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Saturday, November 23, 2013

psychiatry and vodka

Back when I was a teenage moron, I did what morons do: I took certain books, which must be understood from under the weight of some experience, and swallowed them whole, believing everything from the acknowledgements to the letter z in the index. One of those books was Thomas Szasz’s The Myth of Mental Illness. I was a high school debater. Debate in those days, and who knows, probably now, also has a speech division, and I decided I would compete in the persuasive speaking contest by presenting arguments that mental illness was a myth, relying upon Dr. Szasz. So, full of the piss and vinegar of my seventeen years, I stood at the podium and made this argument for the requisite amount of time. My audience consisted,  I remember, of the judge and I believe two other contestents. I don’t remember what they said, and I don’t remember what the judge looked like. I do remember, however, that I had an early premonition that I was not born to be one of life’s persuaders when the judge came to me, in his summing up of the way he accorded points. I was in last place, and the brief comment was, of course there is mental illness. Somehow I think he put this more pithily, like, son, I never heard such nonsense in all my life.
Words to live by – for someone else. I have gone merrily on my way, unafraid to spout nonsense at the drop of a hat. However, sometimes my nonsense changes. I did decide that madness was no myth.
On the other hand, I am not convinced we know more about its reality than we know about the ‘reality’ of normal mentation. Of course, there is a science we can turn to for informed comment on these things – psychiatry.But, but…
I have never been a great fan of psychiatry. My conviction that psychiatry is no great shakes as a science was strengthened by my recent reading of Gary Greenberg’s The Book of Woe, which is an entertaining, wildly biased report on the making of DSM-5.
Greenberg wastes no time in telling you where he is going with this book. The introduction is about the rise and fall of a mental “illness” called drapetomania. I t was discovered by a Southern doctor named Cartwright in the 1850s. Drapetomania, the Southern doctor learnedly opined, was a condition that befell Negros, who suddenly and irrationally wanted to shake off their shackles and escape form their god given estate as slaves in the South. Now, before we laugh at this ludicrous attempt to dress up racism as science, Greenberg writes, we should look at how the way Cartwright elaborated his diagnosis fits pretty well with the way the DSM-5 diagnoses, say, bereavement after the death of a loved one as an “illness”.
This isn’t to say that the constructs created by the psychiatrists aren’t useful. But equally useful is understanding how they came about and their limits.
Greenberg begins, as he must, with the money. The APA faced a crisis in 2009 – the year the project of making a new DSM was announced – because their stock of money was down. While DSM-4 was a steady moneymaker, the pharmaceutical companies that had been pouring money into the APA, facing shortfalls of their own, were reducing their stipends. Plus there were the scandals that arose from Congressional hearings concerning the Pharma-psychiatrist connection. The poster boy of unscrupulous was a Harvard shrink named Biederman who, in the late nineties, decided that there was a certain category of out of control children who were “pre-psychotic”. To make this diagnosis he had to jiggle the categories around, but once he’d done that and publicized the bi-polar syndrome in children, it was time to prescribe the anti-psychotics – which, as Congress found out, brought in the big bucks for Biederman. Well, not that big – they tracked down a nifty million eight he’d received – but psychiatrists aren’t hedge funders, after all. And who knows, Biederman’s heart may have been so constructed that the idea that “half a million children, twenty thousand of them under six years old” were now being treated to a regime formerly reserved for hard core psychotics in hospitals was a good thing.
But more on that in a moment. To turn back to Greenberg’s book: the reproach that had been already leveled at DSM-4, and that was leveled with a greater level of fury at DSM-5, is that both are attempts to medicalize all suffering – that is, to hitch all our moods to the great normalizing machine of psychiatry. And that machine is neither benign nor unprofitable. Big Pharma, that great ox of multinationals that has never, for instance, come up with a cheap way of fighting malaria, has struck gold in the American, and now global, moodset.  Psychiatrists are all too complicit in this gold rush – and all too indifferent to the side effects. Risperdal, the Johnson and Johnson anti-psychotic that was Biederman’s universal panacea, has among its side effect the tendency to cause obesity and thus promote childhood diabetes. And yet, this is considered worth the price.
How has this come about? Well, as Greenberg points out, a circular logic keeps surfacing in psychiatric practice. First, a “disease”is hypothesized on account of a ‘symptom” – some stray bit of sociopathy, some mania, some down mood, some unpleasant ideation. Then it is treated. The treatment consists of drugs that interfere in one way or another with the working of some part of the brain. We can engineer that now to the working on the molecular level. And the patient no longer has the symptom – thus, the disease must be cured. Thus, there must be a disease to be cured.
It strikes me that this, which many psychiatrists call science, many bartenders call happy hour. I kept thinking about those six year olds getting anti-psychotics and wondering: why not vodka? Seriously, it is cheaper, and it will stun the child just as much. A couple of shotglasses and you won’t have the temper tantrum. And the side effects are surely not as dire as the Risperdal.
Of course, Risperdal has a pedigree. It is made in a lab. It must be super-scientific. Whereas vodka is made from a potato by a peasant, or the descendent of one.  And, in fact, vodka and gin used to be prescribed to infants by doctors. Or given by wetnurses.
The point is that if mental illness isn’t a myth, it doesn’t mean we have a science to deal with it, at least in the sense that we have a science to deal with, say, building dams.  “Mood stabilizers” come out of the folk. In the nineteenth century, psychologists made a great effort to heave themselves out of the mire of beliefs that constituted “folk psychology”, as it was labeled by, I believe, Wundt. At the same time, world commerce had made everyday life for even the poor laboring man an experiment in the contact between psychoactive substances and the body: sugar, coffee, alcohol, tobacco, chocolate, cough medicine, etc. The body of knowledge that the folk bring to psychology has to do with vague but firm notions about the body, the brain, and feeling. The body of knowledge now brought to psychology by psychologists is informed by the knowledge of genetics, of neurology, and of the molecular structure of the neural pathways in the brain.  But though these are different levels of specificity, the objects explained by folk and scientific psychiatry are still ambiguous and, to use the five dollar word, only hermeneutically understood – mood, feeling, the blues, depression, enthusiasm, etc.

Unfortunately, the APA has turned any critique of its folkways and doings into some kind of anti-psychiatric agenda, probably secretly funded by scientologists. This is a foolishly aggressive strategy. We can leave Szasz aside, and still doubt that psychiatry has the key that will explain and help us “control” our moods and mental states. That, I feel pretty confident, is never going to happen.

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