Doing Psychiatry Wrong

A Critical and Prescriptive Look at a Faltering Profession

René J. Muller, Ren� J. Muller

• Publisher: Routledge
• Year: 2013
• Print ISBN: 9781138424999
• eBook ISBN: 9781136822995
• Topic: Psychologie
• Subtopic: Psychologie clinique

The prospect that the psychiatric profession has hurt rather than helped many of its patients is incredibly disheartening; however, wrong diagnoses and improper treatment are all too common errors within the field.

Author René Muller presents a revealing look into how psychiatry has failed a great majority of patients, all the while recognizing the valiant efforts made by psychiatrists who maintain their integrity and serve their patients well. The result is an enlightening critique of the profession—one that pits criticism of psychiatry's current biological reduction and exaggerated promises against the accumulated wisdom of a profession that has struggled for a century and a half to understand and help those with mental illness.

CHAPTER 1
Seeing Through the Illusion of Biological Psychiatry

Between 1994 and 2004, I evaluated more than 3,000 psychiatric patients in the emergency room at three hospitals in Baltimore. Some of the patients I saw had unusually challenging problems, and their stories set me to writing a series of articles for Psychiatric Times, which I later collected and published as a book, Psych ER: Psychiatric Patients Come to the Emergency Room.¹

Halfway through my decade in the ER, I began to see that many of my patients were telling stories about their present and past lives that did not square with the diagnoses they had been given.² Eventually, I realized that most of those judged to have bipolar disorder and schizophrenia—to cite just the most egregious mistakes—never did meet the criteria set by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).

Listening to my patients’ stories, it became clear to me what had happened: symptoms they reported were matched by a clinician to the DSM criteria for bipolar disorder and schizophrenia without the meaning of the symptoms ever being ascertained—all but assuring a wrong diagnosis. While working in a community mental health center and for a private practice group, I observed a similar mismatch between patients’ stories and their diagnoses. Gradually, I had to acknowledge that, in psychiatry, misdiagnosing patients had become the de facto standard of care.

Convinced that they had a “brain disease,” many of my misdiagnosed patients took prescribed psychotropic medication that was not needed, sometimes to their detriment. Most of these patients had personality disorders, used illicit drugs, or consistently made the kinds of choices that inevitably lead to erratic emotional states that produce psychiatric symptoms, especially “mood swings.” I was left to wonder how physicians could have violated their responsibility to see and hear their patients correctly, and ignored Hippocrates’s injunction, “First, do no harm.”

Most psychiatrists are trained now to believe that human thinking, feeling, and behavior, whether normal or abnormal, have their primary origin in the workings of the brain’s neural substrate. Patients who have symptoms that meet the criteria for a mental disorder will most likely be told they have some kind of “chemical imbalance” and need one or more drugs to correct the imbalance. The implication here is that they have disordered and pathological lives because they have a malfunctioning brain.

There is good empirical evidence that correctly diagnosed bipolar I disorder and schizophrenia involve a glitch in brain structure and function, though no specific cause for either illness has been established. As much as any other factor, the current crisis in psychiatric diagnosis derives from a leap that was made from the near certainty that some mental illnesses are brain disorders to the unjustified conclusion that all mental illness is biologically driven. If a symptom is merely the behavioral manifestation of a biological malfunction, the idea that symptoms need to be understood in the context of the patient’s life—that is, that abnormal emotion and behavior point back to something the patient is doing wrong and needs to modify—becomes tenuous indeed. If biology is the primary determinant of human experience, then psychoanalytic, psychodynamic, developmental, cognitive, and existential approaches to understanding behavior are of secondary importance. Many psychiatric residency programs no longer teach these theories of the self, or include them only marginally. Responding to this gap in their training, residents in some programs have lobbied vociferously for the return to the curriculum of the dynamic and humanistic approaches to understanding psychopathology.

