39 of 43 people found the following review helpful:
5.0 out of 5 stars
When is an Illness an Illness?, December 16, 2007
This review is from: Shyness: How Normal Behavior Became a Sickness (Hardcover)
Skeptics often assume that the only reason that diagnostic criteria are changed is financial: to line the pockets of the pharmaceutical industry. But there are several other important factors in play. One has to do with the whole way in which illness is conceptualized and a second has to do with the consequences of inaction. Te criteria for treating blood pressure and cholesterol were driven by the realization that even small abnormalities carry significant mortality and morbidity. When we classify an illness, we can either think of it as a "category," like strep throat or a heart attack: an illness that has clearly defined margins. Or we can think about it as a "dimension." So instead of seeing illness as a separate entity, we think of health and illnesses as lying on a spectrum, running all the way from being healthy and well, through mild degrees of just not feeling "right," to being severely ill. Reimbursement requires categorical diagnoses, even if they do not reflect clinical reality.
This second - dimensional - way of thinking is particularly useful when we are thinking about psychological issues. The world is full of people who are a little bit obsessive, or who get bad mood swings. But they are not bad enough to be called an "illness:" They are part of human variation. In fact, having some of these traits can be enormously beneficial: they have continued in the population because they have a survival advantage. If I need to have surgery, I sincerely hope that my surgeon will be mildly obsessive, rather than discovering a few weeks later that he had forgotten to do something he should have. The point then becomes one of asking, "Where do we place the bar between variation and illness?" We do not want to say that every restless child has attention deficit hyperactivity disorder, or that every unhappy soldier returning from war has posttraumatic stress disorder. So the answer to the question, "when is it an illness?" is usually defined on the basis of whether it is causing suffering, and whether, if left untreated, it would produce more or different problems in the longer term, in the same way that untreated diabetes increases the risk of heart, eye and kidney disease.
The trouble is that diagnostic criteria have been defined by committees charged with evaluating research data. Someone once said that a camel is a horse designed by a committee and some diagnoses look like camels. This is not only a problem in medicine. The world's foremost authority on locating acupuncture points recently lamented that the standard textbook contains errors because he was out-voted by a committee!
These two ways of looking at medical, and particularly psychiatric disorders, is one of the issues at the heart of this book.
Christopher Lane is the Miller Research Professor at Northwestern University, and he discusses the way in which, during the 1970s, a small group of leading psychiatrists met and revised and greatly expanding the Diagnostic and Statistical Manual of Mental Disorders (DSM).
He is critical of the efforts of these people and argues that the decisions about restructuring the DSM was careless, and strongly influenced by politics, personal ambition and the shadowy hand of the pharmaceutical industry. From the evidence that he provides, I am sure that there were elements of each. But I think that he underestimates the backdrop to the DSM project.
The first of the modern psychiatric medicines had begun to appear in the 1950s. But during those years and throughout the 1960s and 1970s American psychiatry was still dominated by psychoanalysis for which diagnostic differentiation was not very important. Many psychiatrists felt that the medicines should not be used, since they simply sedated people and thereby prevented them from doing the inner work demanded by psychoanalysis. The approach also lead to the neglect of many disadvantaged populations, for instance the elderly and intellectually challenged, for they were thought to be untreatable.
The new DSM set about trying to define and distinguish mental disorders based not on preconceived ideas about cause, but on the symptoms that patients exhibit. It was an attempt to bring an order that could be used to start scientific research and ultimately give guidance about treatment and prognosis. It was not about social control, and psychoanalysts were not involved simply because they were not interested in precise diagnosis.
Lane rightly emphasizes the role of social factors and social norms in the genesis of psychological distress, but then suggests that we need more psychodynamic psychotherapy.
What has actually happened is that the advances in psychopharmacology have changed what we are able to do to help people; the nature of psychotherapy has also changed. Much of the psychodynamic psychotherapeutic approach has given way to shorter more cognitively based therapies, many of which have been proven to work in controlled studies. Not all of the developments have been positive: the medical model now dominates psychiatry, demand for services and financial considerations have lead to ever-shorter treatments for people in need. But those cannot really be blamed on the introduction of the DSM and the eclipse of psychoanalytic thought.
There continues to be a great deal of debate within psychiatry about the DSM: are we able to use brain imaging or genetic techniques to provide an objective basis for diagnosis? What human variations have erroneously been designated "mental disorders?" and many other issues. Work has already begun on the next revision of the DSM, which is currently due out in 2011. Lane argues that many more common behaviors, including excessive shopping, poor anger management and defiance could become pathologies needing treatment. He is right to warn about the possibility, but may not give enough credit to the careful work that is underway to see what qualifies as an "illness," and what does not.
This is an important, interesting and thought provoking book that should be on the "must read" list of anyone studying psychology, or anybody interested in the inner workings of medicine.
Richard G. Petty, MD, author of
Healing, Meaning and Purpose: The Magical Power of the Emerging Laws of Life
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2 of 2 people found the following review helpful:
5.0 out of 5 stars
Required reading, January 2, 2012
This book,should be required reading for every psychologist, psychiatrist, counselor, and social worker in training, and is a must read for those already in practice. While there have been reviews that talk about Dr. Lane's ranting comentary, it is clear that some ranting is appropriate, given the lack professional overview of this important and unfortunate issue, including the danger to the unknowing public. His research is thorough and the text confronts much of the assumption (not limited to shyness) about the field, held by those who would normally bring the information to our attention. I am giving copies to the local psychological association for members to read and then hand to other members. I am appalled that an English professor, rather than a physician or psychologist, was led to write this but, after 36 years in the field, am not surprised.// Thomas McKnight, PhD., ABPP
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