Tag Archives: somatic symptom disorder

The Chemical Imbalance Theory:  Still Being Promoted

On November 28, Psychiatric Times published an article titled Psychiatric Diagnosis and Treatment of Somatizing Neuropsychiatric Disorders.  The authors are Daniel T. Williams, MD, and Alla Landa PhD, both from Columbia University Psychiatry Department.

The article’s lead-in states:

“Although the somatizing disorders cover a vast array of symptomatic domains across many medical specialties, this article addresses the broad topic conceptually.”

The so-called somatizing disorders have an interesting history in psychiatry.  DSM-III-R (1987) states:

“The essential features of this group of disorders are physical symptoms suggesting physical disorder (hence, Somatoform) for which there are no demonstrable organic findings or known physiologic mechanisms, and for which there is positive evidence, or a strong presumption, that the symptoms are linked to psychological factors or conflicts.” (p 255)

DSM-IV (1994) states:

“The common feature of the Somatoform Disorders is the presence of physical symptoms that suggest a general medical condition (hence, the term somatoform) and are not fully explained by a general medical condition, by the direct effects of a substance, or by another mental disorder (e.g., Panic Disorder).” (p 445)

DSM-5 (2013) states:

“All of the disorders in this chapter [Somatic Symptom and Related Disorders] share a common feature:  the prominence of somatic symptoms associated with significant distress and impairment.” (p 309)

Note that the requirement that the symptoms are not fully explained by a general medical condition has been dropped from DSM-5.  In this latest edition of the manual, the only requirements are that the symptoms are distressing, disruptive, and excessive, the assessment of which is inevitably subjective.

Note also that Drs. Williams and Landa refer to these “diagnoses” as neuropsychiatric disorders, essentially begging the question that they involve neurological pathology.  There is no evidence to support this position.  Nor is there any rational support for the notion that worries and concerns about medical matters should be conceptualized as illnesses, even if the individual’s level of distress and preoccupation is extreme.  But a detailed critique of this matter is beyond the scope of this post.

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The Williams and Landa article is detailed and comprehensive.  It addresses the phenomenology, epidemiology, and developmental course of the so-called somatization disorders.  Under the heading “Postulated pathogenic influences,” the authors present working hypotheses from psychoanalytic theory, learning theory, behavior analysis, social-affective neuroscience, autoimmune sensitization, and theories of dissociation.

On the topic of social-affective neuroscience, the authors state:

“Recent advances in social-affective neuroscience suggest that early interpersonal environment may interact with genetic predisposition and epigenetic changes to affect the neural circuits involved in interpersonal emotions and physical pain. This type of predisposition makes a person particularly sensitive to emotional stressors and presents difficulties in regulating emotional and somatic distress 12.  This could explain the variable vulnerability to somatization under similar stressors among different individuals. It also points to the need to carefully evaluate these relevant vulnerabilities in psychotherapeutic exploration of each patient’s unique biographical narrative.”

The essential point being expressed here is that people develop “excessive” concern about their health or “excessive” sensitivity to pain, because of neural circuitry anomalies.  These anomalies, in turn, stem from the interaction of a hypothesized genetic predisposition and the individual’s early interpersonal environment.

Aberrant neural circuits are fast replacing the discredited chemical imbalances that constituted the cornerstone of biopsychiatry until effectively debunked by psychiatry’s critics.  At present, the aberrant circuits are being postulated with a measure of caution; note the terms “suggest” and “could explain” in the above quote. But in general, the circuitry hypothesis is being actively promoted, and is gathering a good deal of traction.

Incidentally, reference # 12, cited in the above quote, is to an article by Dr. Landa and two other Columbia researchers.  Here’s the final statement from the abstract:

“Specifically, the proposed theory and research review suggest that psychotherapeutic and/or pharmacological interventions that foster the development of affect regulation capacities in an interpersonal context will also serve to more effectively modulate aberrantly activated neural pain circuits and thus be of particular benefit for the treatment of somatoform pain.”

