Ethics & Diagnosis : The Medicalization of Predicaments

1. Ethics & Diagnosis: The Medicalization ofPredicaments Marc A. Forman, MD Dominic A. Sisti, PhD

2. Agenda • Situating Predicaments within the Philosophy of Psychiatry • The Power of Diagnosis • The Uniqueness of Predicaments • Interventions for Predicaments • Discussion

3. What is Mental Disorder? Situating the Concept of Predicaments

4. { Ismental disorder… …amyth …a social construction …a natural kind …a harmful dysfunction …an artifact of a predicament

5. The Standard (False) Dichotomy • Mental illnesses are natural kinds • Biological basis and marked by biological dysfunction (Boorse) • Social dysfunction with biological cause • Mental illnesses are socially constructed or actually manufactured/caused by the enterprise of medicine • The medicalization of deviance • Disease mongering • Social and cultural iatrogenesis effects of medicine: those that are created by a medical bureaucracy that increases stress and dependence while reducing individual choice and self-care. (Illich)

6. Social and Cultural Iatrogenesis • Illich 1975, Medical Nemesis/ The Limits of Medicine • Social and cultural iatrogenesis effects of medicine: those that are created by a medical bureaucracy that increases stress and dependence while reducing individual choice and self-care. • “Medical procedures turn into sick religion when they are performed as rituals that focus the entire expectation of the sick on science and its functionaries instead of encouraging them to seek a poetic interpretation of their predicament or find an admirable example in some person—long dead or next door—who learned to suffer.”

7. The Role of Values • Values, ideals, norms, & ethical goals ground psychiatry. • Nosology reflects these values: Fundamental implicit belief about what constitutes the good life. • A persons should be: • Autonomous • Stable • Independent but relational • Industrious • Self-sufficient • Deficiencies in these capacities mark candidates for disorders

8. Power & Beauty The Ethics of Diagnosis

9. The Ethics of Diagnosis • Given the implicit values of psychiatric nosology, diagnosis is an ethically fraught activity. • Contrast with diagnosis in oncology or other specialty. • Psychiatric diagnosis ought to be aimed at relief of human suffering • Sometimes diagnosis creates more harm

10. The Power of Diagnosis “It is the prerogative to diagnose that enables psychiatrists to commit patients against their wills, that delineates the populations subjected to their care, and that sets in motion the methods they will use for treatment. And it is therefore this prerogative that should provoke perhaps the most fundamental– and, consequently, the most serious– ethical examination.” (Reich, 1999)

11. Purposeful & nonpurposeful misdiagnosis (Reich, 1999) • Purposeful misdiagnosis happens when a clinician knowingly applies a diagnosis to a patient that is inappropriate in order to achieve some end that is, by common definition, medical. • Obviously unethical • Non-purposeful misdiagnosis are notmistakes. They result from a process in which a clinician has both adequate information about the patient and the illness and proper training, but issues an incorrect diagnosis b/c of factors extrinsic to the patient, and does so without being aware. • Insidious • Categories are created for political purposes • Diagnosis is instrumental in meeting a nonmedical goal.

12. Example: Purposeful mis-dx • Often contingent upon managed care or benefits: • Doug is a 22 year old recent college graduate who has had difficulty concentrating, sleeping, has expressed anxious thoughts and ruminates over a recent break up with his girlfriend. He tells his primary physician, who refers him to a psychotherapist. Long story short, after several weeks of CBT and 10mg of Citalopram, Doug felt like his old self. He is however nervous about discontinuing therapy. His therapist agrees to diagnose him with dysthymia so that his insurance will continue coverage. • Concern for patient/beneficent motive • PD-NOS, bi-polar instead of BPD • Diagnosis as detrimental to treatment

13. Example: non-purposeful • Drapetomania: antebellum category describing slaves who attempted to flee. • Rooted in core belief about the non-personhood of slaves

14. Schizophrenia in the USSR

15. The “Beauty” of psychiatric diagnoses (Reich, 1999) { Diagnosis as… …explanation, mitigation, exculpation, reassurance …the humane transformation of social deviance into medical illness …self-confirming hypothesis …exclusion & dehumanization …discreditation …the reflection of social trends

16. Ethics and Psychiatric Diagnosis Long history of ethical concerns about psychiatric diagnoses, such as: Effects of labeling, stigma Exclusion from society, loss of freedom Influenced by value judgments related to social behaviors; mental health based on Protestant ethic, enforces standards of society. Practitioner is “moralist disguised as scientist” (Davis) Self-fulfilling prophecy Errors in diagnosis: Rosenhan experiment—”On Being Sane in Insane Places” Used for political purposes: Nazi Germany, Soviet Union History of use in homosexuality

17. Ethics and Psychiatric Diagnosis Does DSM-IV or V resolve these ethical questions ? “.. it must be admitted that no definition adequately specifies precise boundaries for the concept of ‘mental disorder’ ”(DSM-IV, xxi) Is there an alternative way of examining the question of ethics and diagnosis?

18. Case Report Diagnosing James

19. Case illustrates several questions concerning diagnosis • Metaphysics: Is the patient mentally ill and if so, what is the nature of the mental disorder? • Ethics: What are the harms and benefits of diagnosis? • Pragmatics: Are some mental illnesses better left undiagnosed?

20. James..a story of a boy in trouble 12 year old boy, arrested for shoplifting, with other boys. Knife and marijuana found in group. Sent to Youth Study Center, a detention facility Court-ordered psychiatric : diagnosis of Conduct Disorder, ADHD, probable LD. Residential Treatment Facility recommended; needs full-time mental health intervention to treat his conduct disorder; has poor judgment; at serious risk for impulsive acting-out Mother wants him to stay home, go to mental health clinic

21. James...background Father alcoholic and incarcerated History of domestic abuse Two years below grade level in reading Often truant, but helps sister get to school when mother is working night shift At age 8 referred to clinic by school counselor for behavioral problems, school suspensions, probable ADHD. Medication (risperidone), therapy recommended, (but PMT,CPSST not generally found in our community clinics) Mother’s work schedule made it difficult to keep appointments

22. Diagnosis : What is the matter with James ? Three components of “sickness” in mental health (Taylor) Disease Illness and what is the matter with James?

23. Does James have a disease? • Requires • Specific Cause • Mode of Transmission • Specific Change in Structure • Specific Treatment • Where are we currently ? • Closer to identification of biological, genetic, neurochemical substrates • As yet no mental illness fulfills criteria of disease

24. Does James have an illness? • Illnesses have: • A Natural history • Characteristic symptom patterns • Bipolar Disorder • Major Depressive Disorder • Obsessive Compulsive Disorder • Tourette Syndrome • Specific treatments • However, there are many children who do not yet have an illness, but who have a…

25. predicament /priˈdikəmənt/ 1. A situation, especially unpleasant, troublesome, or trying; one from which extrication is difficult. 2. (in Aristotelian logic) each of the ten ‘categories’, often listed as: substance or being, quantity, quality, relation, place, time, posture, having or possession, action, and passion. Synonyms: dilemma, plight, quandary.

26. The concept of predicaments • David Taylor, 1979. “The Components of Sickness: Diseases, Illness, and Predicaments.” Lancet 8150(2): 1008-1010. • The predicament is the complex of psychosocial ramifications, contacts, meanings, ascriptions • Diffuse and multifactorial • Unstable • Painful • Morally charged • Context is paramount

27. James’s Predicament • Exposure to variety of toxic situations and difficulties • Violence at home • Violence in community • Father incarcerated • Inability to read • Poor school experience • Association with older delinquent boys

28. Predicaments as predictors • Physical abuse • Sexual abuse • Traumatic events • Failures of attachment and bonding, neglect • Separation , divorce • Multiple foster care placements • All of these childhood predicaments increase risk for adult mental illness, substance abuse, physical illness and mortality (ACES Study-Felitti). Predicaments have medical consequences and life-long effects. • Predicaments are not helped by medication or residential placement

29. James: questions to consider and often neglected What is the meaning behind James’ problematic behavior? Does his diagnosis of conduct disorder reflect the total life of the child and the predicaments that he and his mother face? Has he been helped by the diagnosis of a psychiatric disorder? Does he have a psychiatric disorder or is he the victim of a social disorder? Or both?

30. Interventions for Predicaments Society Individual Policy Narrative Medicine Evidence Based Medicine

31. What to do about predicaments? They are not merely “problems in living” (Szasz), but are matters of medical concern. Predicaments can co-exist with illness. Need to combine evidence-based medicine with narrative-based medicine. The HPI is the current chapter in a life narrative “Predicaments have the structure of the novel rather than the textbook” (Taylor) Need to be active at all levels from personal stories to social policy, not only in diagnosis, psychopharmacology and level of care decisions.

32. Individual Level: Narrative Medicine & Ethics • Charon, Stories Matter and Narrative Medicine • Patient stories and narratives recorded on a ‘parallel chart’ • Central goals of Narrative Ethics: Recognizing, absorbing, interpreting, and being moved by the stories of illness • Move away from principles and juridical thinking

33. Narrative Ethics & Predicaments The “rediscovery” of narrative medicine; listening carefully to patient and family stories in order best care for our patients and families. Luria : the importance of integrating “classical science” (now evidence-based medicine) with “romantic science” from the French roman or novel. Fitzhugh Mullan: “The plural of anecdote is policy” Walker Percy: “If you listen carefully to your patients, they will tell you not only what is wrong with them, but also what is wrong with you”

34. The importance of discernment • “The diagnosis of predicaments requires discernment” • Discerning the type & kind of predicament requires thick descriptions and a deep knowledge of patient stories. • Pragmatic appraisal of benefit/harm • Beneficence as overriding ethical principle

35. Macroscopic remedies • Revision of training programs to include narrative ethics, social sciences, and public health. • Social and political activism on the part of both individuals and professional organizations to address structural causes of predicaments.

36. Discussion questions • Have you encountered a patient who was in a predicament who had been inappropriately diagnosed? If so, what did you do? • How might predicaments be differentiated from biomedical causes of mental illness? • Have you avoided making a diagnosis or adjusted a diagnosis to benefit the patient? • Do you think we are asking you to lie about a diagnosis (or lack thereof)? • Is it ever ethically justifiable to diagnose a patient who is in a predicament with a diagnosis of mental illness? If so, in what cases?

37. References & readings Boorse, C., 1975, “On The Distinction Between Disease and Illness,” Philosophy and Public Affairs, 5:49–68, Charon, R. The patient-physician relationship: Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA, 286:1897-1902, 2001. Davis, K. Mental hygiene and the class structure. Psychiatry 1: 55-65, 1938 Felitti, V.J., Anda, R.F., Nordenberg, D. et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. Am J Preventive Med, 14: 245-258, 1998. Illich, I. 1975, Medical Nemesis/ The Limits of Medicine. London: Calder & Boyars. Mullan, F. Me and the system: the personal essay and health policy. In Mullan, F., Ficklen, E, Rubin K (eds), Narrative Matters, Johns Hopkins Univ. Press, pp 2-7, 2006 Luria, A.R. The Making of Mind: A Personal Account of Soviet Psychology. Harvard Univ. Press, Cambridge, 1979

38. Percy, W. Love in the Ruins: The Adventures of a Bad Catholic at a Time Near the End of the World. Avon Books, New York, 1981 • Pridmore, S. Medicalization/Psychiatrization of distress, Ch. 32, University of Tasmania, May 2011. • Reich W. “Psychiatric diagnosis as an ethical problem.” In Bloch S, Chodoff P, Green SA, Psychiatric Ethics, 3rd edition. Oxford Univ Press, 1999, p. 193-224. • Robertson, M., Walter G. Psychiatric ethics---a complicated challenge. Psychiatric Annals 37: 776-779, 2007 • Rosenhan, D.L. On being sane in insane places. Science, 179: 250-258, 1973 • Shackle E. M. Psychiatric diagnosis as an ethical problem. J Med Ethics 11: 132-134, 1985 • Szasz, T.S. The Myth of Mental Illness. Paladin , St. Albans, 1972 • Taylor, D. The components of sickness: diseases, illnesses and predicaments. Lancet (ii), 1008-9, 1979 • The American Heritage Dictionary of the English Language, 4th ed., Houghton Mifflin, 2009. • Thomas, C.R. Evidence-based practice for conduct disorder symptoms. J Am Acad Child Adolesc Psychiatry 45: 109-114, 2006 • Wakefield, J. C, 1992, “The Concept of Mental Disorder: On the Boundary Between Biological Facts and Social Values.” American Psychologist 47:(3) 373–88.

39. Acknowledgements • The Thomas Scattergood Behavioral Health Foundation • The Department of Medical Ethics & Health Policy at the Perelman School of Medicine, University of Pennsylvania • Community Behavioral Health, City of Philadelphia • Tulane University School of Medicine.

40. Contact Marc Forman: forman@tulane.edu Dominic Sisti: sistid@upenn.edu www.ScattergoodEthics.org