Wednesday, 18 June 2008

You don't have to be mad to be in here, but just try proving you're not!

One of the biggest problems facing psychiatry and related fields is, IMHO, the lack of definitive diagnostic tests. You can't take an X-Ray photo of someone's frontal cortex and say "Ah! Your self-control modulator is broken! You've got ADHD!" Although you can use an fMRI to record activity in someone's hypothalamus, you can't use that to diagnose depression. You can't draw off cerebro-spinal fluid and analyse it for schizophrenia, which in a way is lucky because a lumbar puncture really hurts.

These conditions, these disorders or illnesses, are behavioural and that means that diagnosis is behavioural. In fact, with increasing knowledge of behavioural effects of brain injury through trauma, illness, poisoning usw., the number of things which do cause behavioural changes has grown to the point where psychiatry has almost painted itself into a corner, all but declaring that if there's a reason for it, it's not a mental illness. I'm not joking here. After working with acquired bran injury for two years, where the co-morbidity of mental illness is conservatively estimated at 40%, I was driven almost to the point of apoplectic rage whenever a worker in a mental health facility said "Oh, that's a brain injury, that's not mental illness". Never mind if the mental illness existed before the injury or the symptoms didn't present for the first decade afterwards.

But I digress - that's a different rant.

Psychiatry has two big problems, and one is that at no point is it ever possible to find the one cause of a complaint, give it a treatment, and hey presto! Case solved! Now it's just a matter of keeping up treatment until either the cause or the patient has been dealt with! Treatment is, 9 times out of every 10, for life.

Problem two is quite simply one of simple diagnosis - one clinician's "Schizoaffective disorder" might be another's "Paranoid Schizophrenia with suspected substance abuse". Treatment is all too often a matter of seeing what works, and with psychiatric medications, where it may take weeks to build up to potency and weeks to taper off, this can be a long, slow, tedious and painful process.

More importantly, confusion over diagnosis can mean that presentation has far too great a part to play in swaying the clinician's mind. It can mean that reported history can be weighted far too highly. It can mean that inexperienced or over-confident clinicians can be conned by intelligent or simply highly manipulative patients who know how to play the game (read: Pretty much anyone with a personality disorder).

And once someone gets labelled, how hard can it be for the label to be changed?

Many years ago, while at Uni, I heard about a study where people with a clean bill of mental health were inserted into psychiatric hospitals to see how quickly they'd be released.

Now, The Lay Scientist has done an excellent write up of that very experiment, here.

My jaundiced take on it is: Being in a mental health ward means that you obviously have a mental health problem, so therefore you have a mental health problem. Out of 8 volunteers, the quickest exit was 7 days, the slowest an incredible 52 days, and all of them were given a diagnosis upon exit of "Schizophrenia in remission", not "sane to begin with, stop wasting our time".

There are two chilling parts about this 1972 study: One is the bald facts stated above, evidence that the hospitals failed to correctly diagnose sanity (whatever that may be...). Two is the most likely reason why: The staff didn't interact with the patients. The other patients detected the fraud quite well and early on, but not only did the volunteers not have much interaction with the staff, they couldn't even get a polite and reasonable question answered! I am horrified to think of what would have happened in the mental health drop-in centre I used to work in if the staff had been that dismissive. The term "bloody murder" springs irrevocably to mind.

I'd like to think that things had changed but... I'm not too hopeful.

Anyone want to start yet another interminable debate on psychiatry being used by the government to suppress people it doesn't like?


Martin (The Lay Scientist) said...

Thanks for the link!

Regarding the government and psychiatry, by standard take on all such theories is "you really think they're that competent"? All though of course there is well-documented CIA-funded study of techniques designed to "erase" the mind with a cocktail of drugs and shocks, that I may well have to blog about soon.

In terms of the problem today, I'm actually trying to figure out if there's any equivalent research from the last few years. The closest I've seen is the unscientific claim of one journalist that she conducted a similar experiment, but was medicated with anti-depressants instead. Her claim was that changes in medical "fashion" over time affected treatment, which is an interesting, and fairly believable, idea. She didn't back it up very well though, and I've not seen any hard data.

Dubito said...

My pleasure, Martin!

I have a suspicion that anybody trying to replicate Rosenham's result would need as much chutzpah as he showed, and private funding. I'd like to see the presentation to the ethics board, as well.

On the question of psychiatrists-as-government-goons, just yesterday I actually stumbled across this comment I posted in another forum some time back:

"Of course it's a collection of symptoms rather than any specific biochemical imbalance. But you're missing the point if you think that this makes it any less relevant or any less important than any other disorder.

"There is no blood test for schizophrenia either, and if you think that that one is just an excuse to control the people we don't like, then feel free to go and work in an inpatient ward for a week.

"Many medical conditions aren't explained - Chronic Fatigue Syndrome, most mental illnesses, the autism-spectrum disorders - but we battle to treat them because the consequences to the individual suck. And if the individual is enjoying their particular situation but starts hurting other people, then society has to do something about that, which is why involuntary treatment and secure wards exist.

"There is a huge difference between "Annoying eccentric" and "psychotic". It's like the difference between someone who chooses to murder and someone who does it because they are under the sincere belief that it is their duty to kill the anti-Christ.

"Many diagnoses are made in order to justify a treatment that works, yes. Many treatments are started to make life easier for the staff than for the patient, yes. But equally, if a medication helps someone become lucid and self-controlled, the medication is generally a good thing.

"The real problem is not what label is being applied, it's what treatment is (not) being applied. It shouldn't be possible to get subscribed a medication regime without also receiving psychological or otherwise life-skills help as well.

"Focusing too much on labels doesn't help, no matter how rigorously applied the labels are."

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