When Treatment Fails ...

blame the patient.

Psychiatry remains the discipline of medicine that has yet to grasp the nature of the disorders it treats. This explains why it lacks the power to resist social and political fads claiming to solve the problem of human mental distress.

So said Emeritus Prof. Paul McHugh of Johns Hopkins University, the oft-awarded and, at 93, Grand Old Man * of American psychiatry and unrepentant controversialist in the area of sexual identity, gender orientation and reorientation, and randy priests. This one, however, he got right. And it is nowhere more true than in the matter of personality disorder. I set out my case in Chap. 8 of my first book, Humanizing Madness, which turns seventeen this year [1]. Since that was written, DSM5 has come and gone and none of the criticisms which were so obvious back then have been addressed. Nothing has changed, the whole field of personality disorder in psychiatry remains the same pseudoscientific mess it's always been. Briefly, the criticisms are:

• Psychiatry doesn't have a theory of personality, so there is not, and cannot be, a definitive psychiatric model of personality disorder.

• The idea that there are distinct "categories" of personality disorder has no scientific justification whatsoever. The differences between the categories are pure artifice.

• All evidence says that we all have a huge range of personality factors and that these distribute dimensionally, i.e. there is no cut-off between normal and abnormal. Like height or hair colour, it's all a matter of intensity of disturbance, which is subject to interpretation (or prejudice) and everything can change as a result of life experiences.

• The search for a biological basis to personality is driven by the ideological need to find biological "causes" for all forms of mental disturbance.

• Nobody has ever found anything of interest in the search for a biological "foundation" of personality.

• All evidence says the over-riding influences are life experiences, both early life (childhood, teenage) and in adult life (traumatic events).

• There is no reason to believe drugs etc. can be of more than temporary benefit for people with abnormal personality.

• The only conceivable form of management is psychotherapy, for which psychiatrists have no model and, overwhelmingly, no training. This means they can make no money from personality disorder.

A few years later, I put the case that psychiatry is engaged on a massive, long-term project of reclassifying people with personality disorders as "mentally-ill," and putting them on drugs, such that if they weren't mentally-ill before they started these powerful and unpredictable chemicals, they soon will be [2]. Of interest, Psychiatric Times this week has a section on personality disorder (normally, they're not interested in it). Perhaps they were going to say something new but no, even by their undemanding standards, this was boring. And irritating, because of the alphabet soup of abbreviations thrown around.

The first was on the narcissistic personality, called NPD (I hate these abbreviations but we'll have to use them), and started with the usual statistics to show it's important and under-recognised. True. The authors tell us there are three variants, a grandiose type, a fragile type and a high-functioning or exhibitionist type (yes, Donald, they're definitely talking about you). It's common, causes significant impairment and is "poorly understood," mainly (as they didn't admit but we all know) because they don't have a theory of personality. They then described a case of "fragile NPD" associated with depression (major depressive disorder, MDD), a 52yo man with a long psychiatric history who, at different stages, had been prescribed ...

... 5 selective serotonin reuptake inhibitors, 1 serotonin-norepinephrine reuptake inhibitor, 2 atypical antidepressants, 2 tricyclics, 2 monoamine oxidase inhibitors, 3 mood stabilizers, 5 neuroleptics (antipsychotic drugs), ketamine, and electroconvulsive therapy, all with minimal effect.

In any other setting, 22 unsuccessful treatments would suggest that the diagnosis was wrong but this is psychiatry, so they tried him on two more. He seemed to settle so was discharged and promptly fell in a heap again, for which they blamed the patient as he wasn't grateful for his treatment and tried seeing different psychiatrists.

In the description, it's crystal clear that the diagnosis was hopelessly wrong, that they had no concept of what was going on in their patient except he kept falling apart: "...he struggles with feelings of inferiority, self-doubt, and hypersensitivity." That, they decided, meant he was "fragile," which is completely circular: "We label him fragile because he falls apart, and he falls apart because he has an inner fragility."

Just on the limited history they give, this is a classic anxious personality: his "inner fragility" just was his anxiety, but the DSM system doesn't accept anxiety as a personality type. As a result, they didn't recognise the role of his anxiety in producing all his other woes, and they didn't recognise it because they don't believe anxiety is serious. So the patient bounces around from this psychiatrist to that hospital, tried on dozens of treatments that don't work and, one day, when he decides it's all too much and he ends it, they will say: "Yeah, that's those narcissists for you, unpredictable and ungrateful." It's important to remember that the psychiatrist is never wrong. Often in error, as this case shows, but never wrong.

Their next article, on their favourite nag, is "borderline personality." Most psychiatrists I've ever asked have no idea what it's borderline to, or why, but these authors got it right: it was originally a psychoanalytic term that migrated to mainstream psychiatry, but lost whatever meaning it had in the process. It used to mean "on the border between neurosis and psychosis," as though these were reliable categories, but nowadays, it has only two meanings. The first is an indicator of severity of personality disorder. In a study from many years ago [3], people were asked about all 112 symptoms from the personality disorders section of DSM-III. The more they answered Yes to each allegedly distinct symptom, the more likely they were to have been given the diagnosis of Borderline Personality Disorder (BPD). The authors warned:

Insufficient attention has been paid to the fact that every study of Borderline Personality Disorder (BPD) finds substantial and variable overlap with other psychiatric diagnoses... Patients who meet DSM-III-R criteria for BPD constitute a very heterogeneous group with unclear boundaries whose overlap with neighbouring personality disorder categories is extensive.

