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Creating Mental Illness

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Dr. Horwitz provides in this book a well researched assessment of the current state of affairs of the mental health system, primarily in America. He discusses the growth of the number of accepted mental disorders from only a few (around 1900) to somewhere around 500 (DSM-IV, for instance). Much of this growth seems to be attributable to efforts to get third-party payers (generally insurance companies) to pay for treatment.

Horwitz presents plenty of evidence and argument about how clinical trials favor the use of psychiatric medications over counseling (it is difficult to conduct a double-blind controlled, with placebo, study with counseling: usually someone knows when he/she is being counseled or not counseled). He presents additional evidence that professionally trained counselors/therapists have not been shown to be better than untrained counselors -- for the main ingredients in counseling are empathy and support (something often missing in professionally trained mental health workers). He discusses how many of the "new" disorders (that give 500, versus the few that were considered to exist in 1900) are merely sociological problems or the result of sociological problems -- and medications do not usually make them go away, but merely help them be tolerated.

My words cannot really do justice to the high quality of this book. Recommended reading for all mental health professionals and for anyone with concerns about the current status of mental health practices in America, and perhaps the world.

"Creating Mental Illness" provides an excellent account of how mental disorders are defined, diagnosed and treated, as well as how and why the criteria for them have changed so much over time. I used this book in an upper-level undergraduate course on mental health & policy and my students thoroughly enjoyed it. Very well written and organized, "Creating Mental Illness" is that rare book that is both pleasurable to read and educational. I highly recommend it to anyone wanting to learn more about mental health and disorders.

Horwitz is one of those tantalizing authors (see also: Blok, Blom, Boyle, Caplan, Thomas, Walker) in the field who exposes the folly and fraudulence of psychiatric diagnoses, yet fails to follow his own views to their logical conclusion. Below are some of his own persuasive arguments questioning the validity of the foundation of psychiatry and psychotherapy:

* "Contrary to its definition of mental disorder, a basic principle in the DSM definitions of particular disorders is to avoid inferences about the causes of symptoms."
* "The reasons for the proliferation of mental illnesses lie in the historical development of the psychiatric profession over the course of the twentieth century."
* "[T]he grounds for inclusion of the conditions found in the DSM-III, and perpetuated in the DSM-II-R and DSM-IV, did not stem from either theory or research but from the need to maintain the existing clientele of mental health professionals."
* "Through discarding etiology as a means of classification, the DSM could encompass the conditions treated by all competing schools of psychotherapy."
* "If a professional wants to argue, for example, that there is an entity called 'compulsive television watching' she can easily come up with specific criteria ... and train observers to measure the disorder in a consistent way."
* "Insurance forms, not the nature of symptoms, demand precise diagnoses."
* "[O]nce a drug was developed, a specific illness would have to be found that the drug would treat."
* "Once a diagnosis has been created, it enters professional curricula, specialists emerge to treat it, conferences are organized about it, research and publications deal with it, careers are built around it, and patients formulate their symptoms to correspond to it."
* "Diagnostic categories emerged in order to raise the prestige of psychiatry, to guarantee reimbursement from third parties, to allow medications to be marketed, and to protect the interests of mental health researchers and professionals."
* "'Frightening mental illnesses' ... help justify large research budgets for the NIMH."
* "[T]he most direct benefits of high prevalence estimates of depression accrue to pharmaceutical companies."
* "Their dependence on professionals can lead [people] to produce the kinds of symptoms their therapists expect them to have... [the symptoms] vary as professional fashions in diagnosis change."
* "Diagnostic psychiatry recognizes the presence of 'culture-bound' disorders only in other cultures."
* "[T]he best predictor of MPD is having a therapist who believes in the diagnoses."
* "[L]inkage analysis [linking psychotic disorders to particular locations on chromosomes] has to date been the source of more embarrassment than accomplishment in biological psychiatry."
* "[M]ethods of assessing brain structure and function... [and] the discovery of neurotransmitters ...despite rhetoric to the contrary...have not led to significant advances in knowledge about the causes of mental disorders."
* "It does not follow from the fact that drugs produce changes in the brain that the original brain state that is changed constitutes a mental disorder."
* "[P]rofessionals are not more effective clinicians than nonprofessionals... No amount of coursework, training, or experience can create the qualities that lead to successful psychotherapy."

But now comes the big surprise. In spite of all of the above, Horwitz fully believes in "the three major disorders that Kraepelin distinguished one hundred years ago: schizophrenia, bipolar disorder, and endogenous depression." How these "real" disorders can be reliably identified, or how Kraepelin identified them, he doesn't say. On the contrary, he admits that "the distinction between people who can't function appropriately and those who won't function appropriately is far more a moral value judgment than a judgment based on psychiatric knowledge." Nor does he postulate as to the causes of these supposedly real diseases. He only mumbles that there is a "strong possibility that these are brain-based disorders."

