Sunday, April 13 1997
The Washington Post
The Boom in Psychiatric Syndromes
By Sheila M. Rothman
In recent years, the types of behavior that are labeled as diseases
have increased dramatically. Modern psychiatry is ready to treat not
only acute depression and schizophrenia, but moodiness, anxiety and
poor self-esteem, feelings most of us have experienced at one time or another.
Nowhere is this development clearer than in editions of the psychiatrists' desk manual, "Diagnostic and Statistical Manual of Mental Disorders," or DSM. Published by the American Psychiatric Association, the first edition, which came out in 1952, listed 60 categories, including schizophrenia, paranoia and other aberrant forms of behavior. By contrast, the fourth edition or DSM-IV, which came out three years ago, has more than 350 listings (by my count). Many of the disorders it describes have overlapping criteria and subtle manifestations, and each may have six or more symptoms. Patients who exhibit three or more are given the diagnosis.
Since many of us have suffered from at least some of the symptoms that characterize the new illnesses, their status as disorders raises the prospect of defining us all as mentally ill. The proliferation of disease categories is beginning to blur the distinction between health and illness, between person and patient. And by offering to relieve us of the moods and anxieties that are part of everyday life, doctors are providing something other than cures for given ailments: They are ready to help make us better than normal.
Take one of the newly classified diseases, body dysmorphic disorder. BDD, as it is known, is characterized by spending excessive time examining oneself before a mirror and by great concern with the size or shape of a body part. But how do you distinguish the disease from vanity? In her recent book, "The Broken Mirror," Katharine Phillips, a psychiatrist at Brown University School of Medicine who helped to establish BDD's criteria, says that more than 5 million Americans (men as well as women) suffer from it. She concedes that the "difference between BDD and normal appearance concerns may be largely a matter of degree." But that does not dissuade her, or the American Psychiatric Association, from labeling it a disorder -- and including it in DSM-IV.
Another new disease, premenstrual dysphoric disorder (PMDD) is marked by irritability, tension, sadness, lethargy, headaches and weight gain. What transforms these commonplace symptoms into a disease is their timing; they generally appear one week before menstruation and disappear a few days afterward. But are symptoms that are unremarkable and transitory truly indicative of a disease? Is an (imperfect) correlation with a normal bodily rhythm and hormonal shift sufficient grounds to find pathology? With PMDD the line between the normal and abnormal becomes murky.
The editors of DSM-IV are comfortable in expanding further the already broad categories of mental disorders. Under the heading "Other Conditions That May Be a Focus of Clinical Attention," they include the "partner relational problem, sibling relational problem, age-related cognitive decline, bereavement, academic problem, occupational problem, and phase of life problem." Put all these categories together and the division between patient and person virtually disappears.
This is also evident in the expanding group of diseases associated with known eating disorders. The first to be widely recognized, in the 1970s, was anorexia nervosa, the symptoms of which include an intense fear of gaining weight, amenorrhea (the absence of menstruation) and a distorted body image, so that sufferers think they are fat even when they're underweight or emaciated. Anorexia was joined in the psychiatric literature of the 1980s by bulimia nervosa, which is characterized by binge eating or chronic dieting and a persistent concern with body shape and size. Both these disorders represent very real problems for sufferers, but since the symptoms may sporadically appear in healthy individuals, psychiatrists were obliged to evaluate "the context in which the eating occurs," according to the manual. What is "excessive consumption at a typical meal might be considered normal during a celebration or holiday meal." To look at it any other way, we would all be candidates for psychiatric treatment at Thanksgiving.
In a New England Journal of Medicine article entitled "Running: An Analog of Anorexia?" Alayne Yates writes that regular exercise can be symptomatic of disease. Exercise that is too regular -- or, in psychiatric terms, compulsive -- indicates an "activity disorder," writes Yates. At issue is not the timing of the behavior (as in PMDD) or its context (as in bulimia nervosa), but its purpose. In Yates's view, excessive running to lose weight or to control weight becomes pathological. The behavior may well be included in the next edition of DSM: Psychiatry is clearly troubled by tracks, fitness centers and gyms.
The fading distinction between normal and abnormal that these newly defined diseases suggest is still more evident in so-called "shadow syndromes." Proposed by John Ratey, a psychiatrist at Harvard Medical School whose new book takes the term for its title, the syndromes represent "hidden psychological disorders." People who are "a little bit" depressed or anxious or display bad tempers suffer from them. Although Ratey concedes that the manifestations are too mild to fit what he calls "the DSM's concrete blocks," he nevertheless argues that feelings of this sort pose genuine risks: "People's lives can and do crash . . . because of small problems."
