DSM and Disease: Dr. Ghaemi's Partial Answer

Source: American Psychiatric Association

I appreciate Nassir Ghaemi's partial answer to my earlier response to him, regarding the controversy surrounding DSM-5 categories and why the term "disorder" is destined to create confusion among psychiatrists. On that point I believe we're both in total agreement. "Disorder" is indeed a complex, ambiguous term that's often misapplied by psychiatrists in the hope that they'll give scientific credibility to traits and behaviors whose biological foundation is either unknown or nonexistent.

But while Dr. Ghaemi unsurprisingly reaffirms his commitment to think of psychiatric problems as "diseases," with radical consequences for mental health classification that he still avoids outlining, unfortunately he's thus far declined my invitation to specify exactly what the DSM-5 task force should eliminate from the world's diagnostic manual of mental disorders. Consequently, what follows in his response to me are a series of partial or non-answers, as well as a few inaccuracies and factual mistakes.

First, the whole business about Galen, Hippocrates, and other representatives of Greco-Roman medicine. The reason I wrote that Dr. Ghaemi's attempt to reclassify "disorders" as "diseases" would take us back to the age of Greco-Roman medicine is because several of his colleagues are most eager for such a return, and Dr. Ghaemi's enthusiasm for the concept of "disease" struck me as very much endorsing that move. In the early 1970s through the mid-1990s, as he surely will remember, the Armenian-American psychiatrist Hagop Akiskal, known for both his work on temperament and his hostility to "soft-headed" or "pseudo" psychiatry, announced that it was time to update Richard Burton's Renaissance study The Anatomy of Melancholy (1621), not by moving forward but by turning the clock back to the age of Galen, Aurelianus, Soranus, and yes Hippocrates. Why? Because Akiskal thought that the "four temperaments" orienting medicine in the Classical age—the sanguine, melancholic, choleric, and phlegmatic—have "a very modern ring to them."

Ironically, then, while Dr. Ghaemi's colleagues were busy heaping scorn on terms like "neurosis," because they didn't have an obvious biological foundation (indeed, precisely because they pointed to nonbiological forms of distress and suffering), the very scholars he echoes today in preferring "disease" over "disorder" were busy validating theories millennia out of date.

Second, Dr. Ghaemi asserts rather amazingly in his response to me, "There is no link, direct or indirect, between Pharma and the basic structure of today's psychiatric nosology, as set in DSM-III in 1980." I'm guessing Dr. Ghaemi missed the part of my book on DSM-III where Isaac Marks, the world-renowned expert on fear and phobia, relayed to me how Panic Disorder found its way into the third edition of the manual. According to Marks, who was present at the occasion, the CEO of Upjohn Pharmaceuticals, maker of Xanax, opened a key Boston conference on panic by saying, "Look, there are three reasons why Upjohn is here taking an interest in these diagnoses. The first is money. The second is money. And the third is money" (qtd. p. 74 of Shyness).

That's just one rather glaring instance of the mutually beneficial relation between psychiatry and the pharmaceutical industry that has beset the profession since at least the 1980s, and arguably quite a few decades before. Unfortunately, the American Psychiatric Association required DSM consultants to declare conflicts of interest with Pharma only in subsequent editions, after DSM-III had formally approved the existence of 112 new mental disorders in 1980. As Dr. Ghaemi knows, large numbers of his colleagues continue to serve as paid consultants to upwards of two-dozen pharmaceutical companies. Is he really trying to convince me, with a straight face, that such large sums of money (plus the odd trip to Hawaii and the Bahamas) haven't, um, "influenced" their enthusiasm for pharmaceuticals just a bit? Even when their tenure as professors relied substantially or even exclusively on such funding?

Third, Dr. Ghaemi confuses me with a group of antipsychiatrists whose efforts are aimed at undermining the concept of disease altogether. That's a mistake on his part and far from an intention on mine. "Consider the rest of medicine," Dr. Ghaemi exhorts, "and tell me that there is no such thing as disease. If not the diseases of cancer and coronary artery disease and stroke, what are the ethereal conditions that kill people right and left?" Indeed, the list of other medical diseases or conditions is vast and beyond dispute: Aids, Alzheimer's, angina, arthritis, asthma . . . the list is clearly long, even if we stay with the letter "A." Our debt to modern medicine in finding full or partial remedies for such conditions is similarly vast.

But since Dr. Ghaemi began this discussion by outlining his frustration with the term "disorder" in its psychiatric context, where the concept of disease is (as he knows) far more controversial; by declaring that American psychiatry was practising "an exercise in self-delusion" in claiming that it was being agnostic over etiology; and by personally offering to start "a surgical process of excision" to pare back the burgeoning diagnostic manual, I'll end by restating my invitation that Dr. Ghaemi make good on declaring which "disorders" in the DSM should go. These were his exact words: "One approach would be to add about 50 other such common non-disease clinical conditions. All other problems with psychological symptoms, most of which probably represent problems of living rather than diseases, could be left out of any diagnostic definitions."

As I wrote in reply, which 50 "common non-disease clinical conditions" should stay? And which "other problems with psychological symptoms" did he have in mind?

Let me be clear that Dr. Ghaemi and I are in total agreement about the urgent need to reduce the size of the world's diagnostic manual of mental disorders. If the editorial knife were in your hands, Dr. Ghaemi, where would you start making your surgical excisions? Let's get that debate rolling. It's really long overdue.

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References

Akiskal, Hagop S., with William T. McKinney, "Psychiatry and Pseudopsychiatry," Archives of General Psychiatry 28.3 (1973), 367.

Lane, Christopher. Shyness: How Normal Behavior Became a Sickness. New Haven: Yale University Press, 2007.