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The Washington Post
The Boom in Psychiatric Syndromes
By Sheila M. Rothman
(Senior research scholar at the College of Physicians and Surgeons
of Columbia University)
In recent years, the types of behavior that are labeled as diseases
have increased dramatically. Modern psychiatry is ready to treat not
only acute depression and schizophrenia, but moodiness, anxiety and
poor self-esteem, feelings most of us have experienced at
one time or another.
Nowhere is this development clearer than in editions of the
psychiatrists' desk manual, "Diagnostic and Statistical Manual of
Mental Disorders," or DSM. Published by the American Psychiatric
Association, the first edition, which came out in 1952, listed 60
categories, including schizophrenia, paranoia and other aberrant
forms of behavior. By contrast, the fourth edition or DSM-IV,
which came out three years ago, has more than 350 listings (by my
count). Many of the disorders it describes have overlapping criteria
and subtle manifestations, and each may have six or more symptoms.
Patients who exhibit three or more are given the
diagnosis.
Since many of us have suffered from at least some of the symptoms
that characterize the new illnesses, their status as disorders
raises the prospect of defining us all as mentally ill. The
proliferation of disease categories is beginning to blur the
distinction between health and illness, between person and patient.
And by offering to relieve us of the moods and anxieties that are
part of everyday life, doctors are providing something other than
cures for given ailments: They are ready to help make us better than
normal.
Take one of the newly classified diseases, body dysmorphic disorder.
BDD, as it is known, is characterized by spending excessive time
examining oneself before a mirror and by great concern with the size
or shape of a body part. But how do you distinguish the disease from
vanity? In her recent book, "The Broken Mirror," Katharine Phillips,
a psychiatrist at Brown University School of Medicine who helped
to establish BDD's criteria, says that more than 5 million Americans
(men as well as women) suffer from it. She concedes that the
"difference between BDD and normal appearance concerns may be
largely a matter of degree." But that does not dissuade her, or the
American Psychiatric Association, from labeling it a disorder -- and
including it in DSM-IV.
Another new disease, premenstrual dysphoric disorder (PMDD) is
marked by irritability, tension, sadness, lethargy, headaches and
weight gain. What transforms these commonplace symptoms into a
disease is their timing; they generally appear one week before
menstruation and disappear a few days afterward. But are symptoms
that are unremarkable and transitory truly indicative of a disease?
Is an (imperfect) correlation with a normal bodily rhythm and hormonal
shift sufficient grounds to find pathology? With PMDD the line
between the normal and abnormal becomes murky.
The editors of DSM-IV are comfortable in expanding further the already
broad categories of mental disorders. Under the heading "Other
Conditions That May Be a Focus of Clinical Attention," they include
the "partner relational problem, sibling relational problem,
age-related cognitive decline, bereavement, academic problem,
occupational problem, and phase of life problem." Put all these
categories together and the division between patient and person
virtually disappears.
This is also evident in the expanding group of diseases associated
with known eating disorders. The first to be widely recognized, in the
1970s, was anorexia nervosa, the symptoms of which include an intense
fear of gaining weight, amenorrhea (the absence of menstruation) and a
distorted body image, so that sufferers think they are fat even
when they're underweight or emaciated. Anorexia was joined in the
psychiatric literature of the 1980s by bulimia nervosa, which is
characterized by binge eating or chronic dieting and a persistent
concern with body shape and size. Both these disorders represent
very real problems for sufferers, but since the symptoms may
sporadically appear in healthy individuals, psychiatrists were
obliged to evaluate "the context in which the eating occurs,"
according to the manual. What is "excessive consumption at a typical
meal might be considered normal during a celebration or holiday meal."
To look at it any other way, we would all be candidates for
psychiatric treatment at Thanksgiving.
In a New England Journal of Medicine article entitled "Running: An
Analog of Anorexia?" Alayne Yates writes that regular exercise can be
symptomatic of disease. Exercise that is too regular -- or, in
psychiatric terms, compulsive -- indicates an "activity disorder,"
writes Yates. At issue is not the timing of the behavior (as in
PMDD) or its context (as in bulimia nervosa), but its purpose. In
Yates's view, excessive running to lose weight or to control weight
becomes pathological. The behavior may well be included in the next
edition of DSM: Psychiatry is clearly troubled by tracks, fitness
centers and gyms.