Note:  “…psychotherapeutic and/or pharmacological interventions…”, and particularly the suggestion, which is also becoming common in psychiatric circles, that psychotherapy and drug treatment have essentially the same effect:  the modulation of “aberrantly activated” neural circuits.

Certainly psychotherapy affects people’s brains.  All human activity affects the brain. But the notion that talking to a person empathically and sincerely (whether in a professional capacity or simply as a friend) is on a par with the ingestion of psychiatric drugs makes a mockery of human interaction.

The authors discuss the treatment implications of these various “postulated pathogenic influences,” including the need to restructure learned patterns and the establishing of therapeutic rapport.  Under the heading “Approach to treatment,” the authors stress the importance of psychosocial factors:

“…do the symptoms serve to avoid a constellation of stressors with ensuing functional impairment, by allowing the patient to retreat into ‘the sick role’? Moreover, might the symptoms be the body’s reaction to overwhelming stress?”

“Many patients may not be able to articulate the complex environmental stressors that produce feelings of shame or inadequacy. They may cling to the identity of the medically ill patient as a ‘safer’ refuge from life’s adversities. Therefore, the psychiatrist should present the diagnostic hypothesis of SSD tentatively and supportively, noting that it is not mutually exclusive of coexisting physical illness.”

Under the heading “Treatment options,” Drs. Williams and Landa list and discuss:

  • Reassurance, placebo, suggestion and psychoeducation
  • Individual or family psychotherapy
  • Psychodynamic strategies
  • Behavior modification
  • Cognitive-behavioral therapy
  • Group psychotherapy
  • Mindfulness, meditation, progressive relaxation, deep breathing

All of this, apart from the unwarranted implications of neurological illness, sounds fairly encouraging.  But then there’s this:

“Psychopharmacological agents may have specific therapeutic benefit for comorbid psychiatric disorders, including anxiety, depression, obsessive-compulsive disorder, and psychosis, all of which may coexist with and complicate SSDs. In addition, these agents may have nonspecific (placebo) benefits. For patients who have difficulty in grasping the concept of somatization, who have discomfort with psychotherapy, or who want a ‘medicine’ to legitimize the validity of their physical illness and recovery, a supportive discussion of the role of these medications in normalizing brain neurotransmitter function can be helpful. The medicine can be the needed aid that helps the psychotherapy go down.” [Emphasis added]

The fact is that there are no psychiatric drugs that normalize brain neurotransmitter function.  Indeed, the opposite is the case.  Every psychiatric drug on the market today produces abnormal brain function.  So either Drs. Williams and Landa aren’t aware of this, or they are advocating that therapists should deceive their clients on this very fundamental issue.

Unfortunately, but perhaps inevitably, this kind of patronizing disrespect is still widespread in psychiatry, and is fundamentally incompatible with the lofty rapport-building and therapeutic sentiments expressed earlier in the article.  Therapeutic rapport and systematic deception are mutually exclusive.

The very eminent psychiatrist Ronald Pies, MD, has written that the chemical imbalance theory is a kind of “urban legend” – never promoted by well-informed psychiatrists.  Well, Dr. Williams, according to his bio, has been on the faculty at Columbia University for forty years!  He has authored more then 60 publications in peer-reviewed journals and standard textbooks in the fields of psychiatry and neurology.  I think it is reasonable to suppose that he would meet Dr. Pies’ standards for being well-informed, and yet here he is advocating the promotion of the spurious chemical imbalance theory!

Justina Pelletier Is Back Home

I guess everybody knows by now that Justina Pelletier is back with her parents after 16 months in the custody of Massachusetts Department of Children and Families.

According to a Boston Globe report dated June 9, top DCF officials recently submitted papers to the court asking that Justina be returned to the custody of her parents, and a June 19 Boston Globe article confirmed that Judge Joseph Johnstone had, on June 18, issued an order to that effect.

