"Indeed, a minimum of life, an unchaining from all coarser desires, an independence in the middle of all kinds of outer nuisance; a bit of Cynicism, perhaps a bit of ‘tub’."
Friedrich Nietzsche

13 May 2013

The Madness Debate: psychiatry in crisis—again

I'm taking a day out from my research on tramps to have rant about the latest debate on the nature and treatment of mental illness. If this seems self-indulgent, then I apologise to my reader, but had I listened to any more claptrap on Radio 4 from so called experts, without giving in to some cathartic writing, I fear I should myself have succumbed to a certain madness of spirit. Not that madness and tramping are entirely unrelated, nor, come to that, madness and the ancient Cynics. Discussions on how society and individual institutions within society, have exiled, outlawed and punished, those who don't conform to its narrow laws, codes and dogmas are discussed throughout this site. Categorising people as 'mad' is one convenient way in which advancing 'civilisation' marginalises those who do not fit the profile of the model citizen. In our increasingly fragmented, urban and technologically driven world, a world in which people described as suffering from a mental disorder in any given year, currently stands at an alarming 25% of the UK and US populations, one has to pose the question as to whether it is individuals or society at large that is getting madder? As a further indication of a troubled world, the divorce rate in those same two countries has increased to over 40%—and as the list below demonstrates, even many of the causes of divorce do not escape psychiatry's diagnosticians.

And so part of the explanation for the increasing number of people 'diagnosed' with a mental disorder could be the number of new syndromes and diseases that psychiatrists keep adding to their diagnostic categories—thereby pathologising more and more aspects of everyday human behaviour and ensuring the expansion of their profession into the bargain.

The World Health Organisation's 'ICD-10 Classification of Mental and Behavioural Disorders' includes: 10 different ... disorders due to substance abuse, including use of alcoholtobaccocaffeine8 different Eating disordersSleepwalkingLack or loss of sexual desireLack of sexual enjoymentPathological gamblingPathological stealingTransexualismGender identity disorder (unspecified) —9 disorders of sexual preference including Fetishism, Voyeurism and ExibitionismSexual masturbation disorderSexual relationship disorderSpecific readingspellingarithmetical skills disordersUnsocialised conduct disorderSocialsed conduct disorderSeparation anxiety disorderSibling rivalry disorderChildhood emotional disorder (unspecified)Transient tic disordersOther tic disorders—3 classifications of bedwetting—Stuttering and Cluttering. The list is endless, the categorisers have done an excellent job. It is a wonder that only 25% of us a year get labeled mad! 

But it is the resurgence of the tired old 'nature versus nurture' debate that I want to respond to here. Over the past few weeks there has been much foolishness aired in the media about a backlash to the medicalisation of mental illness—even though long overdue. Psychiatrists, clinical psychologists, psychoanalysts, and other experts—particularly if they have recently published a text on the subject—are wheeled out to provide some distraction for readers and listeners, and publicise their books into the bargain. But why are we still having this polarised debate at all?

As a first year student nurse in a North London psychiatric hospital in the late 1970s, I remember being entertained to weekly sessions in which various clinicians and visiting professors would give seminars on various aspects of psychiatry. My favourite at the time was Richard Hunter, a consultant psychiatrist, controversial for his extreme views on the organic causes of mental disorders. Hunter, together with his mother, psychiatrist and historian Professor Ida Macalpine, had published several books to support their thesis, including George III and the Mad Business, Psychiatry for the Poor and Three Hundred Years of Psychiatry. I say my favourite, not because I agreed with Hunter’s views, but by the cool and clinical way he demolished arguments from outraged junior doctors and psychologists of the Freudian school—at a time when Freud was still in vogue.

This was a time when all kinds of wacky practitioners were let lose on vulnerable people with no consideration of 'evidence based practice'—itself a dubious system for protecting and enhancing the reputations of clinicians. There was, for example, an art therapist who interpreted people's dreams from their paintings, even though the individual denied doing anything more than committing paint to paper because they were told to do so. Or the behavioural therapist who smeared dog faeces on the walls of a patient's room to cure their dirt phobia. The list is endless and equally bizarre.

Even then, as a novice mental health professional, I remember thinking, why are all these people taking such extreme views on one side or other of such a pointless debate. Certainly not for the benefit of those whose interests they assumed to be their concern. More, it seemed to me, as with many of the experts who have been appearing in the media recently, it has to do with enhancing their own egos—to borrow a Freudian term. I felt then, as I still do after thirty seven years in the mental health business, that, in most cases, the reason people's lives are interrupted or damaged by a mental disorder has to be both physical AND psycho-social; so why this infantile battle to discredit each others' unyielding points of view.

Maybe some people do have a deep psychological trauma in their life that brings on some kind of mental disorder—or just as commonly a physical disorder. Other's though, may have an acute psychotic breakdown without any obvious psychological trauma in their life at all. The woman who was delighted to be pregnant and then develops a postpartum psychosis as the result of a sudden change in her body's metabolism, requires urgent medical intervention, not psychoanalysis or cognitive behaviour therapy! There are many people from secure and supportive family environments, diagnosed with schizophrenia early in their lives, with no apparent previous psychological trauma. Such people may live independent lives and careers with the help of anti-psychotic medication when previously they would have been confined to an institution.

