On the Diagnostic Manual in Psychiatry (Part 2/3)

Each of us  in  psychiatry has a right  to our own opinion, but no one of us has a right to our own science.  Facts are public and are in the domain of science. They cannot be argued against; we need to test them in a specific way.  That is why there can no longer be many different psychiatric approaches  with all those disparate  schools of psychiatry.   They all have concocted beliefs and theories that are not based in strict science and so of course they differ. No different from differences in politics.  It is just a matter of who has the best argument.  Is childhood sex a fact as the  Freudians believe or used to believe?   Or can you think your way to health?   This is the true underlying principle of all insight and cognitive therapists.  You cannot do that therapy if you don’t believe in that idea whether  explicit or not.  If you believe in insight as curative you are a  cognitivist, no matter how you deny it. It is again thinking your way to health.

 There can be no paradigm shift in psychiatry until we are bereft of the cognitive bias implied in all of this. And it is underlined by psychiatrist Michael First, who was an editor of this Manual some time ago. What he states, grosso modo, is that none of this can be helpful.  What it will help,  and this is acknowledged  by many of my colleagues, is billing insurance companies.  Why is there  such a debate among my confreres about all this?  Because each has a different idea of what constitutes  an affliction.  If you are a psychoanalyst you have one idea, and if you are a Jungian quite another. And  since it all is  part of intellectual fabrication everyone or no one is  right.  None of this is based solidly on neurobiology.  It is as if the brain and the body are two distinct entities that have nothing to do with each other.  These psychiatric disagreements occur because of the theories they adhere to; and those theories reflect the doctor’s  personality, and little else.  A feeling woman is never going to be a cognitivist; she knows feelings and the unconscious, and cannot adhere to the idea that we can make profound change because of a change in our ideas.  

     I have treated hundreds of anxiety states (as explained in my Life Before Birth book), but the origin is nearly always remote and deep in the brain.  How can anyone diagnose it so it can be treated in a few sessions?   It has its beginning often in the first months of life, not life on earth but in the womb.  So those specialists take what the anxiety behavior looks like, try to change it, and when the apparent symptoms go away they imagine there has been success. The problem is that the generating source is still there raging below; that promises early disease and a premature death.  That is what we get for ignoring history, especially the critical nine months of gestation.  We will ultimately be struck down by a reality that is denied or ignored.  We are creatures of need and history; there is no escape from ourselves.

 There seems to be no motivating source in what they do.  Yet the unconscious is merciless and relentless.   The imprints lying there do not go away, not with pleas, exhortation, shock therapy or mechanical  manipulation.  It will only go away when it is addressed, relived and integrated.  Only then.  It needs to be experienced because it never was,  and has remained an alien force inside our bodies.   A small part of the original experience may have been felt but the charge value, the valence or force had to be instantly repressed and put on hold.  It is still there waiting for full connection.  We must eventually address and integrate it into the system.   It is that motivating source that is the origin of so much neurosis and psychosis.   The emperor is naked!

     On any given day there are about five million individuals getting mental health help.   And what they get now is mechanics and count-downs;  cut down mania to 3 days and they believe we have really helped the patient.  I don’t see much science in all this except they say that when the patient is fearful  he  has greater neuronal activity in the amygdala.  OK. Agreed. Now what?  Of  course  the feeling centers will be activated when feelings are.  These are accompaniments, not separate diagnoses.  And the cortisol levels will go up  too, as  they should when we are on  alert. But what to do about it?    We will never find a cure in the minute examination of the neurons; we may find a way to help; i.e., drugs and shock therapy.  But in all this there is no talk  of curing anything.   Where does the illness come from?   Why is it there?  How did it start and why? These are the critical questions that should be asked.    Ask a superficial question and you get a superficial answer. That is   the dilemma those doctors are in; they don’t know how to ask the critical questions.   And why don’t they? Because  their theory and therapy doesn’t allow it. And why not?  Because  their personality and repression won’t allow them to adopt a feeling approach.   Because to speak of cure you need to speak of generating sources.  So they are Behaviorists out of conviction and that conviction emanates out of  repression . How do you beat that?  Moreover, Behaviorism gets paid, and feeling therapies do not.  You see, as I have said before, that if I knock you in the head every time you start to smoke, sooner or later you will stop. Now if my criteria for progress is stopping smoking and I have the research to prove it, then of course I will get backing because no one seems to criticize the criteria I use for progress.   In the same way if I tell a therapist that every time he treats a patient I will give him money (but only if it is cognitive or behavioral), then he will treat in the manner I want.   Or to put it differently, if every time the patient stops smoking I  will  give him one hundred dollars, chances are he  will stop. So isn't that what the insurance companies are doing?

