The idea that psychiatry is made-up and arbitrary

Back in high school, I made the mistake of taking a sociology class.

I’m sure sociology is very interesting and ground-breaking at a graduate or PhD level, but it didn’t take me long to realize that everything below that level was just a not-so-fun game of “Let’s Learn Definitions!” Gesselschaft, Gemeinschaft, mores, quasi-group, ethos, role-set, anomie – word searches and fill in the blanks galore!

This pissed me off more than any class ever has since.

I sincerely felt like all of these terms were 100% made-up – somebody once sat down and said, “I’d like to write about the world has gone to crap and everyone pretty much deserves to die for their heatheness, but it doesn’t sound… scientific.. that way, so I’ll call it ‘anomie’.”

Even worse, asking you to memorize a definition without proof of why it exists is asking for implicit acceptance of a concept that doesn’t deserve it yet.

But the truth is, despite how unclear I am on what it brings to the liberal arts table*, sociology is a real thing.  I just didn’t get any sense of appreciation for it.

This reminds me of how a lot of people in our class feel about psychiatry.  Sure, there’s a few people who just flat-out have never believed in it, and an entire religion dedicated to bringing it down – but aside from that, most people would send their loved ones to a psychiatrist if they started hearing voices or crying 12 hours a day.

I guess the problem is that the “check off the boxes” approach to diagnosis is inherently… well, made-up.  And I defend it instinctively because we don’t see any pertinent serologies or blood tests on the horizon, so we have to use something, right?  It’s nice when 3 psychiatrists independently evaluating a guy can all agree on what he has.  The certainty is comforting.

But the other day I was talking to a psychiatrist, and realized there’s a lot of internal dislike of the system, too.  (here’s a fascinating article about how this is/isn’t shaping the DSM 5.)

See, our psych class is taught based on DSM classifications.  But the psychiatrists I’ve met in real life  don’t even have most of the DSM criteria memorized  – exactly the opposite of the impression we get in class.

When I ask about DSM diagnoses, all of the psychiatrists I’ve met  have said variants of  “Once you’ve identified significant problems, it doesn’t matter if they fall into a category or not.  You can use the closest diagnosis to guide treatment, and eventually, you need one for billing, but it’s not something to obsess about.”  The reason they don’t memorize the DSM is because, when it comes down to it, it’s not going to do your job for you.

And speaking as someone who reads her psychiatry book for fun (nerd alert) – that’s so interesting to me.  Although psychiatry is necessary and helpful, I guess the idea that the DSM categories aren’t always so?   More generally acknowledged than I thought.

So what I wonder if whether we’re focusing only on the DSM categories and how to diagnose each one because a) you gotta walk before you run, or b) our teachers hope it makes us feel like the psychiatric method is scientific (compared to teaching “each patient is an individual, and you have to really find out what makes them tick instead of just sticking them in the first convenient category and calling it a day,” which sounds all liberal-arts-y.)

Because the people who dislike the lack of science in psychiatry?  Are never going to go into psychiatry, no matter how much you try to avoid the liberal-arts-like uncertainty of it.

But the people who feel like the DSM categories are made-up and subjective might be relieved to know that not all psychiatrists treat them as the bible.

*  Isn’t most of sociology covered by cultural and psychological anthropology?  I never understood that.


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12 thoughts on “The idea that psychiatry is made-up and arbitrary

  1. So I majored in anthropology which is slightly more qualitative (at least cultural anthro) than sociology. I’m also very comfortable with the uncertainty that exists in describing human behavior – which is exactly what I think many med students are uncomfortable with in the realm of psychiatry.

    In general, I think the more comfortable one is with uncertainty, the better doctor s/he’ll be. We’re so conditioned in the first 1.5-2yrs of med school to think, “what’s the SINGLE BEST ANSWER???” It’s easy to forget that real people don’t work that way.

    I think psychiatry will really change within the next 20 years as our understanding shifts from seeing mental illness as diseases of the “mind” (some abstract, philosophical thing) to that of organic diseases of the brain. For example: http://www.scientificamerican.com/article.cfm?id=genetics-of-depression and http://www.scientificamerican.com/article.cfm?id=mapping-the-mind

    • Wow, I would’ve picked anthro to be more quantitative than sociology – shows what I know! Thanks for the explanation and the links. (Love Scientific American!)

      I’m excited about psychiatry’s future. It seems like most other fields are narrowing things down to proteins and subunits and chemical cascades – but in psychiatry, the door is still wide open to the big discoveries that change everything.

      Actually, the two things I’ve always been fascinated with are psychology and astronomy. I never saw a connection before, but maybe it’s because we can’t answer the big questions in either.

  2. Wow, so many points to address in this post.

    I think though, regarding the DSM, you just have to keep in mind that it exists for the purposes of categorizing people for drug trials, and not to diagnose people in clinical practice. In reality, people are a lot more diverse in their presentations than the DSM would lead you to believe, but in order to make sure that we’re not enrolling bipolar patients in our trials of a drug for anxiety, we need to have enrollment criteria. Thus the DSM was born.

    As for sociology, my biggest gripe with it was that it spent a whole lot of time whining about how THE MAN oppressed the working man. And in the end, I am a woman of action, and though I like to whine (who doesn’t) I don’t want to base my career around it. Fundamentally I also agree with you that sociology is in large part an agglomeration of several disciplines. I’ll just add economics to that while I’m at it, though don’t ever bring up rational choice theory with a sociologist — you might get shot on the spot.

    What’s cool about anomie isn’t the concept of anomie per se. It’s that Durkheim (who coined the term, I believe) was trying to identify why protestants killed themselves at a higher rate than catholics or jews. To measure this, he did the firsy sociological study, complete with data collection of lots of data and statistics. Anomie was his non-scientific explanation based on what he knew about the three religions, and in fact seems to me like a pretty astute observation given what I know about the three religions. That’s what’s cool about anomie, not the stupid definition.

