Doing Psychiatry Wrong Author Responds to Critique

In his review of my book, Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession¹ (Psychiatric Times, June 2008, page 57), S.N. Ghaemi, MD, MPH, citing George Orwell, writes that I “seek to justify an opinion” rather than “seek the truth.” He claims that my “errors are numerous and fundamental.” Let’s see.

I stand by my claim that the DSM-III was intended primarily as a research tool, putting reliability in front of validity to foster research at the expense of accurate diagnosis.

I was also called to task for my use of the term “diagnosis of exclusion.” According to Wikipedia, “diagnosis of exclusion refers to a medical condition whose presence cannot be established with complete confidence from examination or testing. Diagnosis is therefore by elimination of other reasonable possibilities.”² In my book, I used the term within the bounds of this definition and not, as the reviewer claims, to designate “[thinking] about more common conditions first before diagnosing more severe conditions.”

In Chapter 5, A Blatant Misdiagnosis of Schizophrenia, I tell the story of a friend who, during his freshman year in college, after using multiple drugs and large amounts of alcohol, lost control of his temper during a lacrosse practice and became paranoid. Numerous hospitalizations followed. He was diagnosed at different times with schizophrenia, schizoaffective disorder, and bipolar disorder but was told he did not cleanly make criteria for any of these mental illnesses. At one point, he was simultaneously on 11 different medications!

For some reason, the reviewer concluded, “The author’s ‘proof’ of misdiagnosis was 3 years of psychotherapy in which, essentially, the author felt he understood ‘why’ the patient was paranoid.” Three years of psychotherapy with whom? Not with me-he was never my patient-and surely not with any clinician who had worked with him since he was being treated for a “chemical imbalance” the whole time.

I was eventually able to understand my friend’s paranoia and to discern the meaning of his life story because I listened to him. The reviewer leaves the impression that trying to “understand” paranoia is absurd. In Chapter 7, Willing Psychotic Symptoms, I discuss how paranoia can be psychogenic-hardly a novel idea.³

It appears that the reviewer confused the story of my friend with that of a patient I had worked with for 21 months, which was told in the Epilog, A Man, Crippled by Anxiety, Who Was Previously Misdiagnosed With Bipolar Disorder: Therapy Leading to Structural Change. For some reason, Dr Ghaemi chooses not to discuss the good outcome of this interesting case.

After 20 years, my best guess is that my friend is a world-class drug addict, with the dynamics that go with addiction at this level, and that the only valid diagnoses he was given were for substance abuse and major depression.

My bte noir, the reviewer recognizes, is the overdiagnosis of bipolar disorder. If, after reading Chapter 6, How Psychiatry Created an Epidemic of Misdiagnosed Bipolar Disorder, anyone still wonders why, I recommend taking up Mania: A Short History of Bipolar Disorder⁴ by the Welsh psychiatrist David Healy. Healy shows that the concept of bipolar disorder has been shaped as much by social, cultural, and economic factors-including the drug companies’ “definitional creep” expansion of the DSM criteria-as by dispassionate and rigorous science.

One of my reasons for writing Doing Psychiatry Wrong was to call attention to the consequences of the DSM’s adoption of the meaningless symptom-really, the agnostic symptom-in which neither the clinician nor the patient is interested in discovering how the symptom relates to the patient’s life. The reviewer questions my insistence that the meaning of symptoms should be determined, to the extent possible, before a psychiatric diagnosis is made.

In one study after another, cognitive behavioral therapy (CBT), developed by Aaron T. Beck, MD, and his group at the University of Pennsylvania, has been shown to have a lasting effect in patients with anxiety disorders, depressive disorders, and other psychiatric conditions. Using this technique, the meaning of pathological thoughts that is intrinsic to the patient’s pathology is identified, challenged, and changed. With such strong evidence that CBT works, one can only wonder why the meaning of symptoms is not included in the DSM diagnostic criteria-and is ignored by most clinicians.

Ren J. Muller, PhD

Baltimore

Dr Ghaemi Responds

A critical book review is never pleasant, for author or reviewer, yet because ideas have consequences, such debates are unavoidable. In his book, the author claims that “bipolar disorder should be a diagnosis of exclusion, and made only after other, lesser, diagnoses fail to account for a patient’s thinking, feeling, and behavior” (page 53). This contrasts with the traditional meaning of diagnosis of exclusion in which one needs to rule out more serious illness (not lesser ones) before making simple diagnoses. Thus, we rule out pneumonia before the common cold, and we should rule out bipolar disorder before invoking mere personality traits. In the case of supposed misdiagnosis of schizophrenia (Chapter 5), Dr Muller describes 3 years of personal contact without making it clear to me, at least, even on a second reading, whether he is the person’s psychotherapist or his friend. In either case, the author makes numerous personality disorder diagnoses instead.

Regarding David Healy’s recent book, readers can follow my comments on his critique elsewhere.⁵ I take issue with Healy’s interpretation of psychiatric history. No pharmaceutical companies existed in Paris circa 1854 when bipolar disorder was first described in the modern era much as it is now, not to mention ancient Roman descriptions that parallel current concepts of the bipolar spectrum. On perhaps the key topic that motivates the author, I agree that meaning is important in psychiatry, but there are many perils (including overdiagnosis of personality disorders) in understanding meaning appropriately. The dogma of treating everything as having meaning is not an advance on the dogma of treating everything as meaningless. The truth is more complex than simply taking a position opposite to what is “wrong.”

S. Nassir Ghaemi MD MPH

Boston

References:

References

1. Muller RJ. Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession. New York: The Analytic Press/Taylor & Francis Group; 2008.
2. Diagnosis of exclusion. Wikipedia.

http://en. wikipedia.org/wiki/Diagnosis_of_exclusion

. Accessed August 4, 2008.
3. Laing R. The Divided Self: An Existential Study in Sanity and Madness. Baltimore: Penguin Books; 1965.
4. Healy D. Mania: A Short History of Bipolar Disorder. Baltimore: The Johns Hopkins University Press; 2008.
5. Ghaemi SN. The newest mania: seeing disease mongering everywhere. PloS Med. 2006;7:e319.