Abstract
Labels are very useful. Imagine a supermarket in which all the tins and packages were innominate, and one had to guess their contents by shaking them and weighing them. Shopping would be difficult. Thus labels are essential and in some circumstances bar codes even better. Those who read consumer magazines will know that labels can also be misleading and not reflect the contents of the packages.
Psychiatry is rather like that; if we had no labels, communication would be a problem and management more difficult to conceptualise and describe. But there is a difference. If there is an argument about whether an unlabelled tin contains tomato or, say, onion soup opening the tin would settle it, because we have good enough descriptions of both these substances.
When the issue is straightforward our labels will suffice. If there is an argument about whether someone is suffering from agoraphobia or Alzheimer's disease I believe that it can be settled to everyone's satisfaction by inspecting the patient. I suppose that to do an MRI is analogous to opening the tin.
One problem is to define our categories - the succession of DSMs and ICDs is sufficient testimony to that. Part of the problem is that many of our “categories” are in fact dimensions and their boundaries are uncertain. This is not confined to psychiatry: recent literature on the definition of essential hypertension exemplifies the problem. Not only do opinions differ about the level of the readings, but also whether at particular ages the systolic or diastolic readings are more important. Again, individuals will have very different readings under different circumstances. Sometimes the diagnosis will be obvious and sometimes it will be a matter of opinion.
THE LARGER PROBLEM
More fundamental is whether or not a particular set of phenomena constitutes a disease or, in psychiatry, a disorder. Sometimes there will be little argument; pulmonary tuberculosis, fractured femur and chronic schizophrenia will be accepted by most as diseases or disorders. This is a triumph of common sense over scholasticism, for there is no satisfactory definition of a disease.
The problem of defining “disease” and of relating that definition to psychiatry has been with us for millennia. In the last century, careful and useful attention to the question was given by Kendell[1] and Scadding.[2] Neither could solve the central riddle.
In this country, a scholarly article by George[3] pursued “disease” through a number of languages, cultures and concepts, finally describing each “disease” as a unique event in the organism in which it occurs, but not to my mind providing a satisfactory definition. I shall return to this topic below.
BACK TO LABELS
Since psychiatry cannot function without labels, we must have them. It is important to observe who invents them and who bestows them upon which segment of humanity. Some labels have a long history and have acquired and lost many meanings and mechanisms over the years - hysteria provides a good example. One way of dealing with this problem is to pretend that it does not exist and change its name. That happened to hysteria.
The labels may reflect the tidy-mindedness of those inventing them. Thus, the anxiety disorders are divided into a number of categories. A large multicentre study of anxiety disorders - the Harvard/ Brown Anxiety Disorders Research Program - examined 711 subjects and reported that “By all definitions, subjects with ‘pure culture’ (disorders) represented a minority, especially in cases of Generalised Anxiety Disorder and Social Phobia, where comorbidity was virtually ubiquitous”.[4]
Comorbidity is a good word for diverting attention from the fact that most “categories” are expressions of hope as much as of observation.
The labels are very likely to be the products of committees who reflect the values of the forces in society which happen to be ascendant at a particular time. Thus, in the Psychiatric Dictionary[5] you will find the Episodic Dyscontrol Syndrome. I have the 1981 fifth edition; the first was in 1940. I do not know the pedigree of the term during that time. It was not a good label to bear. After the 1967 Detroit riots, Harvard doctors Vernon H Mark and Frank R Ervin wrote in the journal of the American Medical Association and in their book ‘Violence in the Brain’ (1970) that such behaviour was not due to social disadvantage and victimisation but due to the Episodic Dyscontrol Syndrome. Since the syndrome was due to cerebral dysrhythmia the recommended remedy was to plant electrodes in the brains of protestors. Grants were obtained from the National Institute for Mental Health and the Justice Department's Law Enforcements Assistance Administration to develop their ideas in the Boston-based Neuro-Research Foundation.
Ronald Reagan, then the Governor of California, sought $1.5 million to establish a centre which would be operated by the University of California at Los Angeles with the same intent. Voices were raised against these programs and they did not proceed.[6]
Since the Episodic Dyscontrol Disorder had a bad reputation in 1980 it emerged in DSM-III as Intermittent Explosive Disorder. It remained in DSM-IIIR and is not to be found in DSM-IV.
WHO PROVIDES THE LABELS?
Our labels have many determinants and a notion of what is a disease is upon equally insecure ground. Bestowing a diagnosis upon someone may not only point them in the direction of a particular treatment but may also disadvantage them - as we have seen. It may provide them with a benefit. For example, in some jurisdictions, one can sue for damages if in addition to a physical injury one has acquired a psychiatric disorder. What are the boundaries of a psychiatric disorder?