The activities of Boston Children’s Hospital and Massachusetts DCF in this matter have been the subject of much discussion and controversy.  Justina was initially admitted to BCH with a long-established diagnosis of mitochondrial disease, but from the outset this was challenged by BCH physicians and psychiatrists, and a psychiatric “diagnosis” of somatic symptom disorder was assigned instead.  Lou and Linda were accused of medical child abuse, which essentially alleges that they were, in subtle or other ways, contributing to Justina’s self-image as a sick person.

The entire matter has been debated widely in various forums, and the issues need not be restated here.  There are a few points, however, that might usefully be kept in focus at this juncture.

Firstly, it seems unlikely that the Pelletiers would have achieved the present result if Lou had not made the difficult decision to break the court’s gag order in February of this year.  The resulting publicity became acutely embarrassing for BCH and DCF, and it is reasonable to surmise that a major part of their motivation in recent months has been to find a way to extricate themselves from this situation without having to acknowledge fault.  In this context, it is noteworthy that, as a result of the controversy, DCF Commissioner Olga Roche offered her resignation on April 29, 2014, and this was accepted by Massachusetts Health and Human Services Secretary John Polanowicz.

Secondly, the report that Lou and Linda had made “significant progress” sounds like a face-saving fabrication, in that, firstly, in all of the reports on this matter, there has been nothing to suggest that Lou and Linda were at fault.  And secondly, both parents, as reported in the Boston Globe on June 19, remain committed to their earlier position.  Here’s a quote from the Globe article:

“The Pelletiers said they intend to press their argument that hospitals are too eager to accuse families of medical child abuse without sufficient reason, seizing children from their mothers and fathers.

Linda and Lou Pelletier remain adamant Justina’s ailments have always been physical, not psychiatric. They said she regressed when doctors at Boston Children’s Hospital stopped treating her for mitochondrial disease.

Lou Pelletier said he ‘will not stop until there is a Justina’s Law.’

‘Ultimately, anybody who was involved in Justina’s deconditioning, torture, abuse, needs to be held accountable,’ he said.”

This does not sound like a person who has made “significant progress” in the psychiatric sense of the term.  So the question naturally arises:  in what particular area or matter have Linda and Lou Pelletier made such progress as to warrant a complete reversal of the permanent custody order which was reinstated only three months ago.  Or is this official finding just a face-saving ploy on the part of BCH, DCF, and the court to avoid having to admit error?

Thirdly, there is a pressing need not to let this matter fade away.  Somatic symptom disorder is simply another way of saying that in the opinion of a psychiatrist, based usually on a brief interview, the individual or the individual’s parents are excessively and disproportionately concerned about a particular illness, or about health matters generally.  This, at the very least, seems like very tenuous and unreliable grounds for removing a child from her parents’ custody.

Fourthly, in the early months of this matter, it was suggested in the media that there were overly close links between the child protection team at BCH and the case workers at DCF.  DCF (and similar departments in other states) have a statutory responsibility to investigate complaints of abuse and/or neglect, and to petition the courts as appropriate in the light of their findings.  It is helpful for DCF caseworkers to have good relationships with medical personnel, but there needs to be constant vigilance against these relationships becoming so close that the DCF investigation degenerates into a rubber stamp. This is especially important with psychiatry, where all “diagnoses” and clinical judgments are inherently subjective.

Fifthly, there were also some allegations in the earlier months that BCH may have had some financial agenda, and tended to target “families with good insurance,” in this and similar cases.  This should be investigated by a competent and credible outside authority as a matter of urgency.  A particular question that needs to be asked is:  What proportion of BCH’s psychiatric revenue comes from these kinds of involuntary commitments?

