- Email: [email protected]
Diagnoses are not diseases
1574
VIEWPOINT
Diagnoses are not diseases
Learn to recognize the symptoms of mental illness. Schizophrenia, manic depression and severe depression are brain diseases. HAWAII STATE ALLIANCE FOR THE MENTALLY 1991.
ILL,
In 1980, the American Psychiatric Association (APA) published the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-111).’ This document was celebrated for its deletion of homosexuality from the list of mental disorders, and was hailed as the symbol of a new, "medical" psychiatry. Yet, only three years later, ostensibly because "data were emerging from new studies that were inconsistent with some of the diagnostic criteria," the APA embarked on a revision ofD SM - II J.2 In 1987, DSM-111-R was published. DSM-IV is scheduled for publication in 1994. The psychiatric community seems determined to ground its medical legitimacy on principles that confuse diagnoses with diseases. At the start of my career I began to explore the literal language of psychiatry3 and initiated a debate that continues and whose essence is often misunderstood. Many scientists, doctors, and laypeople believe that if a genetic defect caused a mental illness or a lesion was found in the brains of mentally ill patients, it would prove that mental illnesses exist and are like any other disease; this is not so. If mental illnesses are diseases of the central nervous system, they are diseases of the brain, not the mind. If mental illnesses are the names of (mis) behaviours, they are behaviours, not diseases. A screwdriver may be a drink or an implement. No amount of research on orange-juice-and-vodka can establish that it is a hitherto unrecognised form of a carpenter’s tool. Although linguistic clarification is valuable for individuals who want to think clearly, it is not useful for people whose social institutions rest on the unexamined, literal use of language. Psychiatric metaphors have the same role in medicine that religious metaphors have in theology. Although there is common ground between the images of heaven-hell and sanity-insanity, there is also a difference between them. Death is a future event and no-one can know what will happen afterwards. However, mental health and mental illness refer to the behaviours of living human beings. We know what these terms mean: approved and disapproved, legitimate and illegitimate ways of living life before death. We each make certain basic choices. Either we accept that life is finite and ends in death or we reject this view and embrace the belief in a life after death. Similarly, either we accept life as an unceasing struggle for meaning, legitimacy, and other values that inexorably bring people into conflict with others and themselves, or we reject this view and believe that a mentally healthy state can be attained which would eliminate human strife and personal failure. Religion is, among other things, the institutionalised denial of a finite life. Psychiatry is, among other things, the institutionalised denial of the tragic nature of life; individuals who want to reject the reality of free will and responsibility can medicalise life and entrust its management to health professionals. Marx noted that
"Religion is the opiate of the people." But the opiate is not religion; it is the human mind. Religion is simply a product of our own minds, and so, too, is psychiatry. In short, the mind is its own opiate. And its ultimate drug is the word. Despite these observations, an editorial in The Lancet remained fixated on the mirage of finding the cause of schizophrenia. The editorial writer commented, "What about psychiatric research? We seem to be no closer to finding the real, presumed biological, causes of the major psychiatric illnesses. This is not to decry the value of such research-if the causes of conditions such as ... schizophrenia are found it will be an advance of the same magnitude as the identification of the syphilis spirochaete in the brains of patients with general paralysis of the insane."4 I became a psychiatrist to debunk the biologicalreductionist impulse that has motivated its very origin and which continues to fuel its engines; to combat the contention and to refute the expectation that abnormal behaviours must be understood as the products of abnormal brains. It was easier to do this forty years ago than today. For three centuries, the idea that every "mental illness" will prove to be a brain disease was a hypothesis that could be supported or opposed. However, after the 1960s, such a hypothesis became increasingly accepted as a scientific fact. Of course, it is still possible and legally permissible to say that mental illnesses do not exist. But since only a charlatan, a fool, or a fanatic disputes facts or opposes science, such a critic is likely to be dismissed as irrational. For the time being at least, psychiatrists have succeeded in persuading the scientific community, the courts, the media, and the general public that the conditions they call "mental disorders" are diseases-ie, phenomena independent of human motivation or will. This is a curious development. Until recently, only psychiatrists-who know little about medicine and still less about science-embraced such blind physical reductionism. Most scientists knew better. Michael