This extraordinary expansion of psychiatric illnesses coincides with our increasing interest in biological determinism. Indeed, the two trends reinforce one another. The new field suggests that characteristics once believed to be individual and fluid are, to the contrary, hard-wired into us. Biologists and geneticists are encroaching on the field of psychiatry, hypothesizing that biochemical deficiencies, often caused by a genetic defect, are triggering depression, aggression and anxiety. Although they concede that family dynamics may be relevant, they put nature firmly over nurture. In their view -- and in contrast to the accepted psychiatric thinking of most of the 20th century -- biology matters most. Not surprisingly, this orientation is generating in the public a kind of genomic anxiety, which recent reports on cloning only exacerbate. Perhaps we really are puppets at the end of a DNA string -- our temperaments, like the possibility that we'll develop cancer, defined by our genes.
The most frequently invoked biological explanation for many forms of irregular behavior involves deficiencies in serotonin, one of the brain's natural chemicals that transmit signals between nerve cells. In "The Broken Mirror," Phillips relates body dysmorphic disorder to an "abnormality in the serotonin neurotransmitter system." Other psychiatrists have attributed eating and exercise disorders, shadow syndromes and even PMDD to low serotonin levels. What is their evidence? That patients feel better once their serotonin levels are raised through the administration of medications called SSRIs, of which Prozac is the most often prescribed. Because patients with BDD seem to respond to these drugs, Phillips insists that "disturbed brain chemistry plays an important role" in the disease.
Phillips's reasoning fits neatly with the arguments Peter Kramer put forward in his bestseller, "Listening to Prozac." Both psychiatrists use the same circular reasoning: The existence of a disease is confirmed because treatment sparks a positive pharmacological response. Once upon a time doctors diagnosed the disease and then discovered a cure. Now doctors have interventions that inspire them to create new diseases.
Accept for the moment that a heightened concern with appearance or a little bit of depression does constitute a disease. What type of physician does one go to and for what kind of treatment? Psychiatrists insist that despite the biological cause of these illnesses, they are behavior-related and are therefore best treated by psychiatric methods. Although some psychiatrists still rely on long-term psychotherapy, essential to almost everyone's practice today is Prozac or one of its pharmacological equivalents. And patients with a wide variety of complaints appear to improve on Prozac. Their "self-esteem and self-confidence get a boost," Phillips reports. They "feel more normal."
Although clinical trials confirming claims like Phillips's are in short supply, enthusiasm is rampant. Prozac and similar SSRIs have been successfully used in treating classic obsessive-compulsive disorders (sufferers may not be able to leave the house because hand washing or floor washing consumes the day). Since many of the newly discovered diseases are also characterized by repetitive behavior or concerns, many psychiatrists are convinced that SSRIs will work for them as well. Meanwhile, anecdotes substitute for data. "Prozac," Kramer maintained, "seemed to give social confidence to the habitually timid, to make the sensitive brash, to lend the introvert the social skills of the salesman." Phillips concurs: "The scientist in me wants to be cautious." However, "my treatment of many patients, many of whom have suffered for decades and who have responded well -- sometimes miraculously -- to these approaches leads me to advocate them."
But other medical specialists are competing to treat these new diseases. People concerned about a physical symptom (perhaps a drooping eyelid or large nose) might turn to a psychiatrist to ask why they are so troubled by their appearance. Or they might consult a plastic surgeon, dermatologist, ophthalmologist or otolaryngologist to solve the problem.
The most important distinction among these specialists is their understanding of the cause of the disease. To psychiatrists, the patient's concern about an ostensible defect, not the defect itself, is the source of the problem. The goal is to eliminate the anxiety (whether by psychotherapy or drugs), not to alter the body. To surgeons, it is not a matter of psychological obsession but of tissue and bone. Both specialists can offer a solution, and both claim high success rates.
The new disease categories are also prompting physicians to minimize the differences between cure and enhancement, between returning patients to normal and making them better than normal. Kramer coined the term "cosmetic psychopharmacology" to describe the treatment of patients whose behavior was optimized through Prozac. And Ratey uses SSRIs to treat shadow syndromes on the grounds that: "For many of us, normalcy is not enough. The fact that a dark temper or a pessimistic character may be normal does not mean it is easy to live with." Yet, to the extent that physicians make enhancement their goal, all of us become perpetual patients. With this reasoning, the criterion for visiting a doctor's office will become an existential vision of the person one might be. What a heady task for physicians, and what an anguished position for the rest of us.
No one wants to forgo the therapeutic benefits that 21st century medicine will bring; some of us may even wish to gain a competitive edge through enhancement. But how we can achieve these ends without losing our personal identities or becoming perennial patients is one of the most critical challenges posed by the new psychiatry, biology and genetics. After all, none of us wants to spend the better part of life in physicians' waiting rooms.
Sheila Rothman, senior research scholar at the College of Physicians and Surgeons of Columbia University, is writing a book about the social and ethical implications of genetic enhancement technologies.
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