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.