If behavior has no specific meaning, it can have any meaning. For a variety of reasons, psychiatrists appear to be invested now in assigning the “worst” diagnoses to patients whose behavior is erratic, bizarre, and threatening, and who are difficult to treat with psychotherapy. For some time, the figure cited for the prevalence of both bipolar disorder and schizophrenia was about 1%. After the atypical antipsychotics and the newer anticonvulsant mood stabilizers came on the market and were declared to be user-friendly, the diagnostic net was cast farther out, and those numbers rose dramatically. Surely, a self-serving bias came into play here: by calling a patient bipolar or schizophrenic, the clinician opened the way for the patient to become an illness that needed to be “cured” with medication, and justified downplaying or ignoring altogether the complex dynamic needs of those who would require long-term, demanding psychotherapy. Misdiagnosing a patient could make life easier for the diagnostician, but at the cost of burying the truth about the patient’s life, sometimes forever.

Most wrong psychiatric diagnoses tend to stick with patients. Clinicians are reluctant to risk what they see as the possible adverse clinical or legal consequences of changing their original call, or a call made by another clinician. A particularly cruel consequence of misdiagnosing someone with schizophrenia is that the medication prescribed to quell misread “psychotic” symptoms can itself cause a tardive psychosis, so named because it takes time to develop.³ This is thought to be caused by an over-production of postsynaptic dopamine receptors in compensation for the drug’s blockade of the overactive presynaptic receptors, the explanation posited for the original psychosis. Those who go off antipsychotic medication suddenly are prone to a “discontinuation syndrome,” where psychotic symptoms can occur, even if the patient did not have them initially.

If a patient is misdiagnosed with and treated for cancer, a lawsuit is almost sure to follow. Yet most psychiatric misdiagnosis goes unchallenged by the victims and the courts—an irony, considering that psychiatry is increasingly thought of as a medical discipline. This happens because there is no standard a clinician is held to in justifying the diagnosis of a mental disorder. Physicians diagnosing cancer must have radiological and pathological evidence of a malignant process. Unless a patient’s change in mental status is due to a physiological cause that can be substantiated by laboratory tests—as would be the case with an electrolyte, endocrine, or metabolic derangement, or with drug toxicity—the psychiatrist making a diagnosis must depend on observations of and reports by the patient, and on information volunteered by others. After many years of clinical work, it is clear to me that patients’ reports of abnormal thoughts, feelings, and behavior can be “stretched” to make the diagnosis of any number of mental disorders, simply by matching their symptoms to one or another checklist in the DSM.

Reports of symptoms by patients are often vague and are usually taken by clinicians at face value. Few psychiatrists now have any interest in identifying the possible ways that abnormal thinking, feeling, and behavior could be due to the inauthentic and self-destructive choices a patient is making, or in looking into how unacknowledged (and sometimes unconscious) choices made long ago continue to influence a life. This is what it would be to uncover what the patient’s symptoms mean. Instead, “meaningless” symptoms are targeted with mood stabilizers, antipsychotics, and atypical antipsychotics. I once heard a representative from a leading drug company try to convince his audience that his product was the drug to use when, as he put it, “there is psychosis in the diagnosis.” Not long after that I heard a psychiatrist at a grand rounds conference say, with obvious pride, that he had a “low threshold for diagnosing psychosis.” With psychiatrists and drug companies thinking in this way, the odds that patients will have their stories heard correctly are diminished.

Intuitively, one would expect that the reports of toxic cardiac and metabolic effects sometimes seen in patients taking mood stabilizing and antipsychotic drugs would have encouraged psychiatrists to be more careful about diagnosing mood disorders and psychotic disorders, but this has not been the case.⁴ Instead, as more prescriptions are written every day, drug companies and clinicians who write journal articles about these drugs recommend that patients be informed of the potential risks, have periodic electrocardiograms, and be monitored for weight gain, as well as for elevation of blood glucose and triglycerides.