Polanyi wrote: "We can see then that, though rooted in the body, the mind is free in its actions-exactly as our common sense knows it to be free. The mind harnesses neurophysiological mechanisms; though it depends on them, it is not determined by them."5 Polanyi emphasised that a scientist does not make grandiose theoretical claims or flamboyant promises of impending therapeutic triumphs but accepts certain limitations of his or her profession. "The recognition of certain basic impossibilities has laid the foundations of some major principles of physics and chemistry; similarly, recognition of the impossibility of understanding living things in terms of physics and chemistry, far from setting limits to our understanding of life, will guide it in the right direction."5 ADDRESS SUNY Health Science Center, Syracuse, New York 13210, USA. Correspondence to Prof T Szasz, MD
1575
The more firmly psychiatrically inspired ideas take hold of the collective American mind, the more foolishness and injustice they generate. The Americans With Disabilities Act (AWDA), a federal law enacted in 1990 and scheduled to be fully implemented by July, 1992, is an example. The aim of the law, in part, is "to diminish the stigma of mental illness and reduce discrimination involving ... at least 60 million Americans, between the ages of 18 and 64, [who] will experience a mental disorder during their lifetimes."6 If this is the politically and psychiatrically correct view, how can I maintain that there are no mental disorders? Not very easily. The comments of Will Rogers might help. "Compared to those fellows in Congress, I’m just an amateur ... every time they make a joke, it’s a law! And every time they make a law, it’s a joke."’ The Americans With Disabilities Act is a law, but that does not prevent it from being a joke-and a very bad one at that. Long ago, our lawmakers agreed to let psychiatrists literalise the metaphor of mental illness. Having embraced "mental diseases" they now had to identify the mental disorders covered, and those not covered, under the AWDA. They did so by creating a list of Congressionally accredited mental diseases. The AWDA covers "claustrophobia, personality problems, and mental retardation; [but does not cover] kleptomania, pyromania, transvestism."6 At least compulsive gambling, and with me that Congress agrees stealing, setting fires, gambling, and cross-dressing are not diseases. But it is comical that our Senators and Congressmen do not realise that they have no more ground for excluding these alleged disorders from AWDA coverage than they have for including those that they accept for coverage. At about the same time as these reports on the new deal for the mentally ill appeared in the press,6.8 the American Journal of Psychiatry (the American Psychiatric Association’s official journal) published an article on kleptomania.9 In keeping with DSM-111-R, the author’s premise was that kleptomania is a genuine illness. He explored and documented its incidence, character, and cause. His main conclusion was to propose "a biopsychosocial model of the etiology of kleptomania ... [which] emphasizes possible childhood abuse as a precipitating factor ..." The American Psychiatric Association recognises claustrophobia (which the AWDA accepts as a mental illness) and kleptomania (which the AWDA rejects) as mental disorders on equal ...
footing. I will not discuss here what is meant by the word disease. However, doctors do not normally attribute motives to diseases, and do not call motivated actions "diseases". For instance, we attribute no motive to a person with leukaemia and it would be foolish to say that a certain motive led to
glaucoma. In a newspaper report on shoplifting as a disease, the director of Onondaga (New York) County’s Drinking and Driving Program explains: "Syracuse needs Shoplifters Anonymous ... There are more than 3000 arrests for shoplifting in Onondaga County. It’s costing everyone a fortune."1° Although the program is described as "voluntary", it remains a substitute for a criminal penalty: "If the thief completes the course, the arrest vanishes from his or her record. "10 The report shows that both so-called experts and the media treat shoplifting as a disease, to which they nevertheless then attribute various motives. In the treatment programme,
the
shoplifters
"learn
why they
steal... there are several reasons why people shoplift. They feel entitled. Perhaps they feel prices are too high; they are angry at authority ... It’s a mental health problem."io Although Congress has so far remained unconvinced that the behaviour we call "shoplifting" (but psychiatrists call "kleptomania") is an illness, it is instructive to list some of the behaviours for which psychiatrists have disease names and which the AWDA implicitly accepts as genuine diseases on an equal basis with, say, malaria and melanoma: 300.70 BODY DYSMORPHIC DISORDER
(D vMopopom.