The fading distinction between normal and abnormal that these newly
defined diseases suggest is still more evident in so-called
"shadow syndromes." Proposed by John Ratey, a psychiatrist at Harvard
Medical School whose new book takes the term for its title, the
syndromes represent "hidden psychological disorders." People who are
"a little bit" depressed or anxious or display bad tempers suffer
from them. Although Ratey concedes that the manifestations are too
mild to fit what he calls "the DSM's concrete blocks," he
nevertheless argues that feelings of this sort pose genuine risks:
"People's lives can and do crash . . . because of small problems."
This extraordinary expansion of psychiatric illnesses coincides
with our increasing interest in biological determinism. Indeed,
the two trends reinforce one another. The new field suggests that
characteristics once believed to be individual and fluid are, to the
contrary, hard-wired into us. Biologists and geneticists are
encroaching on the field of psychiatry, hypothesizing that
biochemical deficiencies, often caused by a genetic defect, are
triggering depression, aggression and anxiety. Although they concede
that family dynamics may be relevant, they put nature firmly over
nurture. In their view -- and in contrast to the accepted
psychiatric thinking of most of the 20th century -- biology
matters most. Not surprisingly, this orientation is generating in the
public a kind of genomic anxiety, which recent reports on cloning only
exacerbate. Perhaps we really are puppets at the end of a DNA
string -- our temperaments, like the possibility that we'll
develop cancer, defined by our genes.
The most frequently invoked biological explanation for many
forms of irregular behavior involves deficiencies in serotonin, one
of the brain's natural chemicals that transmit signals between nerve
cells. In "The Broken Mirror," Phillips relates body dysmorphic
disorder to an "abnormality in the serotonin neurotransmitter
system." Other psychiatrists have attributed eating and exercise
disorders, shadow syndromes and even PMDD to low serotonin
levels. What is their evidence? That patients feel better once their
serotonin levels are raised through the administration of medications
called SSRIs, of which Prozac is the most often prescribed. Because
patients with BDD seem to respond to these drugs, Phillips insists
that "disturbed brain chemistry plays an important role" in the
disease.
Phillips's reasoning fits neatly with the arguments Peter Kramer put
forward in his bestseller, "Listening to Prozac." Both psychiatrists
use the same circular reasoning: The existence of a disease is
confirmed because treatment sparks a positive pharmacological
response. Once upon a time doctors diagnosed the disease and then
discovered a cure. Now doctors have interventions that inspire them to
create new diseases.
Accept for the moment that a heightened concern with appearance or a
little bit of depression does constitute a disease. What type of
physician does one go to and for what kind of treatment? Psychiatrists
insist that despite the biological cause of these illnesses, they
are behavior-related and are therefore best treated by psychiatric
methods. Although some psychiatrists still rely on long-term
psychotherapy, essential to almost everyone's practice today is
Prozac or one of its pharmacological equivalents. And patients with
a wide variety of complaints appear to improve on Prozac. Their
"self-esteem and self-confidence get a boost," Phillips reports. They
"feel more normal."
Although clinical trials confirming claims like Phillips's are in
short supply, enthusiasm is rampant.
But other medical specialists are competing to treat these new
diseases. People concerned about a physical symptom (perhaps a
drooping eyelid or large nose) might turn to a psychiatrist to ask
why they are so troubled by their appearance. Or they might consult a
plastic surgeon, dermatologist, ophthalmologist or
otolaryngologist to solve the problem.
The most important distinction among these specialists is
their understanding of the cause of the disease. To psychiatrists,
the patient's concern about an ostensible defect, not the defect
itself, is the source of the problem.
The new disease categories are also prompting physicians to
minimize the differences between cure and enhancement, between
returning patients to normal and making them better than normal.
Kramer coined the term "cosmetic psychopharmacology" to describe the
treatment of patients whose behavior was optimized through Prozac. And
Ratey uses SSRIs to treat shadow syndromes on the grounds that: "For
many of us, normalcy is not enough. The fact that a dark temper or a
pessimistic character may be normal does not mean it is easy to live
with." Yet, to the extent that physicians make enhancement their
goal, all of us become perpetual patients. With this reasoning, the
criterion for visiting a doctor's office will become an existential
vision of the person one might be. What a heady task for physicians,
and what an anguished position for the rest of us.
No one wants to forgo the therapeutic benefits that 21st century
medicine will bring; some of us may even wish to gain a competitive
edge through enhancement. But how we can achieve these ends without
losing our personal identities or becoming perennial patients is
one of the most critical challenges posed by the new psychiatry,
biology and genetics. After all, none of us wants to spend the
better part of life in physicians' waiting rooms. |