Saving Normal

Screen Shot 2015-12-16 at 1.39.02 PMThe iconoclastic psychiatrist Thomas Szasz said that mental illness was metaphorical, not real, because mental diseases lacked biological substrates. The absence of a substrate predisposes psychiatry to overdiagnosis and avoiding overdiagnosis is psychiatry’s biggest challenge. This challenge has been taken up by Allen Frances in Saving Normal. Like Szasz, Frances writes in cultured, erudite prose. Unlike Szasz, Frances believes that psychiatric illnesses are real. To save the mentally ill, to save psychiatry from itself, Frances says we must save normal.

Six years ago, Frances was enjoying retirement after a distinguished career, minding his business sipping cocktails at the annual meeting of the American Psychiatric Association (APA). Psychiatrists were excited about updating the Diagnostic and Statistical Manual of Mental Disorders (the soon to be DSM-V). Frances had chaired the previous edition of DSM, but in the zeal of the latest edition, he saw diagnostic hyperinflation of a frightening scale.

The DSM is psychiatry’s Bible. It defines mental illness, and in the process also defines what is normal. Over time, psychiatrists have responded to Szasz’s taunt by objectively defining mental illnesses with precise signs and symptoms. The scientists in the profession have sought biological reductionism which, for an organ as complex as the mind, is a gross oversimplification.

Objectivity is often mistaken for science and truth, but no line cleanly separates disease from normality. Both reside in the Gaussian curve. Yet Frances saw DSM-V marching relentlessly up the Gaussian plateau, vanquishing normality in its path, and as the chairman of DSM-IV, he felt a moral burden for not anticipating its upgrade.

Lowering diagnostic thresholds enrolls many in the ranks of disease, which Frances compares to Gresham’s Law—bad money drives away good money. Similarly, bad diagnoses drive away good diagnoses. The “likely normal” are treated at the expense of the “really ill.”

The problem with DSM-V is that the lunatics are no longer in the asylum. The asylum is full of normals. The asylum is, of course, metaphorical and the wards of Bedlam, guarded by orderlies wearing white suits, have been replaced by pills. Pharma, arguably, has reduced the stigma of mental illness and lowered the barrier to entering psychiatric illness. Mental illness is also now often treated by non-psychiatrists.

Overmedicalization is the price paid for the de-stigmatization of mental illness, but the plot thickens when Frances inculpates both psychiatrists’ financial conflict of interest with pharma, and big pharma’s direct to consumer advertising, in the assault on normal. The new definition of ADHD (attention deficit hyperactive disorder), for example, could conscript one in five teenage boys to Ritalin. Once you add statins, the modern citizen could be swallowing a pill a day from cradle to grave—making pharma our pastor, our knight, and our king.

I joked with a child psychiatrist that DSM-V ensures that she will not be out of a job. It was a bad joke, and not even funny. She said that it was painful to label normal kids with ADHD but DSM-V forced her. She observed that many parents were actually relieved when their child had that diagnosis—the label seemingly assuaged their parental guilt.
The pendulum has swung. Once thought to be a divine punishment, mental illnesses are now redemptive. But it takes two, sometimes three, to tango. I’ve heard doctors proudly say that they’re “mildly” Asperger’s or “borderline” manic. If every third overachiever has Asperger’s the entity has no meaning. Importantly, as Frances pithily asks, shouldn’t most people be normal?

“Mild” and “borderline” reside in the grey zone. There are no prizes for, nor disputes in, spotting severe depression. But telling apart prolonged grief from depression is trickier. In the grey zone, normality overlaps generously with mild disease. There are no right answers in grey, only trade-offs between overdiagnosis and underdiagnosis.

Physicians can treat the grey in the way they think best. This means that different psychiatrists will call mental illnesses differently. Some will overdiagnose. Some will save normal. Some will underdiagnose. But variation is thought, for unbeknownst reasons, to be the worst thing in healthcare.

And so to reduce this variation the grey is approached with blunt precision, instead of fine art. Yet consistency doesn’t mean psychiatrists won’t overdiagnose. Consistency merely means that all will overdiagnose equally, predictably, and inevitably.

DSM-V is psychiatry’s maladaptation in the grey zone masquerading as science. DSM-V is controversial not because it is arbitrary—arbitrariness is unavoidable when defining mental illness. It is controversial because it draws the arbitrary line too close to the mean.