Sixthly, as pointed out recently by the author of the blog Suffering the Slings and Arrows of Outrageous Fortune BCH’s own Clinical Investigation Policy Manual states:

“Children who are Wards of the state may be included in research that presents minimal risk 46.404 (50.51) or greater than minimal risk with a prospect of direct benefit 46.405 ( 50.52) of subpart D”

The question needs to be addressed:  Are BCH patients who are wards of the state being enrolled in clinical trials/experiments more frequently than children who are not in state custody?  In this regard, it is important to bear in mind that pharmaceutical companies often reimburse facilities large sums of money for each subject enrolled in a study.

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So, the good news is that Justina is home and is overjoyed to be back with her parents and her sisters.  But we need to remember that there have been many other families caught in this web in the past, and there will be more in the future.

Psychiatry does not routinely engage in critical self-scrutiny.  Dogma substitutes for established fact, and there is a pressing need for defense attorneys, guardians ad litem, and indeed judges, to challenge psychiatric assertions, and to maintain a skeptical stance with regards to psychiatric testimony and reports, and to the ontological and explanatory status of the so-called psychiatric diagnoses.  Psychiatric diagnoses are simply not the same kind of thing as general medical diagnoses, and there is a pressing need to embed reflections of this distinction into the legal framework of the child protection system.

Social Services and Psychiatry

The controversy surrounding Justina Pelletier and her family has expanded its scope in recent months, and has now become a general public scrutiny of Massachusetts’s Department of Children and Families.

On April 29, State Governor Deval Patrick gave a press conference in which he announced the resignation of DCF Commissioner Olga Roche.

I think there’s a very real risk of confusing some issues here.  The sad fact is that, despite the enormous strides we have made as a society, there are still a great many children who are abused and neglected.  Every state in the US has a social services department, one of whose statutory responsibilities is to investigate reports of abuse and/or neglect.  The case workers who conduct the investigations are required to follow set procedures.  Often they find that the allegation is unfounded, and the investigation is terminated.  When they do find probable cause, they are required by law to present their findings to a judge, who scrutinizes the evidence in accordance with the normal judicial procedures.  The social services department, the parents, and the child are usually represented by attorneys.

A wide range of options is available to the court, from outright termination of parental rights to outright dismissal of the case. Both of these extremes are rare.  The usual outcome is some kind of remediation program, whereby the parents are encouraged and coached in childcare matters.  Sometimes the children are placed in foster homes pending resolution of issues in the home.   If the home issues aren’t resolved, the foster care placement can be lengthy.

The system isn’t perfect.  Mistakes get made, and sometimes the mistakes are serious. I have no way of knowing if the Massachusetts Department of Children and Families was more error-prone than social service departments in other states. Obviously the commissioner Olga Roche has to take responsibility.  But whether she was personally derelict in her duties or was just the designated fall-gal, I don’t know.

But this I do know: the spotlight has been taken off psychiatry.

The central issue in Justina’s case was, and is, the “diagnosis” of somatic symptom disorder and the allegation of medical child abuse.  And there’s a danger of losing sight of that when a departmental commissioner gets tossed to the wolves and the state governor says

“DCF has one of the toughest assignments imaginable. Every single day they’re called upon to intervene and make difficult decisions…And most of the time, DCF gets it right.”  (Quoted from a Metro article by Morgan Rousseau).

Most of the time, DCF does get it right.  Most of the time they’re dealing with allegations of blatant abuse and neglect; children being raised in unsanitary and unsafe conditions; children being sexually abused and even prostituted; etc… Social services case workers investigate these complaints on behalf of society.  They are bound by strict procedures, and when they go to court they are subject to cross-examination, and their findings are subject to official and legal scrutiny.

The issues are never simple, but the critical questions are usually clear and understandable.  If a child has a broken bone, X-ray reports are introduced into evidence, and the radiologist is subject to cross-examination.  If there are allegations of an unsafe home environment, photographs are produced.  If there are live electric wires protruding from wall sockets, everybody in the courtroom can see the pictures, and everybody knows the potential danger if there are toddlers in the home.  And so on.

