By Liah Greenfeld
Last month’s issue of The British Journal of General Practice contains an editorial “Depression as a culture-bound syndrome: implications for primary care” by Dr. Christopher Dowrick, Professor of Primary Medical Care at the Institute of Psychology, Health, and Society of the University of Liverpool. Dr. Dowrick claims that depression “fulfills the criteria for a culture-bound syndrome,” i.e. , one of the “’illnesses’, limited to specific societies or culture areas, composed of localized diagnostic categories,” like, for instance ataque de nervios in Latin America. In the case of depression the culture area affected is “westernized societies.” Putting the word “illness,” when applied to culture-bound syndromes into quotation marks indicates that Dr. Dowrick does not consider such syndromes real illnesses; it follows that depression–a culture-bound syndrome of westernized societies–is also not a real illness. Dr. Dowrick further argues that depression as a diagnostic category cannot be seen as “a universal, transcultural concept,” because it has no validity and utility, and it does not have validity and utility, because “there is no sound evidence for a discrete pathophysiological basis” for depression. I find myself in absolute agreement with Dr. Dowrick’s two specific statements above (that depression is a culture-bound syndrome of westernized societies, and that there is no discrete pathophysiological basis for this diagnostic category), and yet completely disagree with the implication that depression is not a real disease.
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By Liah Greenfeld
Let us take a little break from the discussion of the historical development of modern emotions and modern mental disease—that is, of the modern mind-—pursued in the previous posts of this blog, and instead focus on the present. May 22 is the official publication date of the much-talked-about DSM-5, a significant day for all who are in any way concerned with mental health, patients as well as professionals who are trying to help them, and therefore for many in the Psychology Today community. The manual has been subject to severe criticism for months preceding its publication; it appears that hardly anyone has a good word to say about it, the time and effort spent in its preparation seems to have been largely wasted. The poor baby is likely to be dead on arrival, stillborn, its own family having turned away, unwilling to embrace it. Just a week ago the mighty NIMH all but completely renounced it.
But why is it such a disappointment? And who or what is to blame for the problems with DSM-5? The answer to the first question, I would say, lies not in anything DSM-5 contributes to the previous versions of the manual (whether in terms of additions or subtractions), but in what it does not change in them at all. The answer lies in that it does not solve the fundamental problem of psychiatry and psychology, i.e., does not provide them with the understanding of the human mental process—tthe mind—healthy or ill. This is, obviously, not a problem which the DSM-5 creates, or which was created by any of the preceding versions of this document. It is the problem at the core of the psychiatric/psychological/mental health establishment in its entirety-—both its research and its clinical branches, and including in the first place its central, most powerful, and richest institution, NIMH.
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Jeremy Safran in “Psychiatry in the News“:
It is one thing to hypothesize that psychological and emotional problems are associated with changes at the biological level (e.g., specific patterns of brain activity or levels of neurotransmitters) or that symptom remission is associated with biological changes. It’s another to assume that the underlying causes of mental health problems are always biological in nature and that meaningful improvements in treatment will only take place when we can directly target the relevant brain circuitry. While it may be the case that biological factors play a more significant causal role in some mental health problems (e.g., schizophrenia) than others, the assumption that the major causal factor for mental health problems is always biological is a form of simplistic reductionism.
I want to be perfectly clear that I do not question the potential value of brain science research. What I do question is the single-minded emphasis on brain science research to the virtual exclusion of all other forms of mental health research. The new NIMH paradigm for research means that the amount of funding available for the development and refinement of treatments such as psychotherapy that are not targeted directly at the brain circuitry (although they do influence it indirectly), is likely to continue to shrink. It is important to recognize that funding priorities shape the programs of research pursued by scientists, and thus the type of research findings that are published in professional journals and disseminated to the public. This in turn shapes the curricula in psychiatry and clinical psychology training programs, which shapes the way in which mental health professionals understand and treat mental health problems. It also influences healthcare policy decisions and the type of coverage provided by third party insurers.
In concrete terms, the explicit NIMH policy shift is likely to mean that despite the large and growing body of evidence demonstrating that a variety of forms of psychotherapy (e.g., cognitive therapy, interpersonal psychotherapy, psychoanalytic therapy, emotion focused therapy) are effective treatments for a range of problems, we are likely to continue to see a decreasing availability of the already diminishing resources that can provide high quality psychotherapy for those who can potentially benefit from it.