ANOTHER SURPRISE FROM AMERICAN PSYCHIATRY

by George W. Albee

[George W. Albee is Professor Emeritus at the University of Vermont. He lives at 7157 Longboat Drive North, Longboat Key, FL 34228 (941 387-8096; gwalbee@webtv.net). He is past-president of the American Psychological Association. He chaired the Manpower Task Force for the Eisenhower Joint Commission on Mental Illness and Health (1957-60) and directed the Task Panel on Prevention for the Carter Commission on Mental Health (1977). He will lecture at British Universities in 2003 as the guest of the British Psychological Society.]   American psychiatry often surprises the field of psychopathology with announcements of newly-discovered mental disorders, with the discovery of new causes of old disorders, and with the discovery that former disorders no longer exist. In the years since the mid 20th century more than 100 new kinds of mental disorders have been added (and many have been deleted) in successive editions of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM). This DSM is the official guide to mental disorders in America. To receive treatment that is supported by health insurance, or by tax-supported agencies, and even by most voluntary agencies, the patient must have a label from DSMIV, the latest version. The alleged causes of many of these mental disorders have been changed over the years. In earlier times the cause often was said to be excessive stress. Shell shock, combat fatigue, poverty, a history of physical abuse and sexual molestation, parental alcoholism, and drug abuse, and many other social stresses had been believed earlier to result in mental disorders. But in recent years we have been told by the nationís leading psychiatrists: "All mental disorders are due to brain malfunctioning", "All mental illness is a brain disease".

When he was Director of the National Institute of Mental Health, Lewis Judd
MD proclaimed the 1990ís to be the "Decade of the Brain" during which
research would locate all the causes of mental disorders in the brain (it didnít).
The recently-resigned Director of the National Institute of Mental Health
Steve Hyman MD (now Provost at Harvard) says: "These are real illnesses of a
real organ, the brain, just like coronary artery disease in a disease of a real
organ, the heart".

E. Fuller Torrey MD, psychiatrist and chief guru of the National Alliance for
the Mentally Ill, argues that people with severe mental disorders have
"neurobiological disorders of their brains that affect their thinking and moods
and that can be measured by changes in both brain structure and function". Torrey is also a leading advocate for involuntary drug treatment of the emotionally disturbed.

Recently an important new mental disorder, Anosognosia (translation: lack of awareness of illness), has been announced by the American Psychiatric Association (see Professional News, 2001, 36, 17, p. 13.). While this phenomenon was long known by the psychological term denial, it is now said to be a result of a brain defect, according to a recent article in Psychiatric News. (September 7, 2001).

Anosognosia is commonly seen in persons (diagnosed by psychiatrists) with serious mental illnesses like schizophrenia. Many diagnosed schizophrenics "do not believe they are ill despite evidence to the contrary" (p.1). Some "have a compulsion to prove to others that they are not ill". (p.1). These people are now said to be suffering from the brain defect that causes anosognosia. This means, of course, that they have two mental illnesses requiring treatment (schizophrenia and anosognosia). The treatment
may have to be involuntary (forced) as they deny being ill at all. (Unclear is whether also denying that one has a brain defect causing anosognosia is itself an illness caused by still another brain defect).

There are several puzzling questions as yet unanswered. Examples:

1. For many years homosexuality was included in the DSM as a mental illness.
A great many people, straights, gays, lesbians, bisexuals, argued that it was
not a "mental illness". Were all of them suffering from anosognosia? Did they
have a brain defect? Since 1972, when homosexuality was removed from the
DSM, it no longer is considered a mental illness. Should there be a diagnostic
category for all those psychiatrists who for many years were wrong when they
insisted that homosexuality was a mental illness when it is not? A puzzle.

2. Some current mental illnesses were not considered mental illnesses until
recently. Adolescent rebellion, arithmetic learning problems, childhood hyperactivity and attention deficit were not mental illnesses until they were put in DSM III & IV. If children were exhibiting these behaviors at the time the behaviors were first called mental illnesses could they argue pre-existing non-illnesses? Does the brain defect occur only after the illness is named?

