Mood Swings

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First Do No Harm and DSM - Part II : Taking Disease Seriously

The misuse of the Hippocratic tradition examined - part II

In the previous post, I showed the emptiness of the slogan of First Do No Harm, as used by Allen Frances, the founder of DSM-IV, in his eristic arguments for a "pragmatic" approach to DSM. I explained that the use of that Hippocratic notion in that way is historically false and scientifically wrong.  Here I will demonstrate how the approached advocated by Dr. Frances also goes against the modern tradition of scientific medicine, as exemplified in the resuscitation of Hippocratic thinking in the work of William Osler at the turn of the 20th century.

If psychiatry is a legitimate branch of medicine, and it includes the treatment of diseases of the body and brain, and it exists within the tradition of science as applied to medicine, then the teachings of William Osler are a key test of whether psychiatry is, or can be, scientific.  The approach of Dr. Frances, unfortunately, fails that test.  (Sources are my article on this topic, another by Paul McHugh, and scholarly work on Osler, as well as Osler's own classic collection of lectures and essays, Aequinimitas,)

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Like Hippocrates, William Osler is often cited but little read. He is most known for his emphasis on patients as persons, as the father of medical humanism, the ideal well-bred physician. Yet in his prime, Osler was a cutting-edge scientifically-oriented physician; he emphasized the importance of pathology, and based clinical skills on pathological confirmation and laboratory testing. (He probably conducted over 1000 autopsies). He also advocated the Hippocratic tradition, stressing clinical observation and diagnosis, and opposing aggressive medication treatment. His therapeutic conservatism (some called it "nihilism") was not simply a personal attitude, but, like Hippocrates the upshot of scientific medicine.


In Osler's age, physicians had recently replaced bleeding and purging with pills and potions. Taking the Hippocratic view, Osler disapproved of those extensive treatments because they disregarded disease.19th century medicine, he taught, was not scientific because it was symptom-, rather than disease-, oriented. (This is exactly the approach taken in DSM-IV and supported by Dr. Frances for DSM-5).

For Osler, scientific medicine begins when we study and learn more about the diseases that produce symptoms; afterwards, not before,  treatments would be clear: "A man cannot become a competent surgeon without a full knowledge of human anatomy, and the physician without physiology and chemistry flounders along in an aimless fashion, never able to gain any accurate conception of disease, practicing a sort of popgun pharmacy, hitting now the malady and again the patient, he himself not knowing which."


In sum, Osler, the leader of modern scientific medicine, felt that scientific medicine is the treatment of diseases, not symptoms. Physicians need to shift their focusing from identifying and treating symptoms to understanding the diseases that cause those symptoms. Once those diseases were understood, Osler held, appropriate treatments would arise. Instead of anti-jaundice treatments for yellow skin, anti-pyretic treatments for fever, pro-energy treatments for fatigue, and anti-chill treatments for coldness, the syndrome causing those symptoms needed to be studied, and if identified as a disease (like hepatitis), treating the single disease would cure many symptoms.


Put another way:  the solution was diagnosis before drugging:
"In the fight we have to wage incessantly against ignorance and quackery among the masses, and follies of all sorts among the classes, diagnosis, not drugging, is our chief weapon of offence. Lack of systematic personal training in the methods of the recognition of disease leads to the misapplication of remedies, to long courses of treatment when treatment is useless, and so directly to that lack of confidence in our methods which is apt to place us in the eyes of the public on a level with empirics and quacks."


This was the line of demarcation between scientific and non-scientific medicine. Non-scientific physicians asked only to know symptoms, followed by treatments. Scientific physicians sought to know if symptoms led to disease, and only then they might treat the disease:


"The 19th century has witnessed a revolution in the treatment of disease, and the growth of a new school of medicine. The old schools - regular and homeopathic - put their trust in drugs, to give which was the alpha and omega of their practice. For every symptom there were a score or more medicines - vile, nauseous compounds in one case; bland, harmless dilutions in the other. The characteristic of the new school is firm faith in a few good, well-tried drugs, little or none in the great mass of medicines still in general use."


Osler also foresaw future politics: if we reject disease-oriented medicine, we are left at the mercy of social forces tending toward overmedication, such as  the pharmaceutical industry.  Osler's warnings are all too familiar: "To modern pharmacy we owe much, and to pharmaceutical methods we shall owe much more in the future, but the profession has no more insidious foe than the large borderland pharmaceutical houses." Just as important, though, are patients themselves, many of whom eagerly feed into such marketing: "Man has an inborn craving for medicine."

Osler thus teaches us the first rule for a Hippocratic psychopharmacology - Osler's Rule: Treat diseases, not symptoms.

Today many psychiatrists practice non-scientific symptom-oriented treatment, giving sedatives for insomnia, stimulants for fatigue or distractibility, anxiolytics for tension, antidepressants for depressive symptoms, and mood stabilizers for lability - leading to an excessive and ineffective polypharmacy.

Because of this non-Hippocratic, non-Oslerian, unscientific practice, critics like Dr. Frances wish to deemphasize adequate available scientific evidence (as is evident, I believe, in our debate about bipolar disorder type II) and distort psychiatric diagnoses so as to limit the harmful use of drugs.  In the process, by wrongly distorting our definitions of diagnoses, this approach, taken in our current nosology of DSM-IV, guarantees that biological research on such false definitions will be fruitless.  It is a vicious circle: because our knowledge of disease is poor, we distort our diagnoses in such a way that we can never progress in our knowledge of disease.  

This is the psychiatry that has been bequeathed to us by the leaders of DSM-IV.  We will have to live with DSM-5 for another generation.  One can only hope that we do not repeat the same mistakes as those which led to our current impasse. 

 

Nassir Ghaemi, M.D., M.P.H.,

is Professor of Psychiatry at Tufts University School of Medicine, and Director of the Mood Disorders Program at Tufts Medical Center in Boston. more...

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