Common Psychiatric Misconceptions

Meguro Counseling Center, Tokyo Japan

Tel: 03-3716-6624|E-mail| Japanese version

While psychiatric problems are real and the treatments helpful and sometimes lifesaving, there are a number of overly positive or overly negative misconceptions about what psychiatric problems are and what psychiatrists can do about them.

The major underlying problems with psychiatry are:

  • 1. The concepts of illness and disorder are fuzzy with no physical proof for most any psychiatric illness compared with many medical illnesses that have physically measurable evidence (stroke, tumor, infection, heart attack, etc.).
  • 2. There is a book called the DSM that is both over-valued as a "bible of proven psychiatric disorders", as well as under-valued as having some good credibility in defining many disorders.
  • 3. Psychiatric treatments either seem scary (medications, shock and other brain stimulation therapies), strange & cash-draining (three-times a week psychoanalysis to work through the sexual conflicts one had as a child with one's parents), or obviously simple common-sense techniques with complex terms (cognitive restructuring for depressives to stop thinking negatively-which is actually a symptom not a cause of depression).
  • 4. Psychotherapies have a strong placebo effect, where hope and expectation can make persons in what is subjective psychic distress feel considerably better depending on what problems a person actually has, and how much the person may be responsive to almost any treatment they think is helpful.

Psychotherapies are shrouded in complex sounding verbiage that is suspicious of “over-selling” that few mental health workers themselves admit. The mentors of new trainees are likely to impress what they know about mental health issues and treatments as “facts” rather than the unfortunate truth that we can’t prove the validity of our diagnostic classification, and neither are psychotherapeutic treatments really evidence-based (none are vetted by the FDA) . Psychotherapy outcome trials can have randomized comparative arms but they can not have single-(patient) blind, double-(therapist) blind, nor blind placebo groups which is a huge problem in studying conditions like depression that have subjective outcomes that are susceptible to bias. Neither the general population, nor most mental health professionals, have any inkling on the magnitude of this problem in claiming efficacy for these therapies.

None of this means that mental illness does not exist, nor does it mean that some treatments are not helpful for certain indications. The purpose of this essay is to provide a sample of the kind of “nuanced” understanding one needs to make sense out of psychiatric problems and their psychotherapeutic treatments. Elaboration of some of the topics brought up here can be seen below.

Misconception 1: Psychiatric Diagnoses can be tested, and are a true description of illness just as any medical illness.

Some psychiatric problems like chronic depression or schizophrenia are more reliable concepts than others like personality disorder. Still the label of a disorder is not really provable or set in stone, and tests are only data sheets. There is no test in psychiatry that attaches a label to a physically measurable parameter, and the recent popularity of genetic testing companies that will give out a mental disorder diagnoses are over-selling a science that one day will be crucial to psychiatric classification, but not yet. The DSM III, was the basis that further editions built on. It may be telling that Dr. Allan Frances, DSM-IV's chairperson was quoted by this paper to have said this about the making of DSM IV, "...it felt better to stabalize the existing arbitrary decisions than to create a whole assortment of new ones". Of course mental illness is real though, read on to understand this.

The missing nuance is that persons do not differentiate the evidence seen in POPULATIONS OF PERSONS with these symptoms vs any one INDIVIDUAL. In populations of persons diagnosed with a more reliable diagnosis like chronic severe depression, there are more persons in the families of these populations with mood disorders compared to the general population, and there are more subtle findings in neurotransmitter function or brain function on various test than the general population, but the type of findings are not consistent across these persons, and many persons with these symptoms do not have any family history or brain findings.

For even more nuance, we need to distinguish the CONTENT of what a patient reports to a clinician vs. the DIAGNOSTIC LABEL that can be given. The content is simply the reported data and symptoms the patient has (in this article we will assume it is truly experienced by the patient, but there are of course situations where patients distort or falsify data). A label is closer to conjecture than the reported symptoms. We do need a label to help guide treatment, but we need to use caution in assuming these labels are actually a proven entities in an individual like, for instance, leukemia, tumor, heart attack, or stroke. Labels are concepts and conjecture that are words out of a clinician’s mouth, they are not like a tumor being seen on an MRI, or leukemia seen on a blood test. A label can help guide treatment, but patients should be clear they are just to guide what to do, not a proof about what one has, and giving an unproven label to a third party should be done cautiously (i.e., a child’s school, place of work, insurance carrier). Only enough information that these entities need to know to help the person should be provided as an unproven and stigmatic label may follow a person’s record for years.

