“Some of these stories are closer to my own life than others are, but not one of them is as close as people seem to think.” Alice Murno, from the intro to Moons of Jupiter

"Talent hits a target no one else can hit; genius hits a target no one else can see." Arthur Schopenhauer

“Why does everything you know, and everything you’ve learned, confirm you in what you believed before? Whereas in my case, what I grew up with, and what I thought I believed, is chipped away a little and a little, a fragment then a piece and then a piece more. With every month that passes, the corners are knocked off the certainties of this world: and the next world too. Show me where it says, in the Bible, ‘Purgatory.’ Show me where it says ‘relics, monks, nuns.’ Show me where it says ‘Pope.’” –Thomas Cromwell imagines asking Thomas More—Wolf Hall by Hilary Mantel

My favorite posts to get started: The Self-Righteousness Instinct, Sabbath Says, Encounters, Inc., and What Makes "Wolf Hall" so Great?.

Monday, June 18, 2012

The Mental Illness Zodiac: Why the DSM 5 Won't Be Anything But More Pseudoscience

            Thinking you can diagnose psychiatric disorders using checklists of symptoms means taking for granted a naïve model of the human mind and human behavior. How discouraging to those in emotional distress, or to those doubting their own sanity, that the guides they turn to for help and put their faith in to know what’s best for them embrace this model. The DSM has taken it for granted since its inception, and the latest version, the DSM 5, due out next year, despite all the impediments to practical usage it does away with, despite all the streamlining, and despite all the efforts to adhere to common sense, only perpetuates the mistake. That the diagnostic categories are necessarily ambiguous and can’t be tied to any objective criteria like biological markers has been much discussed, as have the corruptions of the mental health industry, including pharmaceutical companies’ reluctance to publish failed trials for their blockbuster drugs, and clinical researchers who make their livings treating the same disorders they lobby to have included in the list of official diagnoses. Indeed, there’s good evidence that prognoses for mental disorders have actually gotten worse over the past century. What’s not being discussed, however, is the propensity in humans to take on roles, to play parts, even tragic ones, even horrific ones, without being able to recognize they’re doing so.

            In his lighthearted, mildly satirical but severely important book on self-improvement 59 Seconds: Change Your Life in Under a Minute, psychologist Richard Wiseman describes an experiment he conducted for the British TV show The People Watchers. A group of students spending an evening in a bar with their friends was given a series of tests, and then they were given access to an open bar. The tests included memorizing a list of numbers, walking along a line on the floor, and catching a ruler dropped by experimenters as quickly as possible. Memory, balance, and reaction time—all areas our performance diminishes in predictably as we drink. The outcomes of the tests were well in-keeping with expectation as they were repeated over the course of the evening. All the students did progressively worse the more they drank. And the effects of the alcohol were consistent throughout the entire group of students. It turns out, however, that only half of them were drinking alcohol.

At the start of the study, Wiseman had given half the participants a blue badge and the other half a red badge. The bartenders poured regular drinks for everyone with red badges, but for those with blue ones they made drinks which looked, smelled, and tasted like their alcoholic counterparts but were actually non-alcoholic. Now, were the students with the blue badges faking their drunkenness? They may have been hamming it for the cameras, but that would be true of the ones who were actually drinking too. What they were doing instead was taking on the role—you might even say taking on the symptoms—of being drunk. As Wiseman explains,

Our participants believed that they were drunk, and so they thought and acted in a way that was consistent with their beliefs. Exactly the same type of effect has emerged in medical experiments when people exposed to fake poison ivy developed genuine rashes, those given caffeine-free coffee became more alert, and patients who underwent a fake knee operation reported reduced pain from their “healed” tendons. (204)

After being told they hadn’t actually consumed any alcohol, the students in the blue group “laughed, instantly sobered up, and left the bar in an orderly and amused fashion.” But not all the natural role-playing humans engage in is this innocuous and short-lived.