.
The essential feature of this disorder is preoccupation with some imagined defect in appearance in a normal-
appearing person. 300.14 MULTIPLE PERSONALITY DISORDER. The existence within the person of two or more distinct personalities ... At least two of the personalities, at some time and recurrently, take full control of the person’s behaviour. 302.89 FROTTEURISM. Recurrent, intense, sexual urges and sexually arousing fantasies, of at least six months’ duration, involving touching and rubbing against a nonconsenting person. 302.71 HYPOACTIVE SEXUAL DESIRE DISORDER. Persistently or recurrently deficient or absent sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician.
301.51 FACTITIOUS DISORDER WITH PHYSICAL SYMPTOMS. The essential feature of this disorder is the intentional production of physical symptoms. The presentation may be a total fabrication, as in complaints of acute abdominal pain in the absence of any such pain. The political and popular acceptance of such psychiatric words and phrases as medical terms generates a steady stream of absurdities. But because we judge psychiatric dispositions to be humane, neither the erroneous nature of psychiatric premises nor the injustice of psychiatric dispositions discredits psychiatry as a medical specialty. The
following case-history serves as a good example. A 42-year-old female orthopaedic surgeon is arrested for drunken driving. She resists arrest, refuses to take a breath or blood test, and curses and kicks the police. Taken into custody, she finally consents to take a breath test and registers 0-13 g/dl, over the 0-10 g/dl legal limit for blood alcohol. "At trial she maintained that the circumstances of her behaviour at the time of her arrest were a result of PMS [premenstrual syndrome]"." She was acquitted. Psychiatric News, the American Psychiatric Association’s biweekly newspaper, asked "Does LLPDD [late luteal phase dysphoric disorder] exist?"11 The same question might be raised about every non-bodily disease. The reporter then cites the comments of several psychiatrists, which dramatically show psychiatry’s intellectual bankruptcy and moral desolation: "The decision as to whether or not LLPDD will be assigned its own diagnostic category in the fourth edition of APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is ’a political land mine,’ according to Allen Frances, MD, chair of the Task Force on DSM-IV."11 David Rubinow, a psychiatrist who "has done research at NIH on PMS for more than a decade" offered this opinion: "As far as I am concerned, the decision to include PMS in D SM- IV will be
1576
made on political rather than medical considerations ... It’s quite clear there are a substantial number of people with PMS who never get arrested. To attribute guilt in a crime to PMS is a somewhat hazardous enterprise."" The same argument can be made about any mental illness used to support an insanity defence. John W. Hinckley Jr was acquitted of shooting President Reagan because psychiatrists testified he had schizophrenia. But how many people diagnosed as schizophrenic shoot a president? And of those who do, how many claim they did it to impress an actress? Psychiatrists understand that their entire enterprise hinges on society’s acceptance of the proposition that human beings diagnosed as mentally ill have a brain disease that deprives them of free will. I have tried to clarify the crucial differences between diseases and diagnoses. Diseases occur naturally whereas diagnoses are artifacts. So why do we make diagnoses? There are several reasons:
Scientific-to identify the organs or tissues affected and perhaps the cause of the illness. Professional-to enlarge the scope, and thus the power and prestige of a state-protected medical monopoly and the income of its practitioners. Legal-to justify state-sanctioned coercive interventions outside of the criminal justice system. Political-economic-to justify enacting and enforcing measures aimed at promoting public health and providing funds for research and treatment on projects classified as medical. Personal-to enlist the support of public opinion, the media, and the legal system for bestowing special privileges (and imposing special hardships) on persons diagnosed as (mentally) ill. It is
coincidence that most psychiatric diagnoses are inventions. The aim of the nineteenthcentury model of diagnosis was to identify bodily lesions (diseases) and their material causes (aetiology)P Today, even diagnoses of what were strictly medical diseases are no longer pathology driven. The diagnoses of patients with illnesses such as asthma or arthritis are distorted by economic factors. Final diagnoses on discharge summaries of patients are often no longer made by physicians, but are assigned by administrators skilled in the ways of Medicare, Medicaid, and private-health insurance reimbursement (based partly on what ails the patient and partly on which medical terms for his or her ailment ensure the most generous reimbursement for the services not
twentieth-century
rendered). No
psychiatric diagnosis is, or can be, pathology driven; instead, all such diagnoses are driven by non-medical (economic, personal, legal, political, and social) factors or incentives. Accordingly, psychiatric diagnoses do not point to anatomical or physiological lesions and do not suggest causal agents, but allude only to human behaviours.
