Hard Times For All! Or Not ? - Radu Teodorescu
HARD TIMES FOR ALL! OR NOT?
When I came back from my Christmas holydays some friends made me a gift: an article demonstrating in a very scientific way that psychotherapy is dead. Several things came to my mind: 1. never take Christmas holiday! Risks are too high; 2. Timeo amici et dona ferentes; 3. psychotherapy was declared dead at least as many times as God, but if this time it is true?
I am a psychiatrist, I have to see patients and they seem to count on me in order to alleviate their sufferings. Sometimes I use psychotherapy. What shall I do? What direction will take my professional life from now on? Let us check the press!
In the last month editorial of the Journal of Child Psychology and Psychiatry, entitled “It’s environment, stupid!” one of the big shots of world psychiatry Professor Edmund Sonuga-Barke writes that “Thankfully, because of new genetic technologies of immense quantitative power developed over the past 10 to 15 years, and the recent development of sophisticated methods for testing environmental influence on biological processes, we can at last bypass this stale stand-off over nature vs. nurture dogma. Serious science is now more than ever focused on the power of the environment to shape neuro-developmental processes and pathways…all but the most dogged of genetic determinists have revised their view of the primacy of genetic factors”(1)
Adieu the happy times when some had thought that we all are genetically pre-programmed for future illnesses. Not anymore! Now we think that maybe genes create a vulnerability which might generate a disorder only if the subjects are under specific traumatic circumstances. For example, those of us who have a certain allele are at risk to develop a depressive disorder if only they have experienced maltreatment from significant others in the early childhood. It seems reasonable. In a recent meta-analysis published by JAMA after a review of 14 250 subjects whose DNA was mapped in 14 studies, Risch and Merikangas concludes that they could not find any evidence that the “serotonin transporter genotype alone or in interaction with stressful life events is associated with an elevated risk of depressions in men alone, women alone, or in both sexes combined” (2). Of course their conclusions have been immediately attacked by others with more or less convincing arguments (3). The dispute is not over.
So, after billions spent in the last fifty years on more and more expansive instruments, tones of papers, thousands of congresses, innumerable PhD theses, after “thousand flowers (read departments and research teams) have flourished” as Mao put it, and this on tax-payers money, we are still stuck in the same antic debate nature vs. nurture and the balance as far as mental disorders are concerned goes slightly (or mostly) toward environment.
Back to Sonuga-Barke! He writes that as far as ADHD is concerned “even the most comprehensive genome-wide scans available, with thousands of patients using hundreds of thousand of genetic markers…appear to account for a relatively small proportion of disorder expression”.
ADHD? This brings into mind something! Fashionable disorders in psychiatry! I mean illnesses which appear in a certain historical context, apparently scientifically grounded on empirical observation, which agitates for awhile the professional community and later fades away leaving no trace or at least some discussion on how it was possible to consider it laden-proof disorders. Do you remember nostalgia? No, not Tarkovsky’s powerful movie, the illness. Once upon a time, in 1688 a young healthy man left Bern to study at the University of Basle. Away from home, lonely, without anyone to help and take care of him, caught in an unfriendly network of new rules and surroundings, he lost interest in everything, he did not eat, he did not leave his bed, he was transpiring, he had shortness of breath and palpitations, in short he was dying. First he got medicines, with no result! Than he was send home (psychotherapy avant la lettre?) in order to finish his days near his loved ones. And miracle: he got well and lived a long and happy life.
