From psychobabble to biobabble?
Three years ago, in the TLS, Andrew Scull reviewed David Healy’s book MANIA A short history of bipolar disorder. Here is how he introduced Healy:
Yet he has vaulted to prominence as a fierce critic of standard professional practice; of the role of Big Pharma – the collective name for large pharmaceutical companies – in reconstituting the very terms in which we as a culture understand and respond to mental illness; and of the biobabble that these days has replaced psychobabble as the verbal camouflage for our ignorance about the aetiology of mental illness. Along the way, he has exposed the extraordinary venality of many leading academic psychiatrists; the widespread ghostwriting of what purport to be cutting-edge publications in major journals (apparently produced by eminent scientists but actually concocted by public relations flacks for the pharmaceutical houses); the routine suppression or gross misinterpretation of data on the effects of psychoactive drugs along lines which maximize the profits of the huge multinationals (who thereby extract obscene sums from the sufferings of the mentally ill); the heightened risk of suicide and other untoward events that, perversely, may accompany the ingestion of antidepressants; and the fraudulent “science” on which many contemporary understandings of mental disorder rest. Small wonder that for many Healy has become a professional pariah, and that he plausibly reports being hounded, menaced and attacked by the enormously powerful corporations whose profits he threatens.
In the May 18th issue of the TLS, Scull returns to the theme with an article providing background to the controversy attending the preparation by the American Psychiatric Association of a fifth edition of its Diagnostic and Statistical Manual (DSM). Scull argues that with its third edition, the DSM had made a major departure from the emphasis the first two editions had placed on the psychodynamic genesis of mental diseases (to be treated by psychoanalysis) to one that would replace it with more biologically oriented diagnoses (to be treated now (also) by drugs). The shift was made in part because of “psychiatry’s diagnostic incompetence,” that is, the “the documented failure of psychiatrists to agree on what was wrong in any given case before them.”
DSM III’s triumph marked the advent of a classificatory system that increasingly linked diagnostic categories to specific drug treatments, and an embrace on the part of both profession and public of a conceptualization of mental illnesses as specific, identifiably different diseases, each amenable to treatment with different drugs. Most importantly, since the insurance industry began to require a DSM diagnosis before agreeing to pay for a patient’s treatment (and the preferred course and length of treatment came to be linked to individual diagnostic categories), DSM III became a document that it was impossible to ignore, and impossible not to validate.
The controversy over the new edition of the DSM concerns the likely addition of many new mental illnesses, all treatable by drugs, of course. Scull writes:
As diagnostic criteria were loosened [in DSM III], an extraordinary expansion of the numbers of mentally sick individuals ensued. This has been particular evident among, but by no means confined to, the ranks of the young. “Juvenile biopolar disorder”, for example, increased forty-fold in just a decade, between 1994 and 2004. An autism epidemic broke out, as a formerly rare condition, seen in less than one in 500 children at the outset of the same decade, was found among one in every ninety children only ten years later. The story for hyperactivity, subsequently relabelled ADHD, is similar, with 10 per cent of male American children now taking pills daily for their “disease”. Among adults, one in every seventy-six Americans qualified for welfare payments based on mental disability by 2007.
If psychiatrists’ inability to agree among themselves on a diagnosis threatened to make them a laughing stock in the 1970s, the relabelling of a host of ordinary life events as psychiatric pathology now seems to promise more of the same. Social anxiety disorder, oppositional defiant disorder, school phobia, narcissistic and borderline personality disorders are apparently now to be joined by such things as pathological gambling, binge eating disorder, hypersexuality disorder, temper dysregulation disorder, mixed anxiety depressive disorder, minor neurocognitive disorder, and attenuated psychotic symptoms syndrome.
Yet we are almost as far removed as ever from understanding the etiological roots of major psychiatric disorders, let alone these more controversial diagnoses (which many people would argue do not belong in the medical arena in the first place). That these diagnoses provide lucrative new markets for psychopharmacology’s products raises questions in many minds about whether commercial concerns are illegitimately driving the expansion of the psychiatric universe – a concern that is scarcely allayed when one recalls that the great majority of the members of the DSM task force are recipients of drug company largesse.
All in all, not a pretty picture.