3. Szasz TS. The myth of mental illness. New York: Harper and Row, 1974. 4. Editorial. British psychiatry at 150. Lancet 1991; 338: 785-86. 5. Polanyi M. Life’s irreducible structures. In Polanyi M. Knowing and being: essays by Michael Polanyi. Chicago: University of Chicago Press, 1969. 6. Freudenheim M. New law to bring wider job rights for mentally ill. New York Times 1991; Sept 23: A1 and D4. 7. Rogers W. The congressional record. In: Sterling BB, Sterling FN, ed. A Will Rogers treasury: reflections and observations. New York: Bonanza, 1982: 256. 8. Freudenheim M. At work, a new deal for the mentally ill. Wall Street Journal 1991; Sept 24. 9. Goldman MJ, Kleptomania: making sense out of nonsense. Am J Psychiatry 1991; 148: 986-96. 10. Miller C. Course offers cure for shoplifting. Syracuse Herald Journal 1991; October 17: B1. 11. Karel R. Controversy follows DWI acquittal based on premenstrual syndrome defense. Psychiatric News 1991; 26: 16-18. 12. Szasz TS. Insanity: the idea and its consequences. New York: Wiley, 1987.
BEFORE OUR TIME Dr Gilbert’s
magnetism*
Towards the end of his Harveian Oration on Oct 18,1927, Sir William Hale-White said: "Many who have written about the glorious Elizabethan Renaissance have told us of its literature, its theatres, its politics, its statesmen, its voyages and its romance, but few have dwelt upon its science. Until the latter years of the great Queen’s reign, ignorance, superstition, tradition and false reasoning darkened understanding; but then as with other branches of human activity, so with science, great lights arose in this Country-Gilbert, Bacon and Harvey; men’s minds awoke, the science of electricity was founded, we were taught how to reason and modem physiology was born. English science dates from these three who were contemporaries; fortunately they were not, like Galileo, Bruno, Servetus and others, persecuted on account of the novelty of their pronouncements." To get my message straight about William Gilbert, who was president of the Royal College of Physicians in 1600, let me quote from a letter Galileo wrote about him "I extremely praise, admire and envy this author, for that a conception so stupendous could come into his mind. I think him moreover worthy of extraordinary applause for the many new and true observations he made". Gilbert’s success in medical practice was remarkable. He was widely known in London and consulted by the great. He was physician to Lord Burghley and his wife Lady Cecil and in 1600 was appointed physician to Queen Elizabeth. He attended her at Richmond Palace during her last illness when she refused to go to bed but sat on cushions outside her
REFERENCES 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders of the American Psychiatric Association (DSM-III), 3rd ed. Washington: American Psychiatric Association, 1980. 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders of the American Psychiatric Association (DSM-IIIR), 3rd ed, revised. Washington: American Psychiatric Association, 1987.