But all of this changes in a case of “somatic symptom disorder” and alleged medical child abuse.  In these cases the issues, the “realities,” consist entirely of psychiatric opinion.  When a psychiatrist states on the witness stand that the child “has somatic symptom disorder,” the impression is conveyed that this is a real illness with the same kind of verifiable reality as asthma or diabetes or kidney failure.  So there’s a very strong tendency for the lawyers, and even the judge, to afford the same kind of respect to a psychiatrist’s statement as they would to a report from a radiologist or other genuine medical specialist.

What’s not routinely recognized is that the psychiatric “diagnosis” is nothing more than the psychiatrist’s opinion.  In the case of Justina, the “diagnosis” was somatic symptom disorder, which simply means that Justina in the opinion of a psychiatrist, was inordinately preoccupied with her medical condition.

I have worked with a great many sick people over the years, and have struggled with chronic medical problems myself, and frankly, I can’t even imagine how one could assess whether a person’s concerns in these areas were excessive or inordinate.  And this is especially the case in that, since DMS-5, the “diagnosis” of somatic symptom disorder can be assigned even in cases where the person actually has a real illness!

And the allegation of medical child abuse simply means that, again in the opinion of a psychiatrist, Justina’s parents had been foisting on her the notion that she was sick, and had pressured various surgeons and other specialists  to subject their child to extreme and invasive medical procedures.

Here we have no photographs of exposed electric wires; no reports of young children being left home alone; no evidence of malnutrition or emaciation; no medical evidence of young children having been sexually abused; no X-ray reports of broken bones; etc… Only the opinions and the invented “diagnoses” of psychiatrists!

When Governor Patrick stated that DCF usually get things right, he made no distinction between the kinds of abuse/neglect that social services departments traditionally investigate and the inherently vague psychiatric “abuse” of which Justina’s parents stand accused.

It was perhaps inevitable that media coverage of Justina’s case would expand into a general criticism of DCF and the commissioner.  Criticism of that sort is healthy, and is one of the cornerstones of democracy.  But what’s noteworthy at present is that we’re seeing very little coverage of psychiatry or of the role that the psychiatric “diagnosis” played in this matter.  This is critical, because without the “diagnosis” of somatic symptom disorder and the subsequent allegation of medical child abuse, none of what’s happened to Justina and her parents could even have gotten off the ground.

Psychiatry captured Justina with one of their spurious labels, confident, presumably, that the parents would cave and play along.  But the parents rebelled, and the psychiatric sham was exposed for what it is.  Psychiatry, as usual, had no rational defense, so instead they side-stepped the issues, and the spotlight has moved elsewhere.

And let’s not forget that psychiatry’s leaders are being schooled by Porter Novelli, a major PR firm, in how to interact with the media.

Justina Pelletier: The Debate Continues

On April 1, 2014, Slate published an online article titled Mitochondrial Disease or Medical Child Abuse?  The author is Brian Palmer.  Slate is a daily, general interest web magazine, founded in 1996, that provides “analysis and commentary about politics, news, business, technology and culture,” and is a subsidiary of the Washington Post.  Brian Palmer is Slate’s “chief explainer.”

As the title suggests, the article tries to explore the central question in Justina’s case:  does she have mitochondrial disease or is she a victim of medical child abuse?  The author does a good job of defining the various terms, unraveling the issues, and presenting both sides of the argument, though on balance he comes down in favor of Boston Children’s Hospital.  Here are some quotes:

“It’s easy to get angry about this scenario—and there are some troubling things about the way the conflict has been managed—but the doctors at Boston Children’s deserve a defense.”

“…the science is complicated. Mitochondrial disease (Justina Pelletier’s original diagnosis) and medical child abuse (the Boston Children’s diagnosis) can look extremely similar. Both can be deadly if not treated properly.”

“‘Mito,’ however, is incredibly difficult to diagnose definitively.”

