Feb 202019

MENTAL ILLNESS DEFINED: CONTINUUMS, REGULATION AND DEFENSE presents a perspective on mental health and illness divorced from financial influence, and one that aligns with scientific evidence. The Diagnostic And Statistical Manual (DSM), which is essentially the diagnostic bible of mental illness, began emphasizing discrete conditions with the third edition (DSM-III). The starting point was Panic Disorder known to those in the pharmaceutical industry as the “Upjohn Illness.” Prior to this newly created discrete entity, panic was viewed as part of anxiety, a more intense expression. In DSM-II it was seen as “anxiety neurosis,”—“This neurosis is characterized by anxious over-concern extending to panic and frequently associated with somatic symptoms.” In 1964 Donald Klein published an article suggesting that panic was a distinct illness, and that these attacks could be forestalled by staying on medication. The study was partially funded by Geigy and Smith & Kline & French suggesting the possibility of bias in his concept. Klein being on the DSM-III task force, apparently persuaded the other members of the anxiety and dissociative disorders subcommittee that his view was correct, and panic disorder became an entity. The following year in 1981 Upjohn marketed alprazolam (Xanax) for this disorder when the market for benzodiazepines was declining. Research funded by Upjohn did not show much support for panic disorder as a distinct entity, but it was a good marketing story. Xanax became one of the hottest drugs in psychiatry by the early 1990’s being prescribed by psychiatrists for this new and widespread disorder.

Industry funded experts establish criteria for discrete disorders as laid out in the Diagnostic And Statistical Manual (DSM), and these experts are often funded by the pharmaceutical industry. Lisa Cosgrove and colleagues (Financial ties between DSM-IV panel members and the pharmaceutical industry) published in Psychotherapy and Psychosomatics in 2006 uncovered some relevant findings. They found that 100% of the “mood disorders” and “schizophrenia and other psychotic disorders” panel members had one or more financial associations with companies in the pharmaceutical industry. As David Healy has stated, “As often happens in medicine, the availability of a treatment leads to an increase in recognition of the disorder that might benefit from that treatment.” Panic disorder is such as example.

Natural entities tend to be continuous and mental illness is no exception. Separate continuums do occur, such as depression, anxiety, hypomania-mania, and psychosis as laid out in the book, but subtypes represent fictions as with discrete categories. Quantitative variation often yields qualitative variation as an emergent property. For example, intense levels of anxiety (quantitative) triggers the fight/flight/freeze response central to panic (qualitative). Likewise, melancholic depression with vegetative features emerges with intense depression. Beyond bias for profit considerations, we are all prone to seeing discreteness to simplify information processing: it is easier on the brain to see distinct items than follow a concept such as quantitative variation yielding qualitative variation as an emergent property. However, if psychiatry and clinical psychology are ever to become true sciences, then fictitious entities to simplify information processing and satisfy marketing needs of pharmaceutical companies must be discarded!

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