*
Based on a paper given to the Historical Resources Panel of the Royal College of Physicians of London on Oct 29, 1991. ADDRESS 39 Clarendon Street, Butterfield of Stechford, OBE, FRCP)
Cambridge CB1 1JX, UK (Lord
VIEWPOINT
Diagnoses are not diseases
Learn to recognize the symptoms of mental illness. Schizophrenia, manic depression and severe depression are brain diseases. HAWAII STATE ALLIANCE FOR THE MENTALLY 1991.
ILL,
In 1980, the American Psychiatric Association (APA) published the third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-111).’ This document was celebrated for its deletion of homosexuality from the list of mental disorders, and was hailed as the symbol of a new, "medical" psychiatry. Yet, only three years later, ostensibly because "data were emerging from new studies that were inconsistent with some of the diagnostic criteria," the APA embarked on a revision ofD SM - II J.2 In 1987, DSM-111-R was published. DSM-IV is scheduled for publication in 1994. The psychiatric community seems determined to ground its medical legitimacy on principles that confuse diagnoses with diseases. At the start of my career I began to explore the literal language of psychiatry3 and initiated a debate that continues and whose essence is often misunderstood. Many scientists, doctors, and laypeople believe that if a genetic defect caused a mental illness or a lesion was found in the brains of mentally ill patients, it would prove that mental illnesses exist and are like any other disease; this is not so. If mental illnesses are diseases of the central nervous system, they are diseases of the brain, not the mind. If mental illnesses are the names of (mis) behaviours, they are behaviours, not diseases. A screwdriver may be a drink or an implement. No amount of research on orange-juice-and-vodka can establish that it is a hitherto unrecognised form of a carpenter’s tool. Although linguistic clarification is valuable for individuals who want to think clearly, it is not useful for people whose social institutions rest on the unexamined, literal use of language. Psychiatric metaphors have the same role in medicine that religious metaphors have in theology. Although there is common ground between the images of heaven-hell and sanity-insanity, there is also a difference between them. Death is a future event and no-one can know what will happen afterwards. However, mental health and mental illness refer to the behaviours of living human beings. We know what these terms mean: approved and disapproved, legitimate and illegitimate ways of living life before death. We each make certain basic choices. Either we accept that life is finite and ends in death or we reject this view and embrace the belief in a life after death. Similarly, either we accept life as an unceasing struggle for meaning, legitimacy, and other values that inexorably bring people into conflict with others and themselves, or we reject this view and believe that a mentally healthy state can be attained which would eliminate human strife and personal failure. Religion is, among other things, the institutionalised denial of a finite life. Psychiatry is, among other things, the institutionalised denial of the tragic nature of life; individuals who want to reject the reality of free will and responsibility can medicalise life and entrust its management to health professionals. Marx noted that
"Religion is the opiate of the people." But the opiate is not religion; it is the human mind. Religion is simply a product of our own minds, and so, too, is psychiatry. In short, the mind is its own opiate. And its ultimate drug is the word. Despite these observations, an editorial in The Lancet remained fixated on the mirage of finding the cause of schizophrenia. The editorial writer commented, "What about psychiatric research? We seem to be no closer to finding the real, presumed biological, causes of the major psychiatric illnesses. This is not to decry the value of such research-if the causes of conditions such as ... schizophrenia are found it will be an advance of the same magnitude as the identification of the syphilis spirochaete in the brains of patients with general paralysis of the insane."4 I became a psychiatrist to debunk the biologicalreductionist impulse that has motivated its very origin and which continues to fuel its engines; to combat the contention and to refute the expectation that abnormal behaviours must be understood as the products of abnormal brains. It was easier to do this forty years ago than today. For three centuries, the idea that every "mental illness" will prove to be a brain disease was a hypothesis that could be supported or opposed. However, after the 1960s, such a hypothesis became increasingly accepted as a scientific fact. Of course, it is still possible and legally permissible to say that mental illnesses do not exist. But since only a charlatan, a fool, or a fanatic disputes facts or opposes science, such a critic is likely to be dismissed as irrational. For the time being at least, psychiatrists have succeeded in persuading the scientific community, the courts, the media, and the general public that the conditions they call "mental disorders" are diseases-ie, phenomena independent of human motivation or will. This is a curious development. Until recently, only psychiatrists-who know little about medicine and still less about science-embraced such blind physical reductionism. Most scientists knew better. Michael
