Monday, July 11, 2011

Diagnosis: Unusual; Prescription: Meditation

A pleasant, earnest, and persistent young man telephoned last week intent on ‘helping’ us with a problem that we were about to encounter with the Windows operating system that populates our various computers. His message was clear: he had been instructed by Microsoft to contact us and assist us with the removal of a viral program, origin suspected to be Thailand. While he (helpfully) remained on the phone, we were to go directly to our computer (do not pass ‘Go’; and certainly do not collect the usual $200 swag – that evidently would be his job!), log on to the website he would designate, and presto, we would have dodged another digital bullet. Fortunately, my wife received the call, together with all its urgent instructions – and accordingly informed our obliging young caller that her experience with Microsoft (and it is ample) was that contact is not typically made by telephone. She thanked him for his time (more or less) and ended the call. A few days later, she had occasion to take her computer in for servicing, discovering in conversation with the technician that we were not alone in receiving this uninvited assist. Another less cautious customer had reportedly followed the directives; only to find that, in doing so, he himself installed corrupted code – which then cost him a few hundred dollars to have removed, evidently with the now ‘necessary’ intervention of said helpful and anonymous caller.

I was reminded of the above scenario as I read, with some interest, Ian Brown’s weekend editorial about the soon to be published DSM-V (see our ‘Of Interest’ website, for the full text – of Ian’s article, not the DSM!). The lingo may be a bit unfamiliar to some – the DSM’s are the manuals utilized in making diagnoses of mental disorders, syndromes, etc. Evolving thru’ three previous editions in the past 60 years, the DSM-IV, its current incarnation, is an imposing checklist cataloguing criteria for everything from depression to dementia, psychosis to personality disorders, anxiety to Asperger’s. Ian chooses to highlight the contentiousness that has pretty much preceded the release of each successive edition; largely driven by what some see as a rather arbitrary and scientifically ‘unsupported’ inclusion (and exclusion) of ‘conditions’ that might be better viewed as ‘extremes of normal behaviour’. (PMS, in; homosexuality, out.) He also raises the concern that, with every good (or maybe not so good) diagnosis, comes the need to develop ways of treating said condition. His contention is that, since this is primarily a medical/psychiatric volume (although the ‘protected privilege’ of pronouncing diagnosis is extended to psychologists in Ontario), ‘treatment’ has increasingly come to mean ‘medication’. In short, not to be too inclined to see a suspicious character behind every tree – that would be frankly paranoid, the editorial considers the possibility that the DSM’s have gradually become something of a self-perpetuating marriage between psychiatry (‘we invent the pathology’) and the drug companies (‘we invent the cure’). Hence, my little resonance with the scenario in the first paragraph: first I’ll help you inject a problem into your computer; then I’ll ride in to the rescue (for my $300 fee!). Hmmm, seems a bit circular (and scary).

I also had occasion a few weeks back to catch the end of an interview between Steve Paikin (The Agenda) and an octogenarian, Don Weitz who is a self-described ‘psychiatric survivor’ and ‘anti-psychiatry activist’. (The podcast is viewable at: ). Weitz, an arrival in Canada some 50 years ago as a student in U of T‘s graduate psychology program, became progressively disenchanted with the whole concept of mental illness, partly a reaction to treatment interventions observed during a stint working at CAM-H (formerly Queen St. Mental Health Centre) as a psychologist; and partly responsive to his own earlier experiences on the ‘other side of the window’ as a patient in late adolescence. He has been a vocal critic of all things psychiatric ever since.

As a practitioner, two observations. As a culture, we seem to be getting ‘sicker’, judging from the upsurge in numbers of certain categories of identified dysfunction (depression, attention deficit, anxiety, to name a few). A statistic cited in Brown’s column (NIH survey) notes that presently nearly half of American adults satisfy the criteria for at least one DSM mental illness! I’ve often wondered just what these sorts of reported trends actually reflect. Are there more depressed people in 2011 than in, say, 1990? Are little boys becoming progressively less manageable, more chaotic? My own (perhaps overly optimistic) suspicion is that this increased ‘mental malaise’ may in part be artifactual; that the ‘statistical evidence’ is in part predicated on two sources of somewhat suspect data (not the accuracy of the numbers, but the interpretation thereof): more prescriptions written for conditions typically seen as psychiatric (depression, anxiety); and more lost time work absences, reported as having a ‘psychiatric / psychological origin’. This trend, if my view has any credence at all, is disturbing in and of itself, in that it reflects as much an increased readiness to diagnose a condition – but quite possibly not an actual increase in the base rate of the condition(s) itself. More disturbing still is the reactivity that it seems to engender against taxonomic systems such as the DSM (as typified by Ian Brown’s column), and treatment of psychiatric disorder in general (as portrayed in the Weitz interview). The equivalent of throwing out the baby with the bath water. Certainly there are villains that will attempt to corrupt your computer. And certainly there may be a tendency in some quarters to pathologize eccentric, atypical, unpopular, or extreme behaviours. But it does not mean that we should stop answering the phone or throw out the computer. Nor is taxonomy the problem. What’s that hopelessly overused cliché: guns don’t shoot people; people shoot people. The tools are not the problem. Their application might be.

Oh yeah, the second observation. Restoring my faith on a regular basis is the appearance of clients in my practice, adamant that they wish to implement alternative strategies in addition to and on some occasions in place of medication in management of their presenting symptoms. The capacity for regular mindfulness practice, linked with other cognitive interventions, to sustain gains in a host of areas (anxiety, chronic pain, depression, anger/impulse control) is testament that perhaps we’re not going (straight) to Hell in a psychiatric hand basket. And that we, as a culture are not the uncritical, unquestioning collection of buffoons that the alarmists might suggest.

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