The second meaning is: "We don't like you. You're a nasty, ungrateful patient who makes us look stupid," which is the subject of the second article but we'll have to talk about it next week. The message so far is: psychiatry has no understanding of personality or of personality disorder but has very powerful incentives, professional and financial, to reinterpret personality factors as "mental illness."

We see this most clearly in the "epidemics" of "bipolar disorder" and of ADHD, but there are plenty of others. The reason is as McHugh said:

Psychiatry remains the discipline of medicine that has yet to grasp the nature of the disorders it treats. This explains why it lacks the power to resist social and political fads claiming to solve the problem of human mental distress.

* An old couple walking along the street. The husband says: "You know, if I'd exerted myself more when I was young, I could have been the Grand Old Man of something by now."

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This weekend, I was enormously pleased to send to the publisher the final files for the revision of all my early work. It started two years ago as a plan to revise and update each book but soon bogged down. They're all completely out of date, partly because of progress in other fields and partly my ideas have developed. Instead, I decided to dump those four books and replace them with a single, much shorter volume, called Theories in Psychiatry: Building a Post-Positivist Psychiatry. It should be available in July.

Part I of the new work, covers all theories used in psychiatry today, while Part II is a foray into philosophy of mind. There are six chapters in the first part and eleven in the second, seventeen altogether, but half of them are short so it isn't such a slog as it sounds. In one sentence, psychiatry doesn't have a theory of mind or a model of mental disorder, or, as mentioned above, a theory of personality or model of personality disorder. Modern psychiatry is an ideology of mental disorder, not a science, and, most emphatically, it is not a humanist project. That's that. Anybody who disagrees can send me the material I have requested (but not yet received) from the RANZCP re their treasured "biopsychosocial model":

... specific references where the concept is set out in the form of a scientific model ... (including) the name of the primary author and three or four seminal references where other authors have developed and tested the idea against reality.

The reason I haven't received it from the RANZCP is because it doesn't exist but they're having a little trouble working out how to admit this without looking either stupid or deceptive.

Over the next couple of months, I'll provide weekly summaries of the chapters, starting today with the Preface and Chapter 1. The Preface briefly introduces each section with a sentence of two on each chapter, and hints at why I believe psychiatry has failed to develop its own theories. Chapter 1, Setting the scene: Philosophical foundations of psychiatry, looks at the two major influences on psychiatry as it exists today, the philosophy of René Descartes (1596-1650) and of the modern movement called positivism, dating from 1929.

Descartes is widely disparaged today as having led philosophy of mind up the garden path with his "dual substances" theory. I think he was actually much smarter than his critics, who have fixated on one small aspect of his output in order to mock his work and, the cynic may say, to make themselves look terribly cool and with it. There is a reason why his work is so misunderstood, which I set it out in some detail. Time will tell who's right.

The second influence, positivism, is just on a hundred years old. Starting in different centres in Europe at about the same time, it is today largely known as the work of a group of mathematicians, physicists and logicians called the Vienna Circle, because that's where they were. Their vision of science and thence of philosophy was very restricted: essentially, if we can't see it, we can't talk about it. We can't see minds, so we can't talk about them. From this came the psychological movement called behaviorism, which has now fallen away, and the impetus in psychiatry to reduce everything to biology, which leads to Chapter 2, Biological Psychiatry: Reductio ad Absurdum.

In this chapter, I briefly show how positivism has driven psychiatry into a dead end. The urge to show that it's all biology has led to vast expenditure which has gone and is still going nowhere, and has turned the entire society away from looking for psychosocial causes for mental troubles. We're on a headlong rush down a black hole, one that absorbs money and time and effort and lives and gives nothing in return. However, that's a fairly controversial point of view, so we'll see what emerges. The biggest problem the critical psychiatry movement faces is getting air time. The biological gang can always get their (tired, repetitious) message broadcast but convincing reporters there is an alternative isn't easy.

Talking of that, I contacted the eminent Prof. Ian Hickie to ask if he could justify the two claims he made in his ABC interview recently, namely: (1) As the rate of prescription of antidepressants goes up, the suicide rate goes down. (2): Mental disorder causes adverse life events, not the other way around. Would he be so kind as to provide proof of these claims?

First claim: No answer (It's false, we all know that).

Second: He has a paper in the pipeline in Molecular Biology. That would be interesting, can I have a copy? No answer (Who do you think you're kidding? The children in Gaza expressing suicidal ideas were mentally ill before the bombing started, and their misery and despair has nothing to do with what's happening? Or with being starved? Spare us). It's no wonder psychiatry isn't held in high regard. We press on.

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References:

1. McLaren N (2007). Humanizing Madness: Psychiatry and the Cognitive Neurosciences.; Ann Arbor, Mi.: Future Psychiatry Press.

2. McLaren N (2012). Chaps. 14-16 in: The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press.

3. Nurnberg HG, et al. The comorbidity of borderline personality disorder and other DSM-III-R axis II personality disorders. American Journal of Psychiatry 1991; 148: 1371-1377.

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