Why is it that medical men and women practising the honorable profession of psychiatry are sometimes disrespectfully referred to as ‘headshrinkers’, or ‘shrinks’, or even, by a deliberate mispronunciation of the word, as ‘trick cyclists’?

Perhaps the answer is to be found in a production of the American Psychiatric Association – where else? – called Diagnostic and Statistical Manual of Mental Disorders, specifically the latest (5th) edition published in 2013. Within its hallowed 947 pages we can find the diagnostic criteria of no less than 297 so-called disorders. These are thought up – I kid you not – by committees of psychiatrist who arbitrarily assign number and duration of symptoms to fit the invented diagnoses.

I say so-called, because to talk of a disorder in this context implies the presence of a brain abnormality such as a chemical imbalance or other kind of dysfunction. For example, it used to be thought that deficiency of serotonin was the cause of depression, even though it’s impossible to measure the levels of serotonin or any other neurotransmitter in the living human brain. This idea has recently been thoroughly debunked. In fact, there is no reliable objective evidence for the existence of any so-called mental disorder. Even changes that may be seen on brain scans in people suffering from mental symptoms are in no way diagnostic of any mental disease.

There is a further problem with the ascription of mental symptoms to brain disorders: it disempowers patients by implying that they are victims of something beyond their control and may need treatment with one or more psychoactive drugs, even indefinitely, since some of these diagnoses may be regarded as incurable.

It needs to be understood by both doctors and patients that drugs such as antidepressants and antipsychotics cure no disease but by their side effects, especially emotional blunting and sedation, may make some patients feel better, and this may be preferred by the patients and those involved with them, to the undrugged state. These drugs also have many other potential side effects.

This does not mean that the profession of psychiatry is redundant – far from it. But the emphasis needs to change. Instead of being disease- or diagnosis-centred, it would better be regarded as ‘drug-centred’. This means that people with certain distressing symptoms – depression, anxiety, intrusive thoughts, hallucinations, unconventional behaviour, and the like – instead of being diagnosed with a so-and-so disorder, are taken at their word and asked what they are seeking help with. For example, if someone is distressed by hearing voices, instead of diagnosing the patient as suffering from schizophrenia and offering an ‘antipsychotic’, he or she may prefer to take a drug which experience has shown may quieten the voices. Such a drug may be what’s called an antipsychotic but it wouldn’t be presented to the patient as a specific drug for schizophrenia. Instead, it would be offered as symptomatic treatment with no presumption as the length of time for which it might be needed.

Another advantage of this approach is that it leaves open the possibility of exploring the background of the patient’s distress such that it may be possible to find meaning in what the voices are saying, or in other symptoms. This is where psychotherapy can be of great value.

Otherwise, the reductive approach of assuming the presence of a brain disorder may forestall such exploration. ‘Symptom: hearing voices; diagnosis: schizophrenia; treatment: antipsychotic. Next, please!’

All psychiatrists are familiar with patients who are acutely disturbed, in the grip of severe distress and causing concern or alarm to others. These patients may need restraint and even custodial care, though this should be limited to the absolute minimum time while they are treated with sedatives. This may include antipsychotics until they have calmed down and the situation is better under control.

But rather than such patients being thought of as suffering from a brain disease, one could regard their behaviour as an adaptive, if ill-chosen, response to an intolerable situation in their lives.

Text © Gabriel Symonds

Picture credit: Library of Congress on Unsplash