Usually, patients implicitly accept their psychiatric diagnosis. They are often relieved and reassured to hear that the emotional pain they are suffering is not due to any fault of their own. We live in a culture where people believe they are owed a drug for every problem, and if one is not available it soon will be. In an age of growing secularism, disguised as it is with the many faces of a false spiritualism, a pill on the tongue replaces the communion wafer as a conduit to transcendence, courtesy of neuroscience and psychopharmacology.

Where psychoanalysis once maintained that the unconscious mind ruled behavior and that only the psychoanalyst had the key to unlock its paralyzing secrets through dream analysis and free association, biological psychiatry now insists that a “chemical imbalance” in the brain causes mental illness and that only a medical doctor can write a prescription to fix the problem. Freud felt that psychoanalysis could at best transform neurotic misery into everyday unhappiness. Peter Kramer did Freud one better when he claimed in Listening to Prozac that some of his patients on Prozac felt “better than well.”⁵ If, by taking a pill, patients can get around having to find out why they feel depressed, many will choose to do just that. Most psychiatrists see this pharmacological solution as an acceptable way of handling the problem.

Our inclination toward self-deception—the lie we tell ourselves, which is usually called “being in denial”—is rooted in our need to continuously respond to a world that often does not offer us what we want and need.⁶ Self-deception allows us to believe what we otherwise could not believe, so we can get what we otherwise would not have, or at least have so readily. What the French existential philosopher Gabriel Marcel said about betrayal being “pressed upon us by the very shape of our world” is true as well for self-deception.⁷ We deceive ourselves about things large and small because everyone and every situation we encounter requests—and at times requires—us to do so. As a result, most people are self-deceived most of the time. We go along to get along.

Patients tend to accept the promise of biological psychiatry because it gets them off the hook as creators of their own problems, while offering a solution that does not require them to change their lives. Managed care companies and health maintenance organizations (HMOs) embrace this paradigm because treating symptoms with a pill is cheaper than paying for extended psychotherapy or psychiatric hospitalization. The drug companies are happy because they are getting rich by selling more drugs to more people all the time. And psychiatrists are becoming accustomed to the idea of prescribing pills to treat symptoms (without having to worry about what these symptoms mean) because this is the only way they can earn a living now. Their compensation from third-party payers for a 50-minute therapy hour is paltry, but turning out three medication checks an hour pays pretty well. Psychiatrists who work on inpatient units in psychiatric hospitals are also forced to prescribe medication if they expect to be reimbursed by these same third-party payers.

The notion that we believe what we want to believe has been around for a long time. Fooling ourselves can reach the level of illusion—a condition of being deceived by a false perception—if that perception figures prominently in what we believe and in how we live. As it is most strictly conceived and practiced, biological psychiatry has slowly but surely become not only an illusion but a collective illusion, being subscribed to by so many—patients, doctors, drug makers, insurers—whose needs it meets, if inauthentically. The pie-in-the-sky promises perpetrated through this illusion stretch to the horizon: just spend enough money and do enough research and every mental illness will be understood. There is something for everybody here, which is why the illusion persists.

“Every age has its peculiar folly; some scheme, project or phantasy into which it lunges, spurred on by the love of gain, the necessity of excitement, or the mere force of imitation.” So noted Charles Mackay in Extraordinary Popular Delusions & the Madness of Crowds, published in England in 1841.⁸ Already, in mid-nineteenth-century Europe, Mackay had plenty of examples of self-deception that rose to the level of a collective illusion, scams and follies that gripped large numbers of people and, sometimes, whole nations: the tulip mania in Holland, alchemy, the Great Crusades, and the witch burnings are just a few of those he cited. Every age is susceptible to its unique version of self-deceiving folly. Starting in the mid-twentieth century, one of ours was the outsize role attributed to the brain by psychiatry and society in determining all we think, feel, and do.

