Saturday, February 27, 2010

Psychiatric Diagnosis: The Shorter Version?

If you believed half of the contradictory and baseless assertions of Edward Shorter (Why Psychiatry Needs Therapy, Wall Street Journal Feb 27-28, 2010) you might envision hundreds of thousands of healthy and symptom-free Americans flocking to psychiatrists after seeing themselves described in the new DSM-V and demanding treatment with expensive drugs. And continuing to take these drugs even when they reap no benefit from them.

Nothing could be further from the truth. In fact Shorter should know that many individuals that need help and might seek it, do not, in part because of the stigma that he perpetuates with his pejorative view of mental illness. And like other critics of psychiatry who see the APA's effort to improve on DSM-IV TR as an opportunity, he has failed to offer a better system of categorizing a very real group of individuals who suffer very real symptoms. Few patients continue taking medication unless they feel a definite benefit. And many improve with psychotherapy, ECT, and other treatment modalities.

I will start with the catchy photos at the bottom of the page under the heading "The New Abnormal."

Hoarding: The definition may be new, but the problem is not. What would Shorter have us do with those who want help for this problem?

Mixed Anxiety-Depression: He says himself this combination has been recognized for years. The only new thing about it is its addition to the Manual. Make up your mind, Shorter.

Binge Eating: New? Not! Shorter, you can tell people who want help with this to stop complaining, just control yourself and go away. I can't.

Minor Neurocognitive Disorder: He calls this a commonplace occurrence for anybody over 50. We should not diagnose and treat that which is commonplace? Like the common cold? Like buponic plague? malaria? TB? Last I heard most people in the world suffered from parasitic illness, that's pretty commonplace. Shall we forget about them, too?

Temper Dysregulation Disorder with Dysphoria: He says it's a new way to diagnose fewer kids as bipolar. That's wrong? Perhaps he would have us believe the problem doesn't exist.

Shorter seems to like diagnoses in use in the 50's and 60's he relates to the European scientific tradition, but offers no support for his suggestion that they might have been more "accurate." In fact the diagnoses prior to DSM-III were based largely on very UNscientific psychoanalytic theory, and did not include "nerves" or "nervous breakdown" as he would have us believe. These ill-defined terms from popular language are almost meaningless. Shorter implies that because lithium "sometimes" prevents depressive episodes we should not bother to differentiate bipolar disorder from unipolar mood disorders ignores evidence that some drugs do treat unipolar depressive episodes effectively, and may exacerbate bipolar disorder.

Shorter's assertion that the "new" disorders all respond to the same drugs is not only baseless, but contradicts his later statements that the drugs do not work. He claims that imipramine remains the most effective drug for what he calls "serious" depression. (It also happens to be dangerous in overdose and to have more adverse effects at therapeutic doses than newer agents, many of which cost as little as $10 for a 3 month supply.) Please note that Shorter offers no definition of this category has conjured up on his own, nor any criteria for determining whether someone suffers from it or not. Perhaps we should rename it "Shorter's Disease," but that would be yet another "new" abnormal.

Benzodiazepines: An "undeserved reputation for addictiveness"? In addiction psychiatry we call this denial. I call these drugs practice builders because patients like to keep coming back for more. Has assertion that they are "effective across the entire range of nervous illnesses" is ridiculous, made even more so by the fact that, once again this Shorterism, "nervous illness," has no definition. It doesn't seem to have occurred to Shorter that the large number of prescriptions written might support the idea that many patients become addicted to them.

Shorter would have us believe that DSM-III was a step backward for psychiatry but he fails to mention that it finally dumped psychoanalytic theory and gave us the new phenomenon of multiple psychiatrists examining the same patient actually giving the same diagnosis. This inter-rater reliability was almost non-existent in earlier diagnostic schemes.  Shorter would have us believe that "bipolar" was a new diagnosis. In fact it was just a new name for what was previously called manic depressive illness. Now he tells us what "experienced clinicians" know. And where did you get that piece of information Mr. Shorter? Did you conduct a pole? Do tell us what constitutes an experienced clinician. Would we (or they) really all agree that patients with "chronic depressive illness" (another undefined Shorterist category, thank you very much) "will have" an episode of mania or hypomania? But Mr. Shorter, "mania" and "hypomania" are both defined in the DSM's. Or would you like to propose your own criteria? Or maybe you don't like criteria at all.

Shorter's statement that "anxiety became associated with addiction" doesn't even make sense.

Shorter says that "Major depression" (Does he mean Major Depressive Disorder or Major Depressive Episode?) became the "big new diagnosis." If by this he means that the frequency with which it was diagnosed increased dramatically, I agree, but this may have resulted from changes in reimbursement by insurance companies, another factor Shorter ignores in this discussion.

Shorter assets that SSRI's "don't work for diseases that don't exist." I believe a lot of patients would say otherwise.

If Mr. Shorter this half his students exhibit "disorganized speech" he may not know what it really sounds like. As for "psychosis risk syndrome" identification of at-risk populations may lead to prevention. Shorter would have us pretend such patients don't exist. Even worse he implies that if we don't have "specific treatments" for a disease we should ignore it.

I confess I cannot make sense of Shorter's closing paragraph, but I will resist the temptation to identify it as disorganized speech. What does he mean by what patients "actually have?" Why should we believe the "European tradition" he esteems is so great? And what is it anyway?

Mr. Shorter, all of psychiatry is like drawing "lines in a bucket of water," but that doesn't mean we should give up. Your ideas must be very popular in Canada, where the idea of all these people needing help must incite fear of bankrupting your health care system, but don't you just put them all on the waiting list anyway? or diagnose them all "nervous illness" and give them all benzodiazepines.


  1. All I know is that it was only a few years ago when gays and lesbians were considered ABNORMAL and had a psychiatric diagnosis....hummm that would constitute physicians, politicians, famous people, and the rest of us.... I do believe we have learned something along the way....Thank God I wasn't given meds for my lesbianism....I would still be on them and probably institutionalized.

  2. Bobbie:

    But suppose they came up with a pill that would change your sexual orientation. How many gay people would take it? Is being gay like being left handed? Do you really believe we learned anything, or did we just finally get something right?