3. For many years a very large number of people suffered with a neurosis.
Freud was especially interested in the neuroses and their cure through
psychoanalysis. Popular neuroses included neurasthenia, psychasthenia,
hysteria, hypochondriasis, and multiple personality. But in DSMIV these
long-used diagnoses were stricken from the diagnostic system. Unlike homosexuality, which still exists but is not a mental illness, the neuroses apparently no longer exist. Were all those millions of neurotics suffering from non-existent disorders? If they agreed that they were neurotic, but were not, were they suffering from a still-unnamed disorder that we might call pseudognosia? Is it caused by a brain defect? Is Woody Allen really a non-neurotic?

4. American and British psychiatrists vary consistently and significantly in the
frequency with which they label people "schizophrenic". American psychiatrists
use this diagnostic label far more often than their British colleagues. To check
the possibility that Americans might be more prone to this disorder a clever
experiment sent a group of American psychiatrists to London to see incoming
cases to a mental hospital for diagnosis, and brought a group of British
psychiatrists to Brooklyn to see an incoming set of Americans requiring
diagnosis. Sure enough, the American psychiatrists, true to form, saw larger
numbers of Brits in London as schizophrenic, and the British psychiatrists saw
fewer Americans with this diagnosis. Now the question is: If a British tourist
acting strangely is taken to Belleview Hospital in New York and labeled
schizophrenic can he/she argue that his/her psychiatrist back home
disagrees, and claim not to be schizophrenic? Does he/she have a brain
disease, but only in America? Similarly, if an American labeled schizophrenic
at home, on holiday in England, declares "I am not schizophrenic" is this
declaration valid, or a case of extraterritorial Anosognosia?

5. It is not uncommon for distinguished psychiatrists to disagree on a diagnosis
of schizophrenia, and even for groups of psychiatrists testifying for the
prosecution and for the plaintiff to come to opposing positions. In the trial of the
young man who shot President Reagan (to try to impress actress Jody Foster)
he was seen as sane by psychiatrists for the government and as insane by
psychiatrists representing the family. The jury believed the latter group and
ruled him "Not Guilty by Reason of Insanity ". In an ironic twist he is
incarcerated in St. Elizabethís Hospital in Washington, D.C. in the care of
government psychiatrists who found him sane! Who has the Anosognosia here?

6. Recently it has been asserted that relatives of schizophrenics may show
"early signs" of the condition. They are alleged to be "genetically vulnerable".
Now, it is suggested, these people might benefit from prophylactic
drug treatment, thereby preventing the debilitating consequences of later
full-blown development of the condition. The problem arises: If a relative
does carry a diagnosis of incipient schizophrenia, and denies that they are at
risk, can they be said to be suffering from anosognosia? If they successfully
resist this prophylactic treatment for many years, even a lifetime, and appear
normal throughout does this require correction of an earlier diagnosis of
anosognosia? Can they sue?

7. Finally, there is a mammoth problem. Mary Boyle, a distinguished British
psychologist, has written a brilliant, carefully documented account of the
history of "schizophrenia". She details the confusion, the inconsistency, the
lack of reliability, of the concept and concludes that in all probability there is
no such disease. (It should not be necessary to say that some people do have
psychotic symptoms). But the new label Anosognosia supposedly is common in
schizophrenics (who cannot be schizophrenic if the condition does not exist).
If schizophrenia does not exist then those who deny that they are
schizophrenic are correct and cannot have a brain defect that causes the
denial!

This bizarre situation suggests that brain defects should be identified only by
direct observation (by neurologists preferably) rather than inferred from
unreliable observations. One of the great advancements in human knowledge and thought has come from the rise of science. Science has many characteristics including the reluctance to accept any finding as absolute. Hypotheses are accepted or
rejected with varying degrees of confidence, never with certainty. And
scientists are always ready to examine new findings with appropriate
skepticism. They repeat experiments or design new ones in a serious attempt
to find errors. Unfortunately, in psychiatry, much that passes as research is
financed by the pharmaceutical corporate giants. They pay for the research. They pay the referees who judge the research. They underwrite the cost of the conferences where results are announced and the cost of publishing the psychiatric journals where they are published. The usual freedoms of scientific inquire are missing. Anosognosia is just the latest example of a concept that has not received serious scientific study. But it will be effective in selling more "drugs for the mind".

[Submitted to NY Times OpEd Page, December 22, 2002]