Once illness is defined precisely, Dr Google can wreak havoc. Recently, on renewing my adolescent eating habits after an indulgent weekend in Sin City, I googled “binge eating disorder.” DSM-V defines this as binge eating once a week for three months. Binging is eating lots when not hungry, and feeling embarrassed, disgusted, or guilty. Mercifully, I overeat without contrition. DSM-VI may create a new disease for me though: the remorseless binge eater.

The manufacture of a new disease is a victory not just for pharma and disease awareness groups, but academic experts. Frances notes, wryly, that he has never met an expert who thinks the diagnostic threshold of his pet psychiatric disorder is too low. Ornithologists are proud of knowing lots about uncommon species of birds. For physician scientists, commonality of the disease of their expertise means more funding for research. The purse, whether private or public, raises the prevalence of disease.

Can this be reversed? Frances believes that better aligning of incentives, informed citizenry, and clipping pharma’s advertising wings will help. An independent agency should establish diagnostic thresholds. Frances has little faith in the APA. I don’t blame him.

I doubt democratization will help since consumerism is part of the problem. The guild has surely disappointed, but only the guild can mitigate overdiagnosis. Until such pride is restored, so that doctors disdain overdiagnosing more than they fear underdiagnosing, normal is unsafe. We need more discussion of trade-offs, not more data.

Medicine’s greatest tragedy could be the death of judgment. Discretion may have been the better part of psychiatry, but subjectivity is anathema to biological reductionism. Physicians, in general, have been so shamed out of subjectivity that instead of revolting against a Babel of Rules, we are becoming dependent on them.

Psychiatry is medicine’s sentinel guard. If it can resist overmedicalization so can the rest of medicine. Saving Normal is a mirror for all physicians.

Saurabh Jha is a radiologist in Philadelphia. Follow him on Twitter @RogueRad. This post first appeared in BMJ Blogs.

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8 replies »

  1. To my understanding having a child that can be tagged with a good DSM-V code in some places such as Manhattan is like winning the lottery.

    On a separate issue:

    “Some will overdiagnose. Some will save normal. Some will underdiagnose. But variation is thought, for unbeknownst reasons, to be the worst thing in healthcare…

    Consistency merely means that all will overdiagnose equally, predictably, and inevitably.”

    You cogently explained the failure at Dartmouth and other places for the lack of variation in the treatment of medical illnesses. By using proxies (HMO, ACO, Managed care) to lower costs means that all will under treat and under diagnose equally, predictably, and inevitably.

    As usual excellent execution.

    • Thanks Allan – and good point about HMOs. The folks at Dartmouth missed the main point about variation – medicine is not an exact science and forcing it to be exact creates its own set of problems.

      • That problem might be solved. I understand Kaiser is starting its own medical school. I am sure they will be teaching young minds how to provide the lowest common denominator in care to the patient with a smile.

  2. Wow!

    What a piece! Not only is the DSM not “psychiatry’s bible” but “the asylum” is not full of normals. In fact, patients with severe psychiatric illness cannot get adequate treatment and I suspect at least some of that rationing comes from such trivialization of the field. As far as diagnostic inflation goes there are fewer DSM-5 diagnoses than in the previous edition: http://real-psychiatry.blogspot.com/2013/10/dsm-5-total-diagnoses-revealed.html

    I really wonder about what qualifies a Radiologist to comment on what is normal in psychiatry, especially when I look at MRI scan reports of “normal” 65 year old necks. How many radiologic diagnoses are there for normal 65 year old necks? I am guessing at least 4 or 5.

    Unlike legitimate severe psychiatric illness, there appears to be no shortage of care or MRI scans for normal necks, backs and brains. In psychiatry you have to be mentally ill and “dangerous” to get in line for a possible admission. In the background the MRI scanners are humming 24/7 and the threshold for getting one is low.

    And BTW – subjectivity is not anathema to biological reductionism – brain science will not be science until it can explain how there are 7.1 billion unique conscious states on the planet.

    • It’s a book review old chum. Take your grievance with Allen. & Szasz, who thought the entire field is BS. I disagree with Szasz, FWIW.

      • I have Szasz’s books, from decades ago. I read and enjoyed him back then (his “humanectomy” jibe is one of my favs), before he went way out of his depth and became a wingnut whackjob. Improvements and advances in brain bioanalytics and genetic assays are rapidly kicking him to the dustbin of history.

        • Szasz had a point, but missed a few as well. Mostly the problem is the curse of Gauss – a fine line separating health and disease won’t easily be granted – which means there’s a trade-off between underdiagnosis and overdiagnosis. Public, it seems, prefers the latter to the former, at least implicitly.

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