    Gemeinshaft and Gessellshaft bored the crap out of me to, FYI. I’m really not into Marxism though. Some people love that stuff.

    • Totally agree about economics – I think if I hadn’t majored in neuro, I would’ve been an economics major. I learned more in my microecon class than I did in the rest of my gen-eds put together.

      Yeah, it feels like we’re almost getting 2 completely different messages about the DSM. Our psych course is centered around it, but everything I hear from people with experience says that it’s not the core focus of a psychiatrist’s life at all. But the people I’ve talked to really dislike how DSM-centric everything is now, and some even say it’s made them question why anyone would ever go into psych. Hopefully we’ll move on and talk about other aspects of psych after spring break!

      Thanks for the anomie explanation, that’s interesting! Definitely cooler than the definition.

  3. Wow! Most of the psychiatrists that I know DO know the DSM criteria and use it significantly in their diagnosis. I wonder if it’s just a regional thing? I do understand about the diagnosis being very subjective, though, as a lot of it has to be made based on perceptions and past experience with seeing those traits. BUT…I do think the DSM exists as a basis for those later on “I can just tell” subjective diagnoses.

    Also, I think psychiatry is becoming more scientifically based. As in, fMRI studies are now being used to show brain anomalies associated with certain disorders, as well as more information about signaling events associated with chemical imbalances.

    Most of the med. students at my school think psychiatry is a crock too, though. 🙂

    • Interesting! Yeah, the psychiatrists I know just don’t see the diagnosis as being as important as the med students do. So it might also just be a regional difference in how med students learn psych – the emphasis placed on DSM criteria vs. treatment, etc.

      The psychiatrists I talked to use DSM criteria for the diagnosis, but may have to look up the specific criteria necessary for, say, Histrionic Disorder – because, to them, memorizing the formal definition is less important than focusing on the central problem of inappropriate sexuality.

      Whereas as med students, at least here, if all we learn of Histrionic Disorder is the definition, then it’s like, “Whoa, psychiatrists don’t have the criteria memorized?! Becuase even I have them memorized!” and it’s hard to wrap our minds around the idea that the criteria aren’t the most important part of psych.

      I agree, psychiatry seems to be interesting a really exciting period – I think any researcher in psych has to be pretty pumped about their career right about now. Thanks! 🙂

  4. I would challenge people that even the “harder” diagnoses in, let’s say, internal medicine, are just as subjective as some of those in psych. After all, most lab values are based on a population norm, no? God didn’t just write the 11th commandment to be “Thou shall no potassium above 5!” Same thing with physical diagnoses; can you really tell me the exact amount of cardiac ischemia needed to have an MI? Most diagnoses are based on symptomology – what’s the difference between “chest pain that significantly affects ability to work” and “hallucinations that significant affects ability to work”.

    The biggest fault, IMO, in the DSM, and the reason people are so loath to take it seriously, are the two “cop-out” lines in every condition:
    1) This condition cannot be better explained by substance ingestion
    2) This condition cannot be better explained by a medical condition
    With selling points like that, which make EVERY psych disease subordinate to “medical diseases”, its no wonder people view psych as a second-tier field.

  5. Isn’t it like that in most professions though? You learn in university that everything’s black and white, and that if x happens, y always follows. But then you get into the real world and find out that there are various shades of grey and you learn how to see an overall picture of the problem based on your past experience.

    I’d say in psychiatry, the DSM is a starting point, but with enough experience the shrink learns more about how to treat the immediate symptoms than the textbook method.

    • That’s an awesome point..

      You know, maybe one of the issues is that people who are drawn to medicine are stereotypically more interested in absolute fixes rather than shades of grey, like SR said above. Because, you’re right – most other fields are like that, and if you compare psychiatry to most things outside of medicine (although, as NotHouse said, even medicine isn’t so black and white) – it’s not so fuzzy in comparison.

  6. I think once psychiatrists are in practice, they kind of know what schizophrenia or depression look like, and the criteria aren’t as important. It was painful memorizing the DSM criteria, but they are helpful in arriving at a diagnosis. I bet the docs really do have them memorized, but to them they are just second nature.
    Now that we are in endocrine, I REALLY miss psychiatry…

  7. I was just watching that old Tom Cruise interview on the Today Show (www.msnbc.msn.com/id/26184891/vp/8343554#8343554), in which he says that antidepressants and antipsychotics and stimulants for ADHD are all pointless, and then he goes on and on about how he is an expert in the field of psychiatry and that it’s a pseudoscience and there is no scientific research backing up these medications. At first it irritated me to see such things, as a student of psychology, but I found myself laughing by the end of it. How ridiculous can a person get, really? Dude dropped out of high school.

    From my perspective – I am a psychology grad student, not a medical student – I think that the DSM criteria specifically isn’t hugely important. One of the examples that I think of, often, is the fact that ADHD can’t be diagnosed after age 7 (or something like that). ADHD is so under-diagnosed in girls because of how they tend to be just inattentive instead of both hyperactive and inattentive, that girls will often grow up to be past 7 years old and still suffering from ADHD. If a psychiatrist followed the DSM quite strictly, the diagnosis of ADHD wouldn’t be made. Similarly, adults would never get diagnosed with ADHD. But I think the DSM is meant to be just sort of a guideline, especially since so many disorders mix and mesh, and often there are no strict lines between them. Depression and anxiety share so many symptoms, as can PTSD and psychosis, and ADHD and learning disorders. It’s worthwhile for a therapist to spend time with the patient and deal with all the issues, whatever they are, without needing one particular label. That’s my view, anyway.

    Also, I hate sociology.

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