Consider the anxiety disorders. Their level of anxiety is no criterion. Someone hotly pursued by a lion will be anxious indeed but that is a normal consequence of such an encounter and does not attract a diagnosis. Disability may seem to provide a sound criterion but it is a little complicated. If I have a strong fear of giraffes but there are no giraffes in my environment then I do not earn the DSM-IV diagnosis of Specific Phobia. However, if for some curious reason giraffes become common in the streets of Sydney and I encounter them frequently with consequent disorganisation of my life then I do have a disorder. My movement from normality to disorder is occasioned not by a change in my psychopathology but by a change in the distribution and habits of giraffes.
Need for treatment is no criterion. Those who have survived an air disaster may need to fly again but the consequent anxiety may stand in their way. Appropriate therapy may get them back in the air; one could scarcely regard their anxiety as pathological even though it has responded to treatment.
Let us return to the medico-legal arena. Consider an unskilled worker who has lost a little toe in an accident but is otherwise unharmed. It happens that he is more disturbed by the loss than one might anticipate and there is no doubt about his genuineness. He earns the label of one of the Adjustment Disorders and has grounds for a claim for damages.
Consider another man, grievously wounded in an explosion. He has lost all four limbs, his genitalia and his vision. I cannot imagine a level of anxiety and depression which would - because of its height - be unexpected in such circumstances. He has no psychiatric disorder on the basis of that despair alone and he cannot sue on that basis.
SOME EMPTY DEBATES
There are debates about whether or not alcoholism and gambling are disorders. Since there is no satisfactory definition of a disorder, the question cannot be resolved, except by the acceptance of dogma. Pathological gambling (312.31) creeps into DSM-IV but one has to jump through 10 formidable hoops to earn the accolade.
Homosexuality was once categorised as a disorder and on occasion treated by the application of electricity to sensitive parts of the body. Society has changed and it is no longer a disorder.
The fact that behaviour may jeopardise the life or seriously harm the well-being of the person is not a criterion. Smoking tobacco, climbing mountains in the avalanche season and rock fishing on stormy days carry this possibility, but few would call those pursuing such activities diseased or disordered. Unwise they are by the standards of some, but that is another matter.
These thoughts came into my mind when I read two articles in close succession. The first was the contribution in the Medical Journal of Australia in which responsible and careful professionals with a special interest in eating disorders stated: “Our conclusion, based on the current evidence, is that the scientific basis for the treatment of eating disorders is weak”.[7] True it is that there are other opinions[8] but their assessment cannot be swept aside.
The second was an article by Julia Baird in the Sydney Morning Herald of 30/08/01 describing “Literally hundreds of proanorexia sites (which) have swarmed across the Internet as part of underground movements for anorectics who want to stay that way or become even thinner than they already are”.[9] Ms Baird gives a number of examples of girls who know the consequences of their behaviour and who are determined to pursue it to whatever end ensues.
There is much self-destructive behaviour in the world; its categorisation depends upon where one stands. I have no wish to be a suicide bomber or row across the Tasman single-handed. Placing oneself in jeopardy is common enough: think of it next time you go bungee-jumping or parachuting.
Which are disorders and which are not? There are those who advocate force-feeding severe anorectics. Indeed, in the past there were those who advocated cerebral surgery.[10]
Consider middle-aged men who are grossly overweight and hypertensive and who sustain themselves on an intake of fast-food, alcohol and tobacco. They refuse to modify their lifestyle and will not take medication for their hypertension and hypercholesterolemia. There is no rush to lock them up and change their ways, whether they like it or not. Perhaps it is easier to empathise with one group than the other.
DOING ONE'S BEST
I do not write to criticise those who do their best to produce our labels, for the attempt must be made. Some are well aware of the limitations of such endeavours - the preface of DSM-IV sets the difficulties out very well. My problem is with those who approach a diagnostic system as if it were the Book of Revelations and stretch their patients out upon a psychological bed of Procrustes, lopping off the bits that hang over the edge until they have a diagnosis. Everything else follows automatically.
Evidence-based medicine is an essential part of psychiatry but it has its limitations even when the evidence can be found. It cannot empathise with suffering and it cannot answer ethical and philosophical questions for there is no way in which they can be tested empirically.
The danger is that we shall accept dogma as fact and the opinions of committees in particular communities at particular times as having universal and eternal significance. This is not a new error in the history of the world.
For the penultimate word let us go to the Centre for Medical Ethics of the University of Oslo in Norway. The author points out that the concepts of disease itself have been categorised into such entities as “realist”, “nominalist”, “ontologist”, “physiologist”, “normativist” and “descriptivist”.[11] It is his view that these words refer to profound philosophical issues and that disease is a complex concept that does not easily lend itself to definition.
With all of that I would agree and in particular I would agree with Aronowitz when he states that “Social influences have largely determined which symptom clusters have become diseases”.[12]