“Just as Justina Pelletier exhibited some symptoms consistent with mitochondrial disease, her case also has some of the hallmarks of medical child abuse. One of her chief complaints was digestive trouble, the most common symptom among medically abused children. She had gone through extreme surgical procedures, including the placement of a permanent port in her belly to flush her digestive tract. Her parents had engaged in physician shopping, and experts at Boston Children’s felt that Justina’s emotional state improved when her mother left the room.”

“The doctors at Boston Children’s had few options if they really believed in their diagnosis. Just as the treatment for strep throat is antibiotics, the treatment for medical child abuse is separating a child from her parents. Sending Justina Pelletier home would have represented the height of irresponsibility if their diagnosis was correct. One in 10 children who suffers medical abuse eventually dies at the hands of his or her parent.”

Obviously all of these issues have been debated at great length, not only in the courtrooms, but also in the mainstream media and in the blogosphere.  It is likely that these debates will continue, and will be wide-ranging.

But in this post I would like to focus on just one issue.  If the “extreme surgical procedures” that Justina had undergone were an integral part of the alleged “medical child abuse,” why is the surgeon who performed these procedures not being censured or charged?  Are we to believe that this surgeon performed these extreme procedures without valid cause or justification?  Is it plausible that he/she performed these procedures more in response to parental pressure than genuine medical need?

If, as is claimed, Justina was the victim of “medical child abuse,” isn’t it reasonable to consider the surgeon one of the primary perpetrators?  And if not, why not?  In other forms of child abuse, aiders and abettors are routinely taken to task.  Why is medical child abuse different?

It has been widely reported that an abnormal “congenital band” of cartilage, 20 inches long, was removed from Justina’s abdomen in 2010.  This indeed would constitute an “extreme surgical procedure,” but the critical question is:  was it justified?  Is there a pathologist’s report that casts doubt on the need for the surgery?  If not, then what is the relevance of the assertion that she had gone through “extreme surgical procedures.”  It is possible that a surgeon might excise tissue needlessly either to boost his income or even from over-enthusiasm.  But there exists, in the form of the pathology lab, a time-tested safeguard against this sort of excess.

The validity of the concept of medical child abuse in this case hinges, at least to some extent, on a history of surgical procedures which, apparently, in the opinion of psychiatrists were unnecessary and potentially injurious.  But, on the other side of the scale, we have a surgeon excising real tissue and subjecting this tissue, and incidentally his/her own medical judgment, to critical objective scrutiny.  A surgeon who routinely excises benign tissue, or who performs other unnecessary surgeries, will quickly incur some challenges from the hospital’s Q.A. committee, the medical licensing authorities, and ultimately from malpractice trial lawyers.

By contrast, the psychiatrist’s opinion as to the necessity or appropriateness of the surgery is subjected to no objective check whatsoever.  And perhaps therein lies the answer to my earlier question.  If those psychiatrists who allege medical child abuse had to challenge the surgeons who aided and abetted the alleged abuse, it is likely that in  most cases, the surgeon’s judgment would prevail, and another nail would be put in psychiatry’s coffin.  It’s easier by far to lay the blame on the “persistent and deceptive” parents and to absolve the surgeons and other medical specialties by the blanket contention that they were duped.

DSM-5 And Somatic Symptom Disorder

Under DSM-IV, a “diagnosis” of somatization disorder entailed a history of physical symptoms for which, despite thorough medical evaluation, no satisfactory physical etiology could be established.  In DSM-5, this “diagnosis” was replaced by somatic symptom disorder.  This is essentially similar to DSM-IV’s somatization disorder – with one critical difference.  The newer “diagnosis” can be assigned even if there is an identifiable physical illness.  The essential requirement for the new “diagnosis” – indeed the only requirement – is that the individual is excessively or disproportionately preoccupied with the symptoms.  And who, one might ask, decides if a person’s preoccupation is excessive?  A psychiatrist, of course, whose vast training in drugs and ECT equips him with the wisdom, empathy, and insight to make such judgments.  As the eminent Dr. Biederman proclaimed in a public courtroom on February 26, 2009, a  psychiatry professor is second only to God in status and ability!