The DSM publications of psychiatric disorders is a reasonable attempt to make some clinically useful classification, and a label system to bill insurance carriers (they should be more forthcoming about financial interests). However, all the “research papers”, “working groups”, “inter-rater reliability” of tests, and names of famous academic centers contributing to this work does not mean the DSM does not have big problems in its classification of psychiatric disorders. The symptoms to be rated are subjective, symptoms between different disorders overlap, the criteria change and disorders are added or deleted every 10 or 20 years the DSM is revised, and the DSM labels do not fit cleanly with the ICD (International Classification of Disease) classification-which has the similar problems as the DSM. In addition, the political factions in U.S. psychiatry that clamor for inclusion, deletion, and criteria sets for some diagnoses is an even larger problem that bases some diagnoses (like borderline personality disorder) on years of subjective, conflicting inconclusive research, entire careers, and the very existence of large professional institutions like psychoanalytic institutes. Vested interests in certain sub-groups of psychiatric clinicians and researchers thus warp the reality of what patients should be labeled (Reference). Make no mistake, that the labeling system is partially flawed does not mean psychiatric disorders do not exist. The misconception is that the DSM is set in stone, in reality it is only a model for clinical and research purposes, not an actual proof of an objective classification.

Please see our article on psychiatric diagnoses.

Misconception 2: Psychotherapy (including CBT, mindfulness, and psychoanalysis) has been proven to be effective.

First, this is not a "psychotherapy bashing" essay, there is clearly SOME VALUE to some psychotherapies for certain issues, but a nuanced understanding is required.

The underlying problem was that up until the 1970s and '80s, there were few and only poorly controlled clinical trials of psychotherapy, and insurance companies were starting to see that psychoanalysis and other therapies of the time were billing exorbitant amounts. There became a call from the insurance side for shorter treatments that could prove efficacy in a controlled clinical trial for specific indications. Rather than be out in the financial cold, mental health clinicians said, “ok, we’ll give you clinical trial data”. Unfortunately, that did not mean the data would necessarily be born from robustly controlled clinical trials, nor that the insurance providers would know how a clinical trial in psychiatry with subjective and somewhat vague endpoints would need to be done.

Psychoanalysis (a strict form of psychodynamics) was and still is a vague and unstandardized therapy with hard to measure endpoints (goals), and it started to walk thru the mud with calls for validity studies. The race was on to get on the good side of insurance schemes. To compensate for the deficits in psychodynamics, Rational Emotive Behavior Therapy (REBT) was designed by Albert Ellis in the '50s. This basically said that irrational beliefs caused mental problems. If you are irrational, you might get upset from that of course, but it is known that mental illness causes one to be irrational in the first place. Yes, these psychotherapy inventors took a symptom and turned it around to be the cause (it's like saying that cough is the cause of asthma not the result). About a decade after Ellis, Aaron Beck and his disciples better marketed REBT, rebranding the namesake into the more sleek, CBT- cognitive behavioral therapy (Beck basically stole Ellis’s ideas and eclipsed Ellis and REBT in the wake of CBT). Few therapists now even know the name REBT or Ellis.

The time was ripe to get some therapy off the ground before insurance companies pulled the plug altogether and big-money and fame was at stake. CBT had a manualized procedure for therapy and this allowed the adherents of this therapy to make it seem that these clinical trials were controlled. They randomized the groups, and had blind-raters of outcome (misleadingly calling this a “single-blind” because single-blind is when patients are blind), leading the public and fear-of-starving clinicians to believe these trials were robust when all along they had no single-(patient), or double-(therapist) blind, and no blind placebo (it is impossible to single-blind, double-blind, or placebo control a psychotherapy because patients need to know what they are getting and therapists need to know what they are giving). This is a terrible problem when the endpoints of psychic distress are subjective and most anyone who has hope and expectation will respond to getting a therapy with any reputation around it. Depression was a good first target for CBT because it is easy to bill insurance while labeling most any patient depressed, depression tends to lift upon being given the promise of a therapy that may be effective, clinical trials record 50% improvement as a responder, and the premise of CBT that negative cognitions are the cause of depression is the only instance in all of medicine where a symptom of a disorder is also said to be the cause.

A build-up of deeper research into CBT led to a list of criticisms and weakening effects that were unfortunately drowned out by insurance money that fueled research grants to fund more unblinded trials, special-interest groups that pay clinicians and researchers to market CBT, and their connections to politicians that pushed for national insurance schemes to pay for CBT. A summary of problems with CBT can be seen here and here.

To list here some other issues, 1. There is no regulatory agency like the FDA to evaluate a psychotherapy clinical trial (many psychiatric medications vetted by the FDA are not approved), 2. Clinical trials that pit therapy against medications are a violation of trial logic because blinded medication arms handicap the medication results, and unblinded medication arms do not allow blinding control to function. 3. CBT purports itself to be effective for numerous psychiatric and mental conditions, which starts to defy the logic of actual efficacy of a treatment for a condition, seeming more like a one-size-fits-all product marketed for the masses. 4. It is extremely rare for any psychotherapy inventor or adherent to ever admit that the therapy they designed wasn't useful. Almost every psychotherapy ever put on the table has deemed itself effective: Psychoanalysis, CBT, DBT, dynamic deconstructive psychotherapy, mentalization-based treatment, transference-focused mindfulness, schema-focused therapy, EMDR, neurolinguistic programming, holistic therapy, body energy therapy, etc., for just a few on a long list.