Polanyi wrote: "We can see then that, though rooted in the body, the mind is free in its actions-exactly as our common sense knows it to be free. The mind harnesses neurophysiological mechanisms; though it depends on them, it is not determined by them."5 Polanyi emphasised that a scientist does not make grandiose theoretical claims or flamboyant promises of impending therapeutic triumphs but accepts certain limitations of his or her profession. "The recognition of certain basic impossibilities has laid the foundations of some major principles of physics and chemistry; similarly, recognition of the impossibility of understanding living things in terms of physics and chemistry, far from setting limits to our understanding of life, will guide it in the right direction."5 ADDRESS SUNY Health Science Center, Syracuse, New York 13210, USA. Correspondence to Prof T Szasz, MD
1575
The more firmly psychiatrically inspired ideas take hold of the collective American mind, the more foolishness and injustice they generate. The Americans With Disabilities Act (AWDA), a federal law enacted in 1990 and scheduled to be fully implemented by July, 1992, is an example. The aim of the law, in part, is "to diminish the stigma of mental illness and reduce discrimination involving ... at least 60 million Americans, between the ages of 18 and 64, [who] will experience a mental disorder during their lifetimes."6 If this is the politically and psychiatrically correct view, how can I maintain that there are no mental disorders? Not very easily. The comments of Will Rogers might help. "Compared to those fellows in Congress, I’m just an amateur ... every time they make a joke, it’s a law! And every time they make a law, it’s a joke."’ The Americans With Disabilities Act is a law, but that does not prevent it from being a joke-and a very bad one at that. Long ago, our lawmakers agreed to let psychiatrists literalise the metaphor of mental illness. Having embraced "mental diseases" they now had to identify the mental disorders covered, and those not covered, under the AWDA. They did so by creating a list of Congressionally accredited mental diseases. The AWDA covers "claustrophobia, personality problems, and mental retardation; [but does not cover] kleptomania, pyromania, transvestism."6 At least compulsive gambling, and with me that Congress agrees stealing, setting fires, gambling, and cross-dressing are not diseases. But it is comical that our Senators and Congressmen do not realise that they have no more ground for excluding these alleged disorders from AWDA coverage than they have for including those that they accept for coverage. At about the same time as these reports on the new deal for the mentally ill appeared in the press,6.8 the American Journal of Psychiatry (the American Psychiatric Association’s official journal) published an article on kleptomania.9 In keeping with DSM-111-R, the author’s premise was that kleptomania is a genuine illness. He explored and documented its incidence, character, and cause. His main conclusion was to propose "a biopsychosocial model of the etiology of kleptomania ... [which] emphasizes possible childhood abuse as a precipitating factor ..." The American Psychiatric Association recognises claustrophobia (which the AWDA accepts as a mental illness) and kleptomania (which the AWDA rejects) as mental disorders on equal ...
footing. I will not discuss here what is meant by the word disease. However, doctors do not normally attribute motives to diseases, and do not call motivated actions "diseases". For instance, we attribute no motive to a person with leukaemia and it would be foolish to say that a certain motive led to
glaucoma. In a newspaper report on shoplifting as a disease, the director of Onondaga (New York) County’s Drinking and Driving Program explains: "Syracuse needs Shoplifters Anonymous ... There are more than 3000 arrests for shoplifting in Onondaga County. It’s costing everyone a fortune."1° Although the program is described as "voluntary", it remains a substitute for a criminal penalty: "If the thief completes the course, the arrest vanishes from his or her record. "10 The report shows that both so-called experts and the media treat shoplifting as a disease, to which they nevertheless then attribute various motives. In the treatment programme,
the
shoplifters
"learn
why they
steal... there are several reasons why people shoplift. They feel entitled. Perhaps they feel prices are too high; they are angry at authority ... It’s a mental health problem."io Although Congress has so far remained unconvinced that the behaviour we call "shoplifting" (but psychiatrists call "kleptomania") is an illness, it is instructive to list some of the behaviours for which psychiatrists have disease names and which the AWDA implicitly accepts as genuine diseases on an equal basis with, say, malaria and melanoma: 300.70 BODY DYSMORPHIC DISORDER
(D vMopopom.