The drug companies that conspire with NIMH and the APA to convince us all that we need their poiso- I mean medications, suddenly turn into heroes when it comes to what he considers Kraepelinian diagnoses. "[T]he greatest accomplishment of modern psychiatry [is] the development of efficacious psychotropic medications," and "Schizophrenia ... responds to the phenothiazines and clozapine. Overall, there is little doubt that these medications are 'antischizophrenic' agents, not general tranquilizers." Likewise, he goes on to claim that lithium is an effective treatment for "bipolar patients." Yet when someone with a diagnosis that Horwitz pooh-poohs feels helped by a drug, this "could stem from cultural expectations for success, rather than from the biological impact of the drug itself." He doesn't say whether he means the patient's expectations or the physician's. Though Horwitz acknowledges a study which indicated that "patients [on a] placebo pill had the lowest rates of relapse," he never entertains the idea that the drugs he lauds may be precisely the cause of a great deal of what he considers real mental illness.

Just as Horwitz fails to present evidence for the presence of somatic lesion in his three pet mental illnesses, so he fails to point out that somatic lesion can never be conclusively ruled out. He ascribes the "sensations of pain, fatigue, or distress" of "fibromyalgia in the contemporary United states" to "sociocultural processes" and "the nature of hysteria... [that] represent culturally produced symbolic entities rather than direct indicators of underlying diseases." The unsustainability of this position is given away by the fact that he makes the same claim about Lyme disease (spread by ticks and curable by antibiotics).

Why not just admit that ALL of psychiatry and psychotherapy is bunkum, and mental health workers don't know what they are doing?

Copyright © MeTZelf

I was working the BiPolar shift in the cafeteria of the local mental hospital and overheard this and wanted to share it with you. Bernard Lumbert, orthopolar designate

1st Dr. "So Carl, I see you have finished "Creating Mental Illness" by Alan Horwitz?" (The author spells his name with two "l's" I noted but then I am delusional and observe things others miss)

2nd Dr. "Yes Sig, Enjoyed it very much. A pretty good read." (He would probably fake an orgasm, I mused, all reviewers say "good read")

1st Dr. "Good read? My gawd it's supposed to be fairly heavy stuff. You and I went through Dynamic Psychotherapy and we thought that was heavy. Isn't this social source stuff new? Wasn't Compte an alienist or something?" (Yess, dear sir, and the thought will surge up to your senium that if Sociologists can define maladaptive behavior, they may be able to cure it. Bye bye MD/OD)

2nd Dr. "Well, I skipped around a lot but read chapter 7, about social sources of mental illness, twice." (Read it twice; understand it once, I thought)

1st Dr. "We are psychiatrists, aren't we supposed to know that about sources, and origins and genetic vulnerability? Doesn't that nature trump the nurture of homelife?" (You are drawing to an inside straight with your trump I sez, you can't change people's minds with facts.)

2nd Dr. "Let me give you an example. Do you have patients that are involved with heavy drinking, drug use, and cooking their company books?" (I wait breathlessly)

1st Dr. "Why sure we see them every day. They are not sick, not diagnosable with medical syndromes." (hawl-a lu-ya!)

2nd Dr. "And that is what Dr. Horwitz explains so very well. Many cultural excesses can be transformed into a morbid fixation just like a personality trait becomes a personality disorder if you find it in the DSM. You just add..

"Just add three or more digits..," chortled Dr. Sig. "If it has numbers, it is a personality DISORDER, otherwise it is a personality TRAIT like biting your nails." (Bite this I thought as I handed them each a sliver of new whitefish we just got in.)

2nd Dr. "Well, yes and yes. In our heart of hearts we all know that the etiology, the origin, the mother load(sic) of most dysfunction in most patients is societal." (yes, and you can inherit post traumatic stress syndrome from your grandchildren, I thought as I ladled out a side of creamcheese.)

1st Dr. "But, as Howrwitz noted, the DSM manual, our bible, now lists over 400 mental illnesses and when my dad was practicing there was only 40 on the list. That's quite an increase." (once there were only two rabbits in Australia, I thought, now look at how many there are.)

2nd Dr. "How do you explain the vast increase?" (I waited breathlessly for a vast response)

1st Dr. "Simple, according to Horwitz, there is a hobby amongst the authors of the DSM to create all new diseases that could be treated with all new meds only, thereby creating an expanding market for pharmacies and script writers and downplaying the simpler psychologists who do only oral therapy." (well, the reply was only half vast I thought)

2nd Dr. "See if I got this straight. You are suggesting that the 1,000 scientists who created the DSM, the largest single book written by a committee since the King James Bible, were working in cahoots with providers to sell more drugs?" (This guy is a reglar Sherlock homes, I ruminated as I waited for the next non-sequitir)

"Bernie can I have some more pickle?" Dr. Sigmund asked As he proffered me the plate with one quarter of a dilly on it. "Sure", I replied as I took my razor sharp Swiss Army scalpel and brissed the cucumber with two swift incisions, making three slices where only one was before.
He never noticed the deception, but Carl thought, "That explains it. You just keep slicing mental illness thinner and thinner". Did you know I could read minds?

Seriously, I can read minds. You are gonna like this book!