Doing Psychiatry Wrong: A Critical and Prescriptive Look at a Faltering Profession

Psychiatry has gone wrong by being too symptom-focused, too brain-oriented, and riddled with misdiagnoses. It should go back to seeking the "meaning" of things in patients' subjective experiences. This is the main theme of this short polemic based on case studies. The author selectively cites studies or opinions to make his point rather than trying to get at the truth by offering other perspectives. As George Orwell pointed out, books are of 2 types: those that seek to justify an opinion and those that seek the truth. This is the former. In Doing Psychiatry Wrong, the errors are numerous and fundamental: it is wrong to claim that DSM-III was written primarily for psychiatric researchers,¹ that the concept of "diagnosis of exclusion" means to think about more common conditions first before diagnosing more severe conditions (usually this has meant diagnosing narrowly defined conditions only after first considering broader diagnoses, such as bipolar disorder, that produce similar symptoms), or that antidepressant-related mania should not be used to diagnose bipolar disorder because DSM says so, the author argues, ignoring extensive literature on the much higher risk of antidepressant-induced mania in those with bipolar disorder than those without it.²

As for supposed misdiagnosis, the "blatant" case of schizophrenia misdiagnosis highlighted in the book involved a patient whose diagnosis was schizoaffective disorder. The author's "proof" of misdiagnosis was 3 years of psychotherapy in which, essentially, the author felt that he understood "why" the patient was paranoid. The author's alternative: 5 different personality disorder diagnoses. (Never mind that most of these diagnoses have never been empirically validated as nosologically valid, given mainstream techniques of epidemiology-the gold standard being converging evidence from independent lines of evidence of phenomenology, genetics, course, and treatment response³; again, the author never discusses how to validate diagnoses.)

The misdiagnosis of bipolar disorder seems to be the author's noire. To his credit, in the 3 cases, the author does not entirely rely on the patient's self-report (although he does seem to privilege the patient's perspective, nowhere does he refer to the extensive literature on the lack of insight in mania and psychosis⁴) and seeks either family or other clinician reports in 2 cases. Both cases involve patients with extensive sexual trauma, self-cutting, and mood swings. The author's main point seems to be that mood swings alone should not lead to a bipolar diagnosis. Agreed. Yet the author avoids any literature that shows that the diagnosis of bipolar disorder is missed using DSM-IIIR or DSM-IV criteria (as has been repeatedly shown to happen in about 40% or more patients), none of which involve a mood swing approach to diagnosis.⁵

The author's main qualification, which is repeatedly stated, is that he has seen more than 3000 patients in a psychiatric emergency room setting. Of course, one can see 3 million patients and still be wrong if one is blinded by dogma. Yes, there is much that is wrong with psychiatry: biological methods can be overdone, a drug-for-symptom approach to psychopharmacology is unscientific and can be harmful, and the DSM has many flaws. However, the solution is not simply to see "meaning" and personality disorders everywhere instead. Turning the clock back 30 years solves nothing.

References:

References

1. Shorter E. A History of Psychiatry. New York: John Wiley and Sons; 1997.

2. Akiskal HS, Hantouche EG, Allilaire JF, et al. Validating antidepressant-associated hypomania (bipolar III): a systematic comparison with spontaneous hypomania (bipolar II). J Affect Disord. 2003;73: 65-74.

3. Robins E, Guze SB. Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia. Am J Psychiatry. 1970;126:983-987.

4. Amador XF, Anthony DS. Insight and Psychosis. 2nd ed. Oxford, UK: Oxford University Press; 2004.

5. Ghaemi SN, Ko JY, Goodwin FK. "Cade's disease" and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. Can J Psychiatry. 2002;47:125-134.