   We adopt the theory and therapy that suits our personality; that easily merges one with the other (therapeutic mode is therefore an outgrowth of one’s personality).  If we have never had a feeling and are not  close  to our pain, we will never adopt a therapy that will penetrate defenses and aim at feelings.  Theory, in so many cases, is part of the defense system—beliefs are one aspect of our defenses.   They emerge from the prefrontal cortex and help suppress rising feelings from the right limbic area.  Or to put it better,  beliefs are generated as a result from a surge of powerful feelings from the limbic area which galvanizes the cortex to rush into action to form beliefs which ultimately will hold back those feelings.  They dilute, vitiate and absorb the force or energy of the feeling through a myriad of ideas.  It makes the shrinks comfortable.  The rational we propose “works” and we feel better for a brief time; which is why we need to go back many, many times.

    Who would  adopt something that makes them uncomfortable.  We adopt beliefs, now called  theory, that helps keeps  feelings away.  Yes, we can call it theory but it is still a belief.  That is why real science plays so little a part in all this.  Those manuals of diagnoses never change how we do therapy.  We can still be Cognitive or Analytic therapists even with or despite this manual.   The frame of reference, the theory they adopt seems to have nothing to do with diagnosis.  So how come it never questions how we do therapy?  Why is it a given?  Because we need to go on doing what we are doing without having to change anything, particularly how we do therapy.  Our whole training militates against any change.    So on one side we have diagnoses, and the other side we have treatment.   I know from my training at the Freudian clinic of the West, that they never have anything to do with each other.

On the Diagnostic Manual in Psychiatry (Part 1/3)

Hello my children, and nearly every one of you is young enough to be my child; otherwise if you are too old you are not interested in what I have to say.  And I think of you all as my kids who want to learn; I take it as a sacred trust to fulfill that need.  I am also sure that many of you have an expertise where I could learn. We are all smart in different ways.  Anyway, I print the above from Time Magazine (March 2012) about the new DSM manual, now as thick as the Manhattan Telephone  Book,  to explain why this is nonsense and the  field of  psychiatry/psychology is bankrupt.  It has left science behind; well, not exactly.  It has addressed science through the new machines such as the MRI, but it is cloistered away from the actual practice of therapy.  And never the  twain shall meet.  MRI results never tell us how to do psychotherapy; they tell us what drugs to give or not give.  They tell us more about our neurons in the brain but not what causes them to act the way they do.  We take their actions as a given and go from there, very much like Freud’s Id.  We need to know why cortical neurons are sometimes hyperactive, not just how do we slow them down.  There is a whole system encapsulating behavior, not just something that stands alone without any background information, nor any interrelationship to other parts of us.  We are just “behaving” and the cognitivists/behaviorists say our task is only to change it.  Such a mechanical view of complex human beings.

Look at the above Time description and then multiply it by hundreds of pages to understand the garden variety of neuroses.  It is literally mind boggling.  What it does, as you see, is list behaviors; and the field  is captivated by the behaviorists who never see underlying motivations, who  count this or that behavior as a disease.  Eat too much?  Bulimia.  Eat not enough? Anorexia.  How to define this?  By behavior.  The behaviorists hold sway in the field today.  What you see is what you get; you look for the problem, you see behavior.  You look for the answer and you see behavior.  You look for progress, you look at behavior, and never, never look deeper.  So in their scheme of treatment a certain number of weeks of feeling down puts you in the pathological category called depression.   And, the insurance will pay for this therapy category, for a very brief time only.    I imagine if you were required to to be depressed for 25 weeks before we could diagnose you as depressed you would get grief from the insurance companies.  It all has to be brief; and therefore we are obliged to shorten our therapy accordingly.

Giving fancy names to psychiatric disorders does not make it scientific; it just makes it complicated. And when you rely on lists of names instead of feelings you see how complicated it gets.

All this has to be complicated because when you leave the arena of feelings and travel to the disconnected neocortex you have ever-widening verbiage with less and less sense.  You arrive at an intellectual never-never land.  I guess the whole idea is to make it so complicated; that no layman can understand it, therefore it has the patina of something really “scientific.”   Look, I have two advanced degrees, have been in practice for 60 years and I cannot understand it.   It is just mystifying.  What compels all these names, diagnoses and lists is the behaviorist belief that behavior alone accounts for afflictions.  And since behavior is as broad as the entire human condition, imagine the difficulty in diagnosis. They have built themselves a trap: they define in terms of behavior and then have to list almost all behaviors in terms of neurosis or not.  Whew!!  Let’s see, now I have to count how many months someone has been hypomanic to see if she qualifies for my concocted diagnosis. More important, to see if she qualifies for money.  The diagnosis has to fit, not science, but finance.

So in the category, Expansive Irritable Mood, it needs to go on for days to earn the diagnosis.  Now who decided that?  What about 3 days or six days?  What they conflate is average with normal.  The average  period  is about 4 days; ergo, the diagnosis is for those who suffer for four days.  Below or above can be normal.  If I don’t eat hardly at  all for six days you are anorexic,  but if only 3 days you are normal.  You see the trap in  counting the days.  How about the forces that drive all that?  Examine the fear of elevators.  I have treated dozens of these cases, and the generating source is most often a post-birth trauma of being enclosed in an incubator just after birth.   `The terror of being enclosed all alone with no kind and warm human contact is imprinted at the  time and remains embedded in the system.  Anything later that can trigger the memory (resonance) can set off the original terror and the phobia.  So why dance around the behavior instead of going to the source?  Because  the source is never recognized, particularly with cognitive/behavior therapists who have no place for generating  sources in their psychiatric schemata.   Their theory does not allow it.  “Stay on the surface” is their motto, and they do.   Can anything be more spurious?    We have a whole history of experiences that could help us understand who we are now  and it  is all ignored.  They only want to correct behavior,  which is the modus operandi of the Behaviorists. Only correct what we can see.  What we cannot see is forgotten.

You see the patient has to recount to the doctor whether something is mildly annoying or really terribly debilitating so she can note the depth of the probelm.  I have an article before me written by a patient who was anxious for years and never knew it. Why would they do in this case with our diagnosis?   She was only mildly aware. So is she severely neurotic?   Look at the obsessive-compulsive disorder.  I have treated many who suffer from it. Often there is imprinted terror down deep in the brain that underlies it.  It surfaces as, “If  I try the doorknob twenty times I will be safe.”  It has little to do with a doorknob and more to do with underlying terror that drives the search for trying to feel safe.   If you ignore the underlying force you need to make a list, many lists, because one key feeling can drive multiple behaviors.  


Are you compelled to try the door five times a day or twenty?  If twenty  you are obsessive.  If five???    If even once you are still compelled to try the doorknob to feel safe and that is the underlying motivation, and if you have to do it everyday, I offer you my diagnosis—compulsive.    If the generating source is ignored you have to spin a diagnosis that is off in intellectual never-never land.  Let’ s see, I go to my office, see a patient, and then I have to count her number of episodes.  And then I have to take her word if it is annoying or not.  Yes, I refer her first for an MRI, magnetic resonance, and it comes back "agitation in the amygdala," now what?  Is there  someone who will connect the two (the MRI and the patient’s complaint) from a comprehensive diagnostic point of view?  Will it dictate the therapy we do?    Doubtful.  Each specialist is off on their own.  I have an MRI that shows what happens in the brain when I am compulsive but who notes that there is underlying terror and why?  And above all, what to do about it? For that we need an overarching theory that encompasses theory and therapy so that one informs the other.

The behaviorists are caught in a trap.They have to decide on a diagnosis based only what they can see.  So four days of one behavior makes it a disease but three days does not.  And you need to be depressed for at least one week to qualify; and for what?  To get paid by the insurance companies for a disease called depression.  And it is now called a disease, not because of scientific input, but because of money to be paid.  Here the insurance companies and the psychiatric profession are imbricated and merge into a financial arrangement that suits both well. Behaviorism pays and it helps the insurance companies lower their payouts: brilliant!  Everyone should be happy—except the patient.  Doctors will correct your behavior and your ideas until  you reach what they decide is normal, and voila!, success.   We have become willing tools of the insurance companies whose key role is to keep costs  down; and too, of the psychiatric establishment who has a financial incentive to find quick ways to treat, with diagnoses that lend themselves to quick fixes. And what are the costs?  Us.    The quicker the cure, by  their definition, the quicker the end of therapy. This obviates feeling therapies that do not lend themselves to quick fixes.  The problems are more long-standing, deeper and more remote.   So we accommodate to the companies through specious diagnoses and rearrange our treatment modes.   And then we really believe that we are dealing with real biologic states.  We are  really dealing with financial states with a veneer of psychiatric lingo.  Did I say that the 
APA  brings in millions of dollars through the world-wide sales of the manual?  This is really where finance, politics and psychiatry meld into one. The APA hired a Pentagon spokesman to defend their work,  as if it were a matter of promotion and influence,  not science.  Maybe it really is indefensible.  And maybe it has to be promoted just because it is scientifically indefensible.   And maybe scientists were not engaged to explain it because it cannot be explained within the realm of science. If it were clear and solid science it would not have to be "promoted."