.
The essential feature of this disorder is preoccupation with some imagined defect in appearance in a normal-
appearing person. 300.14 MULTIPLE PERSONALITY DISORDER. The existence within the person of two or more distinct personalities ... At least two of the personalities, at some time and recurrently, take full control of the person’s behaviour. 302.89 FROTTEURISM. Recurrent, intense, sexual urges and sexually arousing fantasies, of at least six months’ duration, involving touching and rubbing against a nonconsenting person. 302.71 HYPOACTIVE SEXUAL DESIRE DISORDER. Persistently or recurrently deficient or absent sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician.
301.51 FACTITIOUS DISORDER WITH PHYSICAL SYMPTOMS. The essential feature of this disorder is the intentional production of physical symptoms. The presentation may be a total fabrication, as in complaints of acute abdominal pain in the absence of any such pain. The political and popular acceptance of such psychiatric words and phrases as medical terms generates a steady stream of absurdities. But because we judge psychiatric dispositions to be humane, neither the erroneous nature of psychiatric premises nor the injustice of psychiatric dispositions discredits psychiatry as a medical specialty. The
following case-history serves as a good example. A 42-year-old female orthopaedic surgeon is arrested for drunken driving. She resists arrest, refuses to take a breath or blood test, and curses and kicks the police. Taken into custody, she finally consents to take a breath test and registers 0-13 g/dl, over the 0-10 g/dl legal limit for blood alcohol. "At trial she maintained that the circumstances of her behaviour at the time of her arrest were a result of PMS [premenstrual syndrome]"." She was acquitted. Psychiatric News, the American Psychiatric Association’s biweekly newspaper, asked "Does LLPDD [late luteal phase dysphoric disorder] exist?"11 The same question might be raised about every non-bodily disease. The reporter then cites the comments of several psychiatrists, which dramatically show psychiatry’s intellectual bankruptcy and moral desolation: "The decision as to whether or not LLPDD will be assigned its own diagnostic category in the fourth edition of APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) is ’a political land mine,’ according to Allen Frances, MD, chair of the Task Force on DSM-IV."11 David Rubinow, a psychiatrist who "has done research at NIH on PMS for more than a decade" offered this opinion: "As far as I am concerned, the decision to include PMS in D SM- IV will be
1576
made on political rather than medical considerations ... It’s quite clear there are a substantial number of people with PMS who never get arrested. To attribute guilt in a crime to PMS is a somewhat hazardous enterprise."" The same argument can be made about any mental illness used to support an insanity defence. John W. Hinckley Jr was acquitted of shooting President Reagan because psychiatrists testified he had schizophrenia. But how many people diagnosed as schizophrenic shoot a president? And of those who do, how many claim they did it to impress an actress? Psychiatrists understand that their entire enterprise hinges on society’s acceptance of the proposition that human beings diagnosed as mentally ill have a brain disease that deprives them of free will. I have tried to clarify the crucial differences between diseases and diagnoses. Diseases occur naturally whereas diagnoses are artifacts. So why do we make diagnoses? There are several reasons:
Scientific-to identify the organs or tissues affected and perhaps the cause of the illness. Professional-to enlarge the scope, and thus the power and prestige of a state-protected medical monopoly and the income of its practitioners. Legal-to justify state-sanctioned coercive interventions outside of the criminal justice system. Political-economic-to justify enacting and enforcing measures aimed at promoting public health and providing funds for research and treatment on projects classified as medical. Personal-to enlist the support of public opinion, the media, and the legal system for bestowing special privileges (and imposing special hardships) on persons diagnosed as (mentally) ill. It is
coincidence that most psychiatric diagnoses are inventions. The aim of the nineteenthcentury model of diagnosis was to identify bodily lesions (diseases) and their material causes (aetiology)P Today, even diagnoses of what were strictly medical diseases are no longer pathology driven. The diagnoses of patients with illnesses such as asthma or arthritis are distorted by economic factors. Final diagnoses on discharge summaries of patients are often no longer made by physicians, but are assigned by administrators skilled in the ways of Medicare, Medicaid, and private-health insurance reimbursement (based partly on what ails the patient and partly on which medical terms for his or her ailment ensure the most generous reimbursement for the services not
twentieth-century
rendered). No
psychiatric diagnosis is, or can be, pathology driven; instead, all such diagnoses are driven by non-medical (economic, personal, legal, political, and social) factors or incentives. Accordingly, psychiatric diagnoses do not point to anatomical or physiological lesions and do not suggest causal agents, but allude only to human behaviours.