Of course talking to someone with stress or mental problems may help them, it may help with self- understanding, how to cope better, how to have less interpersonal conflict, etc. There is clearly SOME VALUE to psychodynamic psychotherapy, CBT, and some others. It’s the over-selling and over exaggeration of specific effects on defined conditions in spite of poorly controlled clinical trials that is the problem. So that's the misconception and the nuanced side of the story.

Misconception 3: Persons angered easily on rejection have borderline personality disorder and DBT (dialectical behavioral therapy) has been proven to be effective for this disorder.

It is probably clear from the title that there are a variety of persons easily angry and over-reactive on rejection and that it might be difficult to put all of them in the same category. Persons angry on rejection are usually angry and impatient in a multitude of situations (is road-rage clearly different than rejection-rage? It all depends on how you argue the anger management pie should be cut-up). Now, DSM-IV had an exclusion criteria for the general criteria of a personality disorder that said, "The enduring pattern is not better accounted for as a manifestation or consequence of another mental disorder." This seems natural that if one has symptoms secondary to a more inclusive underlying cause it makes little sense to give them two diagnoses. For example, if you have insomnia from depression, you would not also be given a diagnoses of "sleep disorder", or if you have lung cancer you do not need to be given a diagnoses of "cough disorder". If you are intolerant, impatient, over-work, have clutter, procrastinate, and get distracted easily, you probably have ADHD. It is likely that your intolerance and impatience caused you to have trouble with people, or you may have exploded on being rejected, making your mood crash and you came to therapy, never bothered by clutter and procrastination. You should not get a multitude of diagnoses including borderline personality. But wait, this great pearl of exclusion criteria logic was actually removed from the DSM-V. This strange maneuver leaves more patients on the treatment table with personality disorder diagnoses AND another diagnoses (i.e., too many diagnoses with no clear discrimination of cause-effect, and requiring a therapist or treatment facility that treats personality disorder).

Reading the criteria for borderline personality in the last link, it might be obvious even to non-professionals that borderline personality criteria overlaps with depressed and irritable persons, (hypo)manic and irritable persons, hyperactive and impatient persons, and others. See this reference. Unfortunately, psychoanalytic researchers and clinicians who have a long history of labeling and studying persons who fit these criteria have a big say in the making of the DSM committees that are part of the American Psychiatric Association, and are quite against changing much about personality disorders because it is one of the last bastions of psychiatry left for psychoanalysis since the explosion of biologic psychiatry in recent decades has eroded psychodynamic causality. In Europe the name has even been changed to emotionally unstable personality disorder, a first-step to moving away from the strict psychoanalytic roots of borderline personality.

Lest I be criticized for conspiracy mongering, see this paper on the development of the DSMs which notes these quotes on the flimsy nature of the diagnosis of borderline personality from the DSM Task Force members themselves: "‘I just don't know what it is’ - but it was a diagnosis that doctors were making....It was only when John Gunderson came up with a paper listing specific characteristics of what he called Borderline Personality Disorder, that we went ‘ah ha – we can put this in book’....While their review is comprehensive in its scope, it does not transcend the usual methodological problems of review-based research, which is susceptible to interpretation bias and unable to control for the multiple variables affecting each study reviewed....We simply discussed things until we were comfortable with it, based on what we as individual members of the group understood and knew. It was really quite primitive compared to what they do now...We didn't know about this. It was all about what we knew from clinical experience and from reading. It was done by consensus of experts, which would now be considered a very trivial approach, but that's the best we could do then....the picture emerges of a Task Force struggling to substantiate its decisions on the basis of solid research...We had very little in the way of data, so we were forced to rely on clinical consensus, which, admittedly, is a very poor way to do things."

Regarding treatment for borderline personality, the effects of most any treatment are known to be small. DBT is the best marketed therapy of the six major treatment camps vying for top position in the psychotherapy race, but none of these therapies can have single-(patient) blind, double-(therapist) blind, nor blind placebo groups which is a huge problem in studying problems with subjective outcomes because all persons regardless of type of care improve a bit, the subjects receiving the care under study have a bit more hope and expectation evident to them from the content provided and the therapist's zeal (see the CBT section above). The Wikipedia page in the last link eruditely states, "more rigorous treatments are not substantially better than less rigorous treatments". Also, only persons with some insight and motivation remain in a treatment setting so that there is some bias in the study group selection vs. persons with borderline personality we might see in the general population. Medications seem effective for associated conditions, but is thought to be limited in treating the core problem of emptiness in borderline persons (see the wiki link).

The end result of all of this is that we don’t really know if borderline personality as a whole should be considered as part of another disorder (like ADHD or bipolar disorder), if each individual should be categorized into another disorder, or if borderline personality needs to be re-branded and more specifically labeled (someday genetic testing may help here). Right now it is a label whose criteria are disordered itself, and the grab for fame and fortune as the first choice treatment of this disorder is another over-sold gold rush in need of regulatory restraint.

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