This story remembered to a 19 years old Johannes Hoffer several other cases he had observed and he coined the name of a new illness, nostalgia, which brought him the subject for his Medical Dissertation and the title which went with. After a long career through centuries the term disappeared buried in the pages of history of medicine, but it inaugurated a very successful new way of getting a PhD. A way which never disappeared since! In 1886, Albert Dadas, a 32 years old man working for the Gas Company of France was admitted in emergency at the St. André Hospital in Bordeaux for exhaustion after a very long voyage. What amazed his treating doctor, Albert Tissié, was not the very bad health condition of the patient but his tears. “He wept because he could not prevent himself from departing on a trip when the need took him; he deserted family, work, and daily life to walk as fast as he could, straight ahead, sometimes doing 70 km a day on foot, until in the end he was arrested for vagrancy and thrown in prison” (4). It followed a doctoral thesis “Les aliénés voyageurs”, a well deserved title for Tissié, a fight between neurologists who thought that the new illness belonged to their field of expertise under the name of “automatisme ambulatoire” and psychiatrists who were convinced that it was a mental disorder under the name of “determinisme ambulatoire”. After many publications, congresses, professorships won for outstanding contributions in the field of “mad travelers”, suggested treatment with anti-epileptic agents (placebo? psychotherapy?) the concept disappeared with the First World War. RIP! Welcome to a new entity: multiple personality disorders. And so on!
A never ending story? Of course not, DSM-V is here to come and solve our problems! Well, not so soon! It was meant to be published this year and now we are told it will be launched in May 2013.
First published in 1952, the DSM has its origin in a US Army manual intended for the use of the military psychiatrists who were to evaluate the capacity of candidates to fight on the battle field. It described 128 disorders in 94 defined categories. DSM-II followed in 1968 and it contained the description of 159 disorders and 137 defined categories. Revolution came with the third edition in 1980 not only because it almost doubled the number of disorders to 227 vs. DSM-I but because Spitzer and his collaborators introduced the concept of “diagnostic criteria” of which there were 962. If the second edition brought APA one million dollars, the third one was a blockbuster sold in almost 500000 copies which earned ten times more. But another revolution which DSM-III started was the one of by-products: pocket editions, casebooks, sourcebooks, instruments, treatment handbooks, etc and if we add the sums generated by DSM-III-R and its derivates probably the total amount will double. A hen with golden eggs! An anti psychiatrist might think that if the number of illnesses increased arithmetically, the amount of money generated by the flow of DSM editions progressed geometrically! Vade retro! DSM-IV came with 357 disorders, 201 defined categories and 1486 criteria. Never in the history of medicine had any specialty tripled the number of illnesses in 40 years! Nobody can stop real progress! DSM was supposed to enhance better diagnosis. To take a simple example, panic disorder, there are several hundreds of possible combinations of criteria which allow the same diagnosis and unfortunately there are still patients who do not fit this plethora of combinations. And as if this was not enough, some of them will get after some years a totally different diagnosis and the initial one will be considered only a particular way of debut for the new diagnosis. Further problems arise from the possibility of having many concomitant diagnoses because of the criteria overlap.
The aim of each new edition of the DSM, at least since DSM-III, was to improve reliability, largely a reaction against those who accused psychiatric diagnosis of being invalid. But in order to carefully assess all these conditions in the way they have been newly described, one needs time, funding and ideological freedom of mind. Already in 1988 Zimmerman asked in an article “Why are we rushing to publish the DSM-IV?” (5) Zimmerman argued that the rapid changes in the DSMs made psychiatric classification a moving target whose lack of temporal stability interfered with the process of careful research and validation of any new category or set of criteria. DSM-IV finally appeared with some useful refinements of details, but with the same conceptual logic and its criteria problematically over-inclusive. Many were deeply dissatisfied and we were promised a new revolution. The miracle solution was supposed to be, at the beginning, a strong, but as time went by, a subtle introduction of dimensions in order to correct the categorical system. After years of hope, some month ago we have heard that DSM-III founding father, Robert Spitzer was angered, to put it mildly, by the process of writing of the new edition. Than DSM-IV founding father, Allan Frances launched an “alert to the research community” in order to be prepared to fight against mistakes which might compromise DSM-V (6) because the present task-force lacks “one of the skill that is …essential…the ability to write clearly and consistently”. Based on some of DSM-IV errors which lead to an overestimation of disorders like autism and attention deficit disorders or had unwanted legal consequences for people accused of sexually violent acts, Frances is worried that “the risks of unintended consequences from an ambitious, secretive, and poorly organized DSM-V are numerous and significant”. Motivated by “commercial” purposes the DSM-V team marketed new interviewing instruments despite the fact that “nothing in the work to date of the DSM-V Task Force inspires confidence in its ability to produce and test” them. Introducing sub-threshold conditions will increase in a dangerous way the number of false positives in the general population “particularly once they are helped along by drug company marketing – resulting in excessive use of medication that often have serious long-term complications”. Finally, Frances menaces APA “which holds the franchise to publish the DSM only by accident” with losing it, “if enough organizations lose confidence in its competence”. First to react, David Kupfer, the father-to-be of the DSM-V, answered by accusing the two ex-fathers of being motivated by their own financial interests since the new edition will stop royalties the pair was receiving for their past work. Reading this debate some might think to be lost in a PSD congress.