During my career, I worked with a great many people who were preoccupied with medical concerns.  Some of these individuals had serious illnesses, and my task essentially was to help them adapt to their medical status and still find ways to have a fulfilling and meaningful life.  In other cases, the matter was less clear cut.  Some didn’t seem to be all that sick, but I stress the word “seem,” because I didn’t know.  My fundamental perspective was that everything a client says should be taken seriously.  I found that in all cases, if I listened carefully, respectfully, and humbly, I could come to an understanding of the client’s perspective. 

I remember working with a young woman in her mid-20’s.  I’ll call her Julie.  She was truly terrified that she had cancer.  She had incurred the irritation of several physicians who accused her of wasting their time, and had been referred to a psychiatrist who gave her a “diagnosis” of hypochondriasis and prescribed an antidepressant.  The young woman chose not to fill this prescription, and instead came to see me.

We talked – or rather, she talked and I listened.  It emerged that during a one-year period, when she was five years old, three family members (an uncle, aunt, and grandmother) had died of cancer!  Obviously the feelings of devastation were crippling – not only for her, but for all the surviving members of the family.  So at the very time when she needed an enormous amount of support, her primary caregivers were themselves reeling in shock and grief.

What made things particularly difficult for Julie was the fact that the impending deaths were never discussed with her.  For her, as a five-year-old child, these individuals were just snatched away into oblivion – by this thing called cancer.  For Julie, there really was a bogey man under the bed.  And when she came to me for help, the bogey man was still there.  For me, whether Julie’s fear of cancer was “proportionate” or otherwise was never an issue.  I started from the simple premise that her fear was valid, from her perspective, and that my task was to help her manage this fear in a way that still allowed her to enjoy life and do the things she wanted to do.

After much discussion, she came to the conclusion that the way forward was: to recognize that because of her family history, she probably did indeed have an increased risk of contracting cancer; to take appropriate counter-measures (including diet and regular medical checks); but to not allow the concern to destroy her life.  Once she had formulated her objectives in these terms, she was remarkably successful in keeping her concerns about cancer in a reasonable balance.  I asked her if she had told the psychiatrist about the three family deaths.  She replied:  “No, he never asked about anything like that.”

The truly appalling thing about this is that the psychiatrist, within the context of his profession’s conceptual framework, was not being negligent.  All he needed for his “diagnosis” at that time was the DSM-III-R list of symptoms:

  • preoccupation with the fear of having a serious illness
  • no actual evidence for the illness
  • the fear is not allayed by medical reassurance
  • the fear has lasted for six months
  • the belief/fear is not of delusional intensity 

For psychiatry, that’s all that was needed to “make the diagnosis” and to legitimize the prescription.

The essential point here is that we humans are strange creatures.  During our childhood years we develop all sorts of ideas and feelings.  Some of them are helpful, others less so.  Some are disastrous.  But they are all understandable, if someone will take the time to listen.  Note that it was no part of my role to “fix” Julie, or even to say that she needed to be “fixed.”   Perhaps the most significant thing I said to her during the time we worked together was:  “If I had walked in your shoes, I would also be terrified of cancer.” My job was to provide an unhurried setting of trust and mutual respect in which Julie herself could explore the sources of her fear, catalog the extent to which it was derailing her goals and her relationships, and formulate remedial action.  At all times, Julie was in the driver’s seat.

But that is not the psychiatric way.  People whom psychiatrists consider excessively preoccupied with these matters are “diagnosed” with somatic symptom disorder, usually on the basis of a short interview and perhaps a five-minute phone consultation with a general practitioner.  And the patient is given neurotoxic pills – to correct the “chemical imbalance” or the “neural circuitry anomaly” or whatever trite and deceptive rationalization is current at the time.  And if, with the passage of years, the hapless client is irreparably damaged by the drugs, then there’s always a locked psych ward and ECT.