            In placebo studies like the one Wiseman conducted, participants are deceived. You could argue that actually drinking a convincing replica of alcohol or taking a realistic-looking pill is the important factor behind the effects. People who seek treatment for psychiatric disorders aren’t tricked in this way; so what would cause them to take on the role associated with, say, depression, or bipolar? But plenty of research shows that pills or potions aren’t necessary. We take on different roles in different settings and circumstances all the time. We act much differently at football games and rock concerts than we do at work or school. These shifts are deliberate, though, and we’re aware of them, at least to some degree, when they occur. But many cues are more subtle. It turns out that just being made aware of the symptoms of a disease can make you suspect that you have it. What’s called Medical Student Syndrome afflicts those studying both medical and psychiatric diagnoses. For the most part, you either have a biological disease or you don’t, so the belief that you have one is contingent on the heightened awareness that comes from studying the symptoms. But is there a significant difference between believing you’re depressed and having depression? There answer, according to check-list diagnosis, is no. 

            In America, we all know the symptoms of depression because we’re bombarded with commercials, like the one that uses squiggly circle faces to explain that it’s caused by a deficit of the neurotransmitter serotonin—a theory that had already been ruled out by the time that commercial began to air. More insidious though are the portrayals of psychiatric disorders in movies, TV series, or talk shows—more insidious because they embed the role-playing instructions in compelling stories. These shows profess to be trying to raise awareness so more people will get help to end their suffering. They profess to be trying to remove the stigma so people can talk about their problems openly. They profess to be trying to help people cope. But, from a perspective of human behavior that acknowledges the centrality of role-playing to our nature, all these shows are actually doing is shilling for the mental health industry, and they are probably helping to cause much of the suffering they claim to be trying to assuage.

            Multiple Personality Disorder, or Dissociative Identity Disorder as it’s now called, was an exceedingly rare diagnosis until the late 1970s and early 1980s when its incidence spiked drastically. Before the spike, there were only ever around a hundred cases. Between 1985 and 1995, there were around 40,000 new cases. What happened? There was a book and a miniseries called Sybil starring Sally Field that aired in 1977. Much of the real-life story on which Sybil was based has been cast into doubt through further investigation (or has been shown to be completely fabricated). But if you’re one to give credence to the validity of the DID diagnosis (and you shouldn’t), then we can look at another strange behavioral phenomenon whose incidence spiked after a certain movie hit the box offices in the 1970’s. Prior to the release of The Exorcist, the Catholic church had pretty much consigned the eponymous ritual to the dustbins of history. Lately, though, they’ve had to dust it off. The Skeptic’s Dictionary says of a TV series devoted to the exorcism ritual, or the play rather, on the Sci-Fi channel,

The exorcists' only prop is a Bible, which is held in one hand while they talk down the devil in very dramatic episodes worthy of Jerry Springer or Jenny Jones. The “possessed” could have been mentally ill, actors, mentally ill actors, drug addicts, mentally ill drug addicts, or they may have been possessed, as the exorcists claimed. All the participants shown being exorcized seem to have seen the movie “The Exorcist” or one of the sequels. They all fell into the role of husky-voiced Satan speaking from the depths, who was featured in the film. The similarities in speech and behavior among the “possessed” has led some psychologists such as Nicholas Spanos to conclude that both “exorcist” and “possessed” are engaged in learned role-playing.

If people can somehow inadvertently fall into the role of having multiple personalities or being possessed by demons, it’s not hard to imagine them hearing about, say, bipolar, briefly worrying that they may have some of the symptoms, and then subsequently taking on the role, even the identity of someone battling bipolar disorder.

            Psychologist Dan McAdams theorizes that everyone creates his or her own “personal myth,” which serves to give life meaning and trajectory. The character we play in our own myth is what we recognize as our identity, what we think of when we try to answer the question “Who am I?” in all its profundity. But, as McAdams explains in The Stories We Live By: Personal Myths and the Making of the Self,

Stories are less about facts and more about meanings. In the subjective and embellished telling of the past, the past is constructed—history is made. History is judged to be true or false not solely with respect to its adherence to empirical fact. Rather, it is judged with respect to such narrative criteria as “believability” and “coherence.” There is a narrative truth in life that seems quite removed from logic, science, and empirical demonstration. It is the truth of a “good story.” (28-9)
Dan McAdams

The problem when it comes to diagnosing psychiatric disorders is that the checklist approach tries to use objective, scientific criteria, when the only answers they’ll ever get will be in terms of narrative criteria. But why, if people are prone to taking on roles, wouldn’t they take on something pleasant, like kings or princesses?