Where are we to find the truth we need for our day-to-day practice? Maybe in the peer-reviewed journals? For the first time in history the US Public Library of Science used a court order in order to obtain “evidence showing how the pharmaceutical company Wyeth employed commercial ghost writers to produce reviews, published in academic journals, under the names of academic authors” (7). Last year Steven Greenberg, associate professor of neurology at Harvard Medical School published an article on scientific ideas and how prestige and the conviction that they are true are developed by analyzing the pattern of citations among academic journals. As a neurologist he picked the affirmation that β amyloid “is produced by and injures skeletal muscle fibres in the muscle disease sporadic inclusion body myositis”(8). Among the 766 articles published on the topic, 10 receiving the largest traffic were identified as “authorities”; all supported the claim and received 94 % of citations. Only 4 of them contained experimental data, all came from the same laboratory and in fact two presented the same data without citing each other. There were 6 papers almost never mentioned; all contained data which refuted the hypothesis and received 6 % of citations. Authority was built through “the choice of which articles to cite and which to ignore (citation bias), by citing but distorting content (citation diversion) and by using citation to invent facts (citation transmutation).” When analyzing arguments used in National Institute for Health applications for grants, Greenberg identified the use of citation bias, diversion and even pure invention. How many of the articles we read would be validated when examined through Greenberg’s lenses?
Are these hard times for psychiatry, psychotherapy and connected fields? Someone might be tempted to agree when reading some of the critical appraisals from which we have selected only a few. We might also disagree if critique will allow us to avoid past pitfalls and open new perspectives. Are mental disorders a reality? Certainly even if we might discover in the future that they are far of what we believe today. Is the mental suffering a reality? That is sure. Under these circumstances we have plenty of work and even time to dream. Why not dream of studies funded by National Institutes of Psychiatry and free of ideological constraints or commercial interests?!
Since it is not for the first time psychotherapy was declared dead, the announcement of its new death might have been greatly exaggerated.
1. Sonuga-Barke EJS. It’s the environment, stupid! On epigenetics, programming and plasticity in the child mental health. J Child Psychol Psychiatry and Allied Disciplines 2010; 51:113-115.
2. Risch N, Herrell R, Lehner T et al. Interaction between the serotonin transporter gene (5-HTTLPR). Stressful life events, and risk of depression: A meta-analysis. JAMA 2009; 31(23): 2462-2471.
3. Rutter M, Thapar A, Pickles A. Gene-environment interactions. Arch Gen Psychiatry 2009; 66(12): 1287-1289.
4. Hacking I. Mad travelers: Reflections on the reality of transient mental illnesses. Charlotsville, London: The University Press of Virginia, 1998.
5. Zimmerman M. Why are we rushing to publish the DSM-IV? Arch Gen Psychiatry 1988; 45(11):1135-1138.
6. Frances A. Alert to the research community be prepared to weigh in on DSM-V. Psychiatric Times 2009;dec 3rd:1-3.
7. Goldacre B. Bad Science. Hit and myth: curse of the ghostwriters. The Guardian 2009; aug 8th:13.
8. Greenberg SA. How citation distortions create unfounded authority: analysis of a citation network. BMJ 2009;339:b2680.