But even if there were an original, identifiable cause that could be linked to symptoms of, say, depression or anxiety, what if such problems also featured physical symptoms such as insomnia, headaches, etc., possibly aggravated by the medication used to treat their original symptoms? Not just prescribed medication such as Benzodiazepines and Prozac, but over the counter painkillers that contain dangerous levels of caffeine (not to mention coffee itself taken in excess, or other caffeine containing drinks including green and jasmine tea that people take in the false belief they are beneficial to health!). Such medications produce not only tension headaches but heart palpitations which in turn increase stress, and so on and so on. By the time most people present to a doctor for help (with either physical or mental symptoms), it is, for all practical purposes, impossible untangle the multiple causes and aggravating factors that have led to them seeking help. Even then, many GPs have a poor training in psychiatry and will either compound the problem by prescribing more drugs, or refer to a psychiatrist before basic medical tests are exhausted—even constipation can cause psychosis! Likewise, the psychiatrist may diagnose and treat a mental disorder, with all the stigma that may bring, when the underlying problem is physical or psycho-social. Added to which, physicians, surgeons, and other general hospital workers, are notoriously poor at providing care to people with serious mental illness who are admitted to their wards for medical treatment or surgery.

Perhaps I should just get straight to the point and state the obvious in case someone has missed it:  the body and the mind are linked! So it is hardly surprising that when the one of them gets sick, the other is also affected. In most cases, the further we stay away from health care workers, therapists and the burgeoning voluntary sector (whose primary preoccupation—apart from out-branding their competitors in the battle for funding—seems to be constantly inventing ever more ingenious and politically correct terms to describe madness), the better. All are competing with each other for an ever diminishing pool of resources—and for their own narrow self-interests. And although I have come across some outstanding and dedicated practitioners in my time, there are many more who are at best ineffective, and at worse dangerous because they are out of their depth but won’t admit it.

But for those of us who do need urgent intervention when things go wrong, by separating out psychiatry as a discipline from general medicine (not to mention other conditions that fall outside both, such as autism and learning disability) it is hardly surprising that we often end up with more problems than we started out with. Even more so as we are all guinea pigs for multi-national drug corporations who, with the collusion of doctors, are ruthless in their attempts to get a bigger market share for their products. For anyone who thinks I am going over the top here, I return again to the example of painkillers. Next time you go to a supermarket, just check out the number of tension headache relieving drugs on the shelves that contain caffeine. Then consider that the reason you may be buying so many of these analgesics is to keep the debilitating headaches from your caffeine addiction at bay—yes, you are addicted to the very tablets you have been buying as a cure. It was the same with benzodiazepines and other anxiety relieving and sleep promoting drugs at the end of the last century; after a few weeks of use they produced the very symptoms you took them to relieve, only this time you were also addicted.

And so I do have some sympathy with the view that we may need to fix our own lives (socially, emotionally, nutritionally, etc) before we consider medical or psychiatric intervention. But even those for whom such intervention is not only helpful, but entirely necessary, they too should have a much greater say over their own destiny. At the end of the day, sick or well, what we all wish for is a roof over our head, money to buy the basic comforts of life, and respect from others; except that the current UK Government's austerity measures will make that increasingly difficult for many disabled people—but that's a rant for another day!

The problem with psychiatry is that it has become the victim of its own success. It set out long ago to cure not only severe and disabling illness, but also 'unhappiness'. Except that unhappiness, sadness, even some quite disabling responses to catastrophic events such as a bereavement, are a normal part of being human, not an illness. Doctors gave us pills and therapies that not only failed to stop us from being unhappy, they made us sick as well. Everything in our lives has now become the target of expert advice and intervention from the food we eat to the direction our bed faces. The debate about the cause and cure of mental illness, or whether there is such a thing at all, will no doubt continue. It will continue because the egos and narrow career interests of individual clinicians and academics depends on it. In the meantime, even if we depend on psychotropic medication to function independently in the world, we should all look to claiming back as much of our lives as we can from the armies of clinicians, therapists and earnest volunteers, all of whom want and need a bigger piece of it than they are entitled to expect.   

Footnote: It was announced in the media this week that the actress Angelina Jolie had been persuaded by doctors to have both her breasts removed as a "preventative" measure against contracting breast cancer. Geneticists had identified that Ms Jolie had an 87% chance of inheriting a rare form of the cancer from her mother. A very precise figure, which even if correct, meant that she also had a 13% chance of not contracting the disease at all; or, living decades longer with two perfectly healthy breasts. After all, there are some pretty advanced screening techniques these days that can identify cancer before it becomes life threatening to those in high-risk groups. The sentimental bilge associated with this news item feeds into the omnipotence of medical science; a symptom of how 'sick' our society has become. Such are the ways that doctors mess with our bodies and our mind.

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