On My Mind: Questioning assumptions of modern psychiatry

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Every summer Harvard brings some of the great teachers in psychiatry to Martha’s Vineyard. Dr. Nassir Ghaemi, a psychopharmacologist and psychiatrist at Tufts and Harvard, author of “A First-Rate Madness,” and a frequent Vineyard visitor, has taught classes on the Island for mental health professionals for several of the past summers. He has changed the way that I think about the medications we prescribe, the diagnoses we pass out, and the basic assumptions we doctors have about mental illness.

According to Dr. Ghaemi, most of what we call “mental illness” is part of the human condition or the result of injury to the brain. According to studies, at least 25 to 50 percent of Americans will, at some point during their lives, suffer from a “mental illness.” To diagnose people with attention-deficit disorder when they are easily distractible, or with generalized anxiety disorder when they are preoccupied with worry, or with negative preoccupations as having a depression, is, in Dr. Ghaemi’s view, akin to labeling people with fevers as “fever disordered.” The traits that we view as indicators of “mental illness” are normal human experiences, and if you graph populations with regard to most of them, what you will find is a bell-shaped curve where some people have these experiences more than others. (Dr. Ghaemi prefers the word “experiences” to the word “symptoms.”) Some people are shorter and others taller, but you wouldn’t diagnose a shorter-than-average person as having a “shortness disorder.” The same should be true for the degree to which people worry, feel blue, or have trouble focusing.

Dr. Ghaemi further points out that many of the traits that we call “disorders” are actually adaptive. “People who have a depressive outlook are often more realistic and empathic. People with manic symptoms are often more resilient to stress, can be inspiring leaders, and are more creative.” I would add that people with what we call ADHD are often superb at delegating and understanding complex problems. CEOs are far more likely to have some of these traits than the rest of us. Similarly, people who worry a lot are often more cautious and determined to “get it right,” and Dr. Ghaemi points out that they can be better at protecting themselves and their families.

What is there about post-traumatic stress disorder that is so clearly characterized by nightmares, emotional numbing, and hypervigilance? Isn’t that a disorder? Dr. Ghaemi believes that it is more accurately described as an injury than a disorder. When children are hit, neglected, have sexual boundaries crossed, it changes their brains in well-documented ways. It is more like a scar than a disease.

What about alcoholism? When severe alcoholics stop drinking, they experience often lethal withdrawal symptoms — craving and anxiety attacks that mimic panic attacks. Isn’t that a disease? Perhaps not. It has been pointed out that the great success of the British Navy in the 19th century was fueled by its daily ration of rum. Alcohol fuels impulsivity and courage. There is a genetic loading for alcohol dependence, just as there is for height. But Dr. Ghaemi suggests that substance dependence isn’t a disease in the sense that Type 1 diabetes, Parkinson’s disorder and strep throat are. It is a trait that goes awry when the brain is injured by a toxin.

So are there real diseases in psychiatry? He would say that there are at least two, schizophrenia and severe “manic-depressive disease.” These are well-validated diagnoses. If you graph a population, you will see that people with these symptoms are not simply on one end of of a normal bell curve; they are serious outliers, statistically significant in their remove from the norm. (By the way, most modern psychiatrists prefer the term bipolar disorder to manic-depressive disease. Dr. Ghaemi points out that not everyone with the disease experiences both poles; some people will never become depressed, while others will only become depressed.)

Dr. Ghaemi often uses world leaders to demonstrate that the symptoms of mental illness are not necessarily always negative. He points out that — like them or revile them — J.F.K., Ted Turner, Winston Churchill, Adolf Hitler, and Donald Trump all have or had periods of high energy, libido, and creativity. At times all have been infectiously enthusiastic, hero-like, and persuasive; all have had lives punctuated by periods of a minimal need for sleep, expansive thoughts, and rapid speech. In short, Dr. Ghaemi points out, all could be described at times as having been manic, but all used this trait to their advantage. Evolution may have left us with these characteristics for a reason.

Some of these characteristics might also earn certain leaders the diagnosis of narcissistic personality disorder. But Dr. Ghaemi points out again that most personality disorders are not really valid diagnoses. Rather they are labels created by committees of psychiatrists and psychologists who noticed that aspects of the human condition create problems for some people; where certain traits were found in combination with one another, they gave them names and called them disorders. Traits that define “narcissistic personality disorder,” for example, include grandiosity, lack of empathy, and a sense of entitlement.