Psychiatry has always been viewed with some suspicion. One hears it said, sometimes in jest, sometimes seriously, that psychiatrists are more abnormal than the patients they treat (no one claims that cardiologists have worse hearts than their patients or that surgeons are themselves in need of surgery). Hollywood has often portrayed psychiatrists as betraying their patients, while simultaneously destroying themselves. Perhaps these filmmakers, and the writers who create the stories behind their films, are the ultimate seers into the human condition. Freud himself acknowledged, “Imaginative writers are valuable colleagues. In the knowledge of the human heart they are far ahead of us common folk.”⁹ Maybe these creative people knew all along that psychiatry never really did get it right, or serve its patients well, not when psychoanalysis was in vogue and certainly not now that biological psychiatry runs the show.¹⁰

The affront to psychiatry caused by the insistence that all mental illness derives from a brain chemical imbalance occurred simultaneously with a general decline in Western culture. People used to talk about “selling out,” which meant giving up what they really believed in, usually for the promise of fame or money. Selling out once implied a lower level of personal integrity and satisfaction. These days, that lower level is unabashedly courted by most people from the start, and no one feels the less for beginning at that level, or staying there. The closest anyone comes now to acknowledging an ultimate good in the workplace is what the business world likes to call “creating value for shareholders.” This is the program the drug companies follow as they continue to help define and bankroll biological psychiatry. What a fine way to say that greed is the only good, as the Michael Douglas character Gordon Gecko does in the iconic 1987 film Wall Street. In this new ethical dispensation, Gecko may make our skin crawl, but there is no contravening ethos strong enough to convince us that he is wrong, either.

It is no surprise that, in the absence of any other value, money filled the vacuum as the default value and became the ultimate desideratum. Many psychiatrists now are acquiescing to billable hours and the bottom line as the primary objectives of their work. I have colleagues who, at the end of the day, wonder if any goal other than survival is even worth considering. Freud understood that those under attack often identify with the aggressor as a strategy for dealing with their anxiety and surviving the onslaught. Simply put, psychiatrists have surrendered to market forces. Gratification delayed during years of medical and specialty training calls out to be slaked, school tuition and the mortgage need to be paid, and a dignified retirement must be secured.

A psychiatrist friend, who has spent his entire career on the staff of one of the country’s premier psychiatric hospitals and is about to retire, told me with a hint of smugness that he made $200,000 during the previous year. Then he told me, without any detectable regret, that he was seeing over 400 patients a month. This is a clinician who started his career doing therapy with patients, then, under pressure, turned to doing three medication checks an hour. Some psychiatrists I know have started referring to themselves as neuropsychiatrists or psychopharmacologists to emphasize their allegiance to the currently fashionable—and profitable— quick fix. Others left the profession in disgust and despair.

As a clinician who writes about patients, I am imbued with what Albert Camus saw as the writer’s responsibility to be a witness to the injustices of his time.¹¹ Staying silent after seeing people harmed by the ultimate “helping profession” would be to tacitly accept this dark irony. For the better part of a decade, though I was sometimes critical of how so many of the patients I worked with in the ER had been misdiagnosed and wrongly medicated, I did not directly question the integrity of the profession itself. The articles and the book, Psych ER, that I wrote bas...

Table of contents

• Contents
• Preface
• Acknowledgment
• CHAPTER 1 Seeing Through the Illusion of Biological Psychiatry
• CHAPTER 2 How Biological Psychiatry Lost the Mind and Went Brain Dead
• CHAPTER 3 The Brain Cannot Account for What We Think, Feel, and Do
• CHAPTER 4 The Lost Art of Psychiatric Diagnosis
• CHAPTER 5 A Blatant Misdiagnosis of Schizophrenia
• CHAPTER 6 How Psychiatry Created an Epidemic of Misdiagnosed Bipolar Disorder
• CHAPTER 7 Willing Psychotic Symptoms
• CHAPTER 8 How Psychiatry Does Depression Wrong
• CHAPTER 9 Saving Psychiatry From the Brain
• CHAPTER 10 Doing Psychiatry Right
• EPILOG
• Notes
• Index