3. Szasz TS. The myth of mental illness. New York: Harper and Row, 1974. 4. Editorial. British psychiatry at 150. Lancet 1991; 338: 785-86. 5. Polanyi M. Life’s irreducible structures. In Polanyi M. Knowing and being: essays by Michael Polanyi. Chicago: University of Chicago Press, 1969. 6. Freudenheim M. New law to bring wider job rights for mentally ill. New York Times 1991; Sept 23: A1 and D4. 7. Rogers W. The congressional record. In: Sterling BB, Sterling FN, ed. A Will Rogers treasury: reflections and observations. New York: Bonanza, 1982: 256. 8. Freudenheim M. At work, a new deal for the mentally ill. Wall Street Journal 1991; Sept 24. 9. Goldman MJ, Kleptomania: making sense out of nonsense. Am J Psychiatry 1991; 148: 986-96. 10. Miller C. Course offers cure for shoplifting. Syracuse Herald Journal 1991; October 17: B1. 11. Karel R. Controversy follows DWI acquittal based on premenstrual syndrome defense. Psychiatric News 1991; 26: 16-18. 12. Szasz TS. Insanity: the idea and its consequences. New York: Wiley, 1987.
BEFORE OUR TIME Dr Gilbert’s
magnetism*
Towards the end of his Harveian Oration on Oct 18,1927, Sir William Hale-White said: "Many who have written about the glorious Elizabethan Renaissance have told us of its literature, its theatres, its politics, its statesmen, its voyages and its romance, but few have dwelt upon its science. Until the latter years of the great Queen’s reign, ignorance, superstition, tradition and false reasoning darkened understanding; but then as with other branches of human activity, so with science, great lights arose in this Country-Gilbert, Bacon and Harvey; men’s minds awoke, the science of electricity was founded, we were taught how to reason and modem physiology was born. English science dates from these three who were contemporaries; fortunately they were not, like Galileo, Bruno, Servetus and others, persecuted on account of the novelty of their pronouncements." To get my message straight about William Gilbert, who was president of the Royal College of Physicians in 1600, let me quote from a letter Galileo wrote about him "I extremely praise, admire and envy this author, for that a conception so stupendous could come into his mind. I think him moreover worthy of extraordinary applause for the many new and true observations he made". Gilbert’s success in medical practice was remarkable. He was widely known in London and consulted by the great. He was physician to Lord Burghley and his wife Lady Cecil and in 1600 was appointed physician to Queen Elizabeth. He attended her at Richmond Palace during her last illness when she refused to go to bed but sat on cushions outside her
REFERENCES 1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders of the American Psychiatric Association (DSM-III), 3rd ed. Washington: American Psychiatric Association, 1980. 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders of the American Psychiatric Association (DSM-IIIR), 3rd ed, revised. Washington: American Psychiatric Association, 1987.
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Based on a paper given to the Historical Resources Panel of the Royal College of Physicians of London on Oct 29, 1991. ADDRESS 39 Clarendon Street, Butterfield of Stechford, OBE, FRCP)
Cambridge CB1 1JX, UK (Lord