options as open once we
are honest. The problem now is that we are dishonest,
and I’m giving an analysis of why our intuitions are that these people should be treated even
though it’s pretty obvious that they are false positives. Dr. First, any thoughts on that? It’s way out of my area. Ok. I appreciate the comment and you didn’t
go down the rabbit hole. But I think in terms of social justice having
the right to do something but knowing what the right thing to do is really important. I think that that’s really what we want
to think about. I could say a lot more but I don’t want
to interrupt. Next question. My name is Steve Williams and I appreciate
the presentation. I think you’re actually being too kind to
the reimbursement system, but I don’t want to go there because there doesn’t seem to
be support for it anymore; but what we’re going to go to I don’t know. My question is a little more specific, and
that is I have become aware lately of a phenomenon called adverse childhood events and heard
a fairly cogent presentation on it. I wonder if you’re familiar with this sort
of new developing thinking. Because it gets at this issue of the sort
of change in DNA, the change in the neuroscience of the brain that if you experience a number
of adverse childhood events, your actual biology changes. I don’t know if this is a confluence of
issues, but I wondered what your thoughts might be if you’re aware of it. Are you talking about early trauma? Well, I became aware of it just recently. There have been a couple of new papers published
recently. Communities are beginning to adopt this sort
of screening, widespread screening. It’s fairly limited right now to a few communities
to try to get at what happened to children or to adults that causes dysfunction in their
life. Absolutely. By the way, there is a fairly large group
I find when I’m giving DSM workshops or stuff like that that is upset that DSM-5 did
not take adequate account of this new research to define some kind of — not so much posttraumatic,
in the sense in DSM — but chronic minor traumas that much of the new literature is looking
at. Absolutely, we know — and it’s not only
there but in genetics as well — we’re discovering all sorts of ways we didn’t realize by which
things can be modified, can be reshaped, as well as the basic discovery some time ago
that we grow new neurons and create new neuronal pathways. We’re not frozen in our brains after a certain
age as they used to believe. All of this has to be addressed, but it isn’t
yet. And it also raises interesting conceptual
questions about disorder. If we’re all being shaped to some degree
by what happens in our childhood — and some, due to their traumas, are then set for life
in certain ways — how does that change how you think about disorder, for instance, or
what the boundaries are between disorder and nondisorder? I mean, I think the puzzle and the interest
go all the way back to before most of these new discoveries, to studies like the Dodge
study in which he confirmed that a large group of people who were abused in their childhood
had a much higher chance of being abusers. But here’s what the interesting finding
was: the entire effect was explained by the degree to which the early abuse caused the
person to have a change in their belief system, their meaning system, that made them believe
that things were dangerous and that people would respond violently to them. To those who were early abused and didn’t
come to believe that, they didn’t have higher rates of child abuse later on. To those who came to see the world as dangerous
intrinsically, they had higher rates of child abuse later on. So what I’m saying is it’s going to take
us a long . . . This RDoC is partly aimed at this, it’s following people longitudinally,
developmentally, both normal and traumatized and disordered. Trying to get an overall view of how we are
shaped in the long run, which we really don’t have a clue about. And after all, to define disorder you have
to understand normality. We’re not there yet. One of the problems with that is the specificity
of having these adverse childhood events. One of the disorders proposed for DSM-5 that
didn’t make it in — and I was in favor of it not going in — was a version of fetal
alcohol syndrome, psychiatric. The problem was that the original definition
seemed to be that almost any maternal use of alcohol was enough it and some kind of
behavioral phenomenon in the child was going to be called this thing. To try to blame the alcohol for this result
. . . Mothers who use alcohol when they’re pregnant probably have a lot of other risk
factors going on and to blame . . . So the thing is so complicated that it’s one of
those things that putting things in a diagnostic system without knowing what’s really going
on can create a new false positive problem. So you have to be very careful. I think it’s important that the point you
bring up, the number of traumas, can affect people. One of the things we have to be careful of
is two thirds of who we are is how our environment affects us, one third is biologic. Different people are resilient in different
ways. We know people have different types of genetic
makeup in terms of how resilient they are to trauma, so that’s why it’s a good screening
opportunity to review things. One more comment, just to take up Michael’s
very good point. One problem is our theories become so powerful
and compelling that we go into the false positives area. I once was doing a study on conduct disorder
and to some of the vignettes I was having clinical judgments about whether a kid had
a disorder when he was acting antisocially under certain contextual conditions. I threw into one of the vignettes that the
young person had been sexually abused as a child. No matter how rational, no matter what I put
into the vignette other than that, at that point in time all these clinicians in training
said yes, they must have a disorder. It was their theory that child abuse must
cause disorder that made them respond rather than any of the cues, any of the contextual
stuff that I put in, that really was more pertinent to whether their behavior was driven
by a dysfunction or not. So it’s something to think about that we
want to get this right instead of again inflating the false positive domain. My name is Joanne Hoganson and I’m here
representing Public Health. I’m Director of Nursing at the Kent County
Health Department and one of the things that we work with is access to care. I couldn’t help but think as I heard you
that we in Kent County have a significant access to care challenge, especially around
psychiatric needs of adolescents. It does make me wonder if an over-diagnosis
may be contributing to filling psychiatric offices and clinics and in-house treatment
when in fact some of those same disorders might be better treated in a support group
or in a church youth group or in some other kind of environment, therefore leaving space
for those that truly have a disorder. I was just wondering if you had a comment
about that. My guess is that there is such a shortage
of clinicians, even though in theory that may be the case, I think there are so many
if you got rid of some of those cases there would still be a big access problem. The access problem between payment and available
clinicians spread out geographically is so huge, I doubt that shifting would make that
much of a difference. That’s the argument for ADHD. The usual argument against ADHD as being grossly
overdiagnosed is actually it’s being misdiagnosed. That there are normal being labeled but there
are still lots of people out there who are not getting treatment. So it’s a misallocation. So I think in general you’re absolutely
right. I think that every time a normal person is
getting resources and they don’t really need it, given how scarce things are, there are
all these people out there who really do need it and aren’t getting it. I agree. Way back in the old days when community mental
health centers were new, they were explicitly put in to help the people be deinstitutionalized,
to help support them in the community. But there was a natural trend to treat, by
the clinicians as much as anybody else, to treat what some people dismissed as the worry
of, well they might have true disorder, they might not, marital problems, all sorts of
problems. And we really weren’t doing our job. I think that getting clearer on the false
positives, I totally agree with what Michael said. There are a lot of people who need treatment
who aren’t getting treatment, but getting clearer on this problem would help to allocate
resources better. Whether it would clear out the clinics, I’m
dubious. Whether it would allocate resources better? Absolutely. And, an embarrassment to all us clinicians,
peer counseling for milder problems is remarkably effective even when compared to professional
intervention. So peer counseling has not been adequately
given its due and used, for obvious reasons. One last question. Any more questions? I guess we will enjoy watching the election
then. Please join me in thanking Dr. Wakefield and
Dr. First. Outstanding. Thank you for joining us and enjoy the Michigan
fall that’s coming. Hope we’ll see you March 27th

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