            Since our identities are made up of the stories we tell about ourselves—even to ourselves—it’s important that those stories be compelling. And if nothing ever goes wrong in the stories we tell, well, they’d be pretty boring. As Jonathan Gottschall writes in The Storytelling Animal: How Stories Make Us Human,

This need to see ourselves as the striving heroes of our own epics warps our sense of self. After all, it’s not easy to be a plausible protagonist. Fiction protagonists tend to be young, attractive, smart, and brave—all the things that most of us aren’t. Fiction protagonists usually live interesting lives that are marked by intense conflict and drama. We don’t. Average Americans work retail or cubicle jobs and spend their nights watching protagonists do interesting things on television. (171)

Listen to the ways talk show hosts like Oprah talk about mental disorders, and count how many times in an episode she congratulates the afflicted guests for their bravery in keeping up the struggle. Sometimes, the word hero is even bandied about. Troublingly, the people who cast themselves as heroes spreading awareness, countering stigmas, and helping people cope even like to do really counterproductive things like publishing lists of celebrities who supposedly suffer from the disorder in question. Think you might have bipolar? Kay Redfield Jameson thinks you’re in good company. In her book Touched By Fire, she suggests everyone from rocker Curt Cobain to fascist Mel Gibson is in that same boat-full of heroes.

            The reason medical researchers insist a drug must not only be shown to make people feel better but must also be shown to work better than a placebo is that even a sham treatment will make people report feeling better between 60 and 90% of the time, depending on several well-documented factors. What psychiatrists fail to acknowledge is that the placebo dynamic can be turned on its head—you can give people illnesses, especially mental illnesses, merely by suggesting they have the symptoms—or even by increasing their awareness of and attention to those symptoms past a certain threshold. If you tell someone a fact about themselves, they’ll usually believe it, especially if you claim a test, or an official diagnostic manual allowed you to determine the fact. This is how frauds convince people they’re psychics. An experiment you can do yourself involves giving horoscopes to a group of people and asking how true they ring. After most of them endorse their reading, reveal that you changed the labels and they all in fact read the wrong sign’s description.  

            Psychiatric diagnoses, to be considered at all valid, would need to be double-blind, just like drug trials: the patient shouldn’t know the diagnosis being considered; the rater shouldn’t know the diagnosis being considered; only a final scorer, who has no contact with the patient, should determine the diagnosis. The categories themselves are, however, equally problematic. In order to be properly established as valid, they need to have predictive power. Trials would have to be conducted in which subjects assigned to the prospective categories using double-blind protocols were monitored for long periods of time to see if their behavior adheres to what’s expected of the disorder. For instance, bipolar is supposedly marked by cyclical mood swings. Where are the mood diary studies? (The last time I looked for them was six months ago, so if you know of any, please send a link.) Smart phones offer all kinds of possibilities for monitoring and recording behaviors. Why aren’t they being used to do actual science on mental disorders?

            To research the role-playing dimension of mental illness, one (completely unethical) approach would be to design from scratch a really bizarre disorder, publicize its symptoms, maybe make a movie starring Mel Gibson, and monitor incidence rates. Let’s call it Puppy Pregnancy Disorder. We all know dog saliva is chock-full of gametes, right? So, let’s say the disorder is caused when a canine, in a state of sexual arousal of course, bites the victim, thus impregnating her—or even him. Let’s say it affects men too. Wouldn’t that be funny? The symptoms would be abdominal pain, and something just totally out there, like, say, small pieces of puppy feces showing up in your urine. Now, this might be too outlandish, don’t you think? There’s no way we could get anyone to believe this. Unfortunately, I didn’t really make this up. And there are real people in India who believe they have Puppy Pregnancy Disorder

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