American Medicine Is Still Stuck in the 1950s!

In the musi­cal Guys and Dolls, the char­ac­ter named Ade­laide has a psy­cho­so­mat­ic cold. As she explained,

The aver­age unmar­ried female
basi­cal­ly inse­cure
due to some long frus­tra­tion may react
with psy­cho­so­mat­ic symp­toms
dif­fi­cult to endure
affect­ing the upper res­pi­ra­to­ry tract.

Guys and Dolls is a quaint arti­fact from the 1950s. Nev­er­the­less, the Amer­i­can Psy­chi­atric Association’s Diag­nos­tic and Sta­tis­ti­cal Man­u­al still gives doc­tors per­mis­sion to say, “It’s all in your head” if they can’t imme­di­ate­ly fig­ure out what’s wrong with you. An arti­cle of mine that was pub­lished in the jour­nal Med­ical Hypothe­ses says that doc­tors can­not make that kind of diag­no­sis with­out mak­ing an error in rea­son­ing. For that rea­son, I argue that the APA should remove con­ver­sion dis­or­der and som­a­ti­za­tion dis­or­der from the DSM. The fifth edi­tion of the DSM (DSM-5) is due in 2013.

The APA pub­lished the first edi­tion of its DSM in 1952. The DSM-I was based large­ly on the clas­si­fi­ca­tion sys­tem used by psy­chi­a­trists in the mil­i­tary and the Vet­er­ans Admin­is­tra­tion. The DSM-II, which was pub­lished in 1968, was sim­i­lar to the DSM-I but includ­ed more ideas from Freudi­an-style psy­cho­dy­nam­ic psy­chi­a­try. By the ear­ly 1970s, how­ev­er, Amer­i­can psy­chi­a­try was fac­ing strong crit­i­cism from the sci­en­tif­ic com­mu­ni­ty as well as from social activists. Many psy­chi­atric diag­noses seemed to be arbi­trary and unsci­en­tif­ic and could be used for bad social pur­pos­es. In response to this crit­i­cism, the APA appoint­ed a task force in 1974 to revise the DSM. The APA pub­lished the DSM-III in 1980.

One of the task force’s goals in writ­ing the DSM-III was to make the process of psy­chi­atric diag­no­sis more sci­en­tif­ic. Anoth­er pur­pose was to make sure that a diag­nