In psychiatry, the cost of erroneous scientific theories can be incalculable. Get things wrong (or even only half right) and once adopted by the profession it can take years to weed them out. The result can be millions of shattered lives.
Some of the world鈥檚 leading psychiatrists believe that this is just what has happened in their craft today. Poor diagnosis, shaky science and drugs with costly side effects all point to the same conclusion: psychiatry is badly in need of a radical overhaul.
Among the profession鈥檚 critics is Nancy Andreasen, professor of psychiatry at the University of Iowa and editor of the respected American Journal of Psychiatry. Andreasen loves her profession, but is all too aware of its shortcomings in an age when 450 million people worldwide are affected by mental illnesses.
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Rather than diagnosing narrowly defined illnesses by ticking a list of symptoms in a clinical manual, she wants a more humanistic, 鈥減henomenological鈥� approach, which means psychiatrists paying more attention to the broadest possible context of the patient鈥檚 suffering 鈥� from cultural, sociological, philosophical and political points of view, as well as medical, neurological, genomic and pharmacological ones.
This is some admission, because Andreasen was one of the authors of the third and revolutionary edition of what is arguably the bible of modern psychiatry, the Diagnostic and Statistical Manual of Mental Disorders. She told Liz Else how it all went wrong.
I鈥檝e heard you say, 鈥淚鈥檓 proud to be a psychiatrist,鈥� but you also say you don鈥檛 like to admit to your profession in public. How does this square up?
I believe being a psychiatrist is both fascinating and privileged because we are entrusted with the most personal and intimate information anyone can share with a doctor. But I don鈥檛 usually tell people I鈥檓 a psychiatrist because as soon as you do that, on an aeroplane or practically anywhere, you immediately start having to practise psychiatry because mental illness is so common. They have a family member that they want advice about, for example. That is the main reason I don鈥檛 say I鈥檓 a psychiatrist. The other reason is that, in the public mind, there can be an image of psychiatry as very soft-headed.
What do you think is wrong with psychiatry today?
There is less emphasis on careful observation. The fundamental point is that the individual patient and his or her uniqueness should form the centrepiece of clinical practice. That is one of the central points of phenomenology. There is an increased tendency to make diagnosis through checklists, with less emphasis on the interesting uniqueness of each individual patient and on the humanism that lay at the heart of early psychiatry. We tend to over-biologise, we oversimplify the mechanisms of mental illness: in a reductionist framework, depression is a serotonin disease, schizophrenia a dopamine disease. But if we look only at brains, we fail to recognise the important role that personal life experiences may play in losing our minds.
It鈥檚 useful for psychiatrists to remember that the word comes from the Greek psyche, which means breath, life, animating principle or spirit. Contrast that with the Greek word for mind, which is nous, or the word for brain, which is encephalon. Literally, a psychiatrist is a healer of the spirit, not of the mind or brain.
鈥淭here is an increased tendency to make diagnoses via checklists鈥�
Does that explain why patients are prescribed so many drugs?
Doctors and patients began to think that most problems could be solved by popping a pill. In the US, at least, we have had some serious over-prescribing for conditions such as attention deficit disorders, anxiety and depression. Sometimes people see medicines as cosmetic surgery for the mind.
And some of those drugs can be a very mixed blessing?
Almost all medications have some side effects. The art of medicine, so to speak, is finding the right balance of dose and side effect. Some of the older antipsychotics did have side effects to do with the motor system: tremors, shuffling gait, restlessness. Newer antipsychotics have fewer of those side effects but have a tendency to produce weight gain. Some believe that modern antidepressants can cause suicide.
What鈥檚 the solution to the problem of modern psychiatry?
What we need to do is collect data from all levels: molecules, cells, tissues, organs, cognitive and emotional systems, behaviour, exposure to environmental influences. This is going to require rather a lot of data. I love psychiatry because when we do it right, it is the only speciality that emphasises the understanding of individual human beings within the context of a unique environment and personal life history.
You are very critical of the Diagnostic and Statistical Manual of Mental Disorders (DSM), yet you helped to write earlier versions of it.
DSM is based on careful observation but it is just not complete 鈥� it was never meant to be the absolute truth. That鈥檚 what people miss. We put in enormous caveats: use this book as part of a total clinical evaluation, use with great care, for use only by qualified doctors, and so on. But it represented a huge shift. It introduced diagnostic criteria. We wanted to make a statement about the importance of making psychiatry more objective.
One example is the description of schizophrenia: in DSM II, it is about five sentences. In DSM III, there are four or five pages of description followed by diagnostic criteria. We also managed to take out neurosis, which was important because we thought it was especially vague 鈥� and we put in a new approach to classification so we could incorporate medical and psychosocial elements of a clinical evaluation when it came to reaching a diagnosis.
So why are you now so critical of it?
Let鈥檚 take schizophrenia again. I chaired the schizophrenia working group for DSM IV, which lists the symptoms as delusions, hallucinations, disorganised speech, disorganised behaviour and negative symptoms. We wanted to keep it simple. But we only list eight of the general symptoms for schizophrenia. This is not a complete description. You have to know much more than just those DSM criteria before a patient can be reliably diagnosed. I don鈥檛 like 鈥渃ook books鈥� that say you must treat every person with schizophrenia with an antipsychotic drug. It isn鈥檛 that simple.
Your own research concentrates on brain tissue in patients who have taken drugs for schizophrenia. What do you hope to learn?
My own work has already shown that people with schizophrenia have an ongoing loss of brain tissue. The question is: why? Is it because of the disease itself? Is it because of the side effects, or even toxicity, from medication?
But there is evidence that mental activity can change brain structure 鈥� which suggests that the brain can be changed without drugs?
In my book, The Creating Brain, I describe a study of the brains of London taxi drivers by Eleanor Maguire and her colleagues from University College London. These drivers undergo two years of intensive training in which they have to memorise thousands of routes in the city. Maguire found that the size of the drivers鈥� hippocampus was larger than that of a control group and that this increase correlated with the number of years they had spent driving. I think these results could have implications, not just for treating mental illnesses but for education and child rearing.
鈥淲e know that people with schizophrenia lose brain tissue. But why?鈥�
Does this interest in creativity hark back to the start of your academic career, as an assistant professor with a PhD in English literature? How did you end up in psychiatry?
I was 25 when I started medical school. I鈥檇 had a bad time with complications during my pregnancy with my first-born daughter. This exposed me to the medical profession and got me so interested and grateful that I changed direction. Being a serious literary scholar created an interest in creativity and early in my career I did a study of creativity in mental illness. Now I鈥檝e made the time to write a book about it 鈥� and concluded I would have to write five books about creativity to say all the things I would like to say.
Profile
Nancy Andreasen is professor of psychiatry at the University of Iowa College of Medicine. Her lab developed the world-famous BRAINS imaging software. She delivered a keynote speech earlier this year at the Phenomenology and Psychiatry for the 21st Century conference at the Institute of Psychiatry in London. Her most recent book, The Creating Brain: The neuroscience of genius, is published by Dana Press ($23.95).
What you can鈥檛 learn from a book
Few would have thought that a slim clinical manual would become a global publishing sensation, least of all its authors. Yet that is what has happened to the Diagnostic and Statistical Manual of Mental Disorders, first published in 1952 by the American Psychiatric Association (APA).
Now into its fourth edition, DSM was meant to help doctors diagnose mental illnesses by categorising diseases according to a small number of telltale signs. What has happened, say Nancy Andreasen and many other psychiatrists who have helped to write DSM, is that it has become the main reference for diagnosis, something it was never intended to be. Now psychiatrists everywhere are reluctant to diagnose an illness unless its symptoms can be found in DSM.
The first two editions were influenced by psychoanalytic therapies that were then dominant in the US, though less so in Europe. These therapies assumed that no one was inherently mad: mentally ill people were fundamentally the same as everyone else, and their disorders were reactions to external events. There were two 鈥減oles鈥� of illness: the north pole of psychosis, a disconnect from reality characterised by hallucinations, delusions and illogical thinking; and the south pole of neurosis, in which people suffered from a distorted sense of reality rather than a complete break with it. But diagnosis was not based on sharply defined symptoms.
Up until 1973, DSM regarded homosexuality as a mental illness. This was removed after a vote among members of the APA, following protests from gay rights groups. By then the psychoanalytic model was in retreat as a new generation of psychiatrists with heavy-duty science backgrounds, such as Andreasen, began to demand stronger diagnostic evidence.
But this didn鈥檛 stop the ever-expanding DSM becoming a must among students, doctors, drug companies, health insurers and policy-makers all over the world. Psychiatry students had to be word-perfect in DSM categories to pass their exams.
As the revisions to DSM multiplied, so did the criticisms: the manual鈥檚 diagnostic categories were called prescriptive, arbitrary and driven by literal-mindedness. They did not reflect all opinions in psychiatry, said the critics, nor even a complete set of all psychiatric disorders worldwide.
