Saturday, May 29, 2010


"Fortunately analysis is not the only way to resolve inner conflicts. Life itself still remains a very effective therapist."

Karen Horney

Alan Schatzberg, M.D., outgoing president of the APA, has presented a solution for what he sees as a major problem besetting the DSM-5 process, that is, excessive coziness with the common folk and their darned opinions:

"One thing we ought to consider is using more technical language. Our cardiology colleagues don't talk about heart attacks but use the term myocardial infarction. Hematologists are not attacked for including leukemia in their nomenclature, and they wouldn't think of giving it up for "way too many white cells disorder" (WTMWCD)! Why shouldn't we follow their lead? To my view, bulimia would be a better term than binge eating disorder. The latter was attacked by a prominent psychiatric critic as suggesting he could be diagnosed with the disorder after a heavy Thanksgiving dinner. Our language should indicate the severity of the possible impairment. Simiarly, temper dysregulation in children sounds too much like temper tantrums. They are not the same, but the use of the language is problematic. We need to be more serious about our terminology. In the end, we will get it right."

Yes, this is what ails contemporary psychiatry, the lack of abstruse terminology that will mystify and impress the hoi polloi (which wouldn't be a bad term for a mental disorder, come to think of it). Time to haul out the Latin and German dictionaries. American psychiatry's cardinal sin has been false modesty, and an unwillingness to stick its fingers into as many pies as possible. We need to be more aggressive in educating the purblind populace about the grave severity of their mental states, crying out for the local psychiatrist. We need to exaggerate the degree of our actual knowledge, for the good of our patients of course.

What is noteworthy about myocardial infarction, though, and countless other terms from other disciplines, is the useful work that the names do in indicating specific and potentially modifiable pathophysiology (in this case, the death of cardiac muscle cells). Unfortunately it's hard to think of a single psychiatric diagnostic term that has that level of specificity. Are neurologists wringing their hands over the term stroke, which seems to enjoy both wide general use and a meaningful clinical designation?

This sounds like the kind of throat-clearing that might lead a psychiatrist to wear a white coat, which is about as useful on a shrink as it is on an accountant. Not really, of course, as perhaps a white coat would helpfully accentuate the placebo effect, as would the casual use of dumbfounding (if insignificant) expressions like amygdalar aberration, or hippocampal ischemia, or limbic encephalopathy. (Unless the patient starts laughing). Yes, melancholia sounds way cooler than depression, but apart from those of us who enjoy cool words, what would the former accomplish beyond self-importance?


Anonymous said...

The difference between a disorder referred to by its technical name and the same disorder referred to by its cosy colloquial name is that the former is more amenable to pharmaceutical intervention.

Retriever said...

Well done! You are so right...:)

And I always loved Karen Horney.

Will link.

Write more, write more.

The Alienist said...

I have to admit that I have mixed feelings about this one. I am concerned about the dilution of meaning of psychiatric terms as they become more popular among the general public. The most obvious example is the word "depression." The vagueness of this term leads some to inflate the severity of their condition ("I'm not happy, so I must have depression.") while allowing others to minimize the suffering of others ("There's nothing wrong with're just a little depressed."). Unfortunately, some have worsened the problem by trying to make illnesses a badge of honor. Take the parent of an underachieving child. They may hear from some well meaning clinician that children with ADHD are bright, creative, and simply have a different way of learning. They think, "My child is bright. The way he smeared food on his sister was very creative. Obviously he has ADHD." The advantage of a specialized nomenclature would be that the terms we used would have a precise clinical meaning. Still, I think that it is far from certain that we can protect our terms from degradation through popular use. Our field of study is simply too interesting.

On the other hand, having terms that suggest a knowledge that we do not posses is of no help to our patients or to our profession.

Novalis said...

Thanks for your comment, and I see your point. I've long thought that the general medical issue most similar to the anxiety and depression that are the heart of psychiatry is chronic pain, which also exists on a continuum ranging from the trivial to the appalling.

It's just difficult to specify (and by implication, to wrest from casual common parlance) phenomena that exist on such a smooth spectrum from clear pathology to arguable normality. "Cancer" is no longer a recondite term, but no one speaks of it casually, because with rare exceptions (otherwise healthy older men with prostate neoplasms perhaps) it is clearly demarcated from the realm of health.