Dr. Ghaemi further notes that while physicians sometimes determine that a person has several concurrent diagnoses, in fact, there is a hierarchy of diagnoses. Someone like Winston Churchill, for example, might reasonably be diagnosed with narcissistic personality disorder, alcohol dependence, and bipolar disorder — all three at once. But the grandiosity that can lead to a diagnosis of narcissistic personality disorder is often seen in people who are manic. Similarly, about 60 percent of people with classic bipolar disorder will have alcohol dependence, and many of them have a problem with alcohol only when manic. So, was Churchill an alcoholic, or was his drinking a result of his bipolar disorder? Was his alcohol use a form of self-medication to take the edge off his mania, or his depression? Dr. Ghaemi would diagnose only the bipolar disorder (or manic-depressive illness) and see the other diagnoses as covered under the “real diagnosis.” (See his recent article in Washington Monthly for a discussion of the diagnoses of President Trump and other historical figures: bit.ly/ghostofgoldwater.)

If Dr. Ghaemi is right, and many so-called mental illnesses are not so much diseases as they are amplified versions of normal components of the human condition, how can physicians help their patients who are emotionally and psychically suffering? “The good news,” Dr. Ghaemi says, “is that we have more medications, biological treatments, and effective psychotherapies than ever before. The downside is that medications are generally overprescribed. All medications are harmful. It is because they affect the body and brain that they are effective. They do things that are helpful and they do things that are harmful. It is only their indication and dosing that makes them relatively safe.”

He points out that we have drugs to help people who have difficulty paying attention, getting to sleep, relaxing, and tolerating emotional pain — all of these being things that almost all human beings experience at some point in their lives, to greater and lesser degrees. He questions the long-term efficacy of serotonin reuptake inhibitors like Prozac, especially for mild or moderate depression. He is concerned about the long-term effects of stimulants such as Adderall, particularly on the developing child or adolescent brain. And he points out that these drugs, which are heavily marketed by pharmaceutical companies, are being prescribed more and more commonly, despite the fact that many of our modern medications are associated with withdrawal symptoms, cardiac side effects, and metabolic side effects such as weight gain.

Dr. Ghaemi advises that if you are among the approximately 10 percent of the population who have a true mental illness — severe manic-depressive illness or schizophrenia — then you probably need to be on medication. And if, for other troubles, medications work for you with few side effects, use them. But use them with caution, educate yourself about their risks and side effects, and consider whether you need them in the long run. Find doctors who are cautious and skeptical. And avail yourself of the excellent psychotherapies that are available to help people with the painful aspects of the human condition.

Dr. Charles Silberstein is the chief psychiatrist at Martha’s Vineyard Hospital, and writes regularly about issues Islanders have with mental health.

To learn more about Dr. Ghaemi’s ideas, go to his website and newsletter, The Psychiatry Letter (psychiatryletter.com).

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3 COMMENTS

  1. I would not trust any doctor who gives a diagnosis of mental illness about someone he has never examined. I don’t care if he’s famous or not. It’s not like there are x-rays, MRI’s, sonograms, blood tests, or any other physical indicators that could possibly be used from a distance in consultation to determine something about someone you’ve never even met. It is arrogant and dangerous when medically trained doctors start thinking that a person’s fame makes it okay for them to promote irresponsible diagnoses, which, in fact, further damage an already ignorant pubic outlook on mental illness. After all, the symptoms of a supposed schizophrenia diagnosis-from-afar may be masking another disease entirely, like a brain tumor or even Lyme disease. There is no other very serious, life-altering illness I can think of where a doctor would dare to assume a diagnosis without examining the patient. Beyond greedy, immoral, dishonest, impulsive, selfish, unaware, uneducated, unread, inarticulate, lacking compassion, etc, I don’t know what is or isn’t medically wrong with Trump, if anything, and neither does any doctor who has never examined him. I can say a lot of negative things about Trump, but saying he is mentally ill, something that should NOT be seen as any more negative than cancer, is just plain wrong. Any doctor should know better. This is a criticism of Dr. Ghaemi, not Dr. Silberstein.

    • How can we tell someone is introverted or depressed if they lock themselves in their home and never open the door or answer the phone? Do we have an obligation to compare individuals to persons who have been examined by doctors in the interest of protecting the public?

  2. I don’t trust Dr. Ghaemi, because to me it sounds like he’s being dismissive of a large portion of suffering that is genuine regardless of whether it’s biological or a piece of the human condition, and that the pay off is the gratification that comes from splitting hairs and feeling “right” rather than helping.

    Maybe I’m wrong, maybe I’m overreacting because it’s too close to home. But I see a diagnosis (for the most part) as existing within a spectrum designed to help us process what we are dealing with and what treatment/accomodations we need. I spent a lot of time with undiagnosed and misdiagnosed ADHD. Most of my symptoms were written off as normal and a part of my personality. So I was left wanting to put a bullet in my head because I felt inherently stupid. Diagnoses are imperfect tools. But I don’t see the purpose in writing them off rather than making them the best they can be.

    Basically, I’m saying that from my understanding of what is being said here: this is irresponsible and idealistic at best and I’d probably be dead if this guy had been treating me so maybe it’s wise to take all this with a grain of salt.

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