The fifth edition of the so-called bible of psychiatry, usually referred to as DSM-5, which means the Diagnostic and Statistical Manual of Mental Disorders, was published by the American Psychiatric Association in 2013. It contains an expanded list of diagnoses of mental illnesses compared with the 4th edition. I do not intend to enter into the controversy of whether many of the latest inclusions are real illnesses, or ‘disorders’ – as they are invariably called in this book.
Incidentally, it would read better, in my view, as well as making the book a lot shorter, if the word ‘disorder’ were dropped. For example, instead of shyness – yes, this is actually regarded as a mental illness – being called social anxiety disorder, why not just call it social anxiety? Schizophrenia is now schizoaffective disorder and drug abuse is labelled substance use disorder, etc. Well, no doubt psychiatry has moved on a bit since I did my psychiatric residency in the 1970s, but how much is due to real progress in understanding the causes of mental illness and how much is just a difference in nomenclature? It is true that many more drugs are now available, and very helpful they can be – particularly in the more severe forms depression and in psychoses (such as schizophrenia). However, it should be kept in mind that these are empirical treatments: they may work but how they work is speculative. The oft-quoted fond idea that such drugs adjust a chemical imbalance in the brain that is the cause of the disorder is unproven. There is no way at present to measure levels of serotonin, dopamine or other neurotransmitters in the living human brain, and anyway the alleged chemical imbalance may well be the result of the mental disturbance rather than the cause.
These thoughts came to mind recently after I read an autobiographical account of severe depression suffered by the late American author William Styron: Darkness Visible: A Memoir of Madness (1989). He is probably best known for his controversial novel, Sophie’s Choice. The experiences he describes are harrowing, but he eventually recovered after being admitted to a mental hospital. It seems the secure environment and empathy of the staff were the major factors in his recovery. He was not given ECT (electro-convulsive therapy) and there is little mention of drugs. But why did he become depressed? Brain disease? Probably, but what was the cause of that? Mr Styron tells us: he abused alcohol for forty years and was addicted to a sleeping tablet called Halcion which was unwisely prescribed long term and in high dose. Under these circumstances it is hardly surprising he became depressed. In addition, there was likely a psychological cause in that he lost his mother to cancer when he was only thirteen.
I regard the use of drugs in mental problems, not as a cure, but as a means of helping patients cope with a difficult time in their lives, and I do prescribe them when necessary. However, I believe it is just as important – if not more so – to try to help patients work through the underlying problems and repressed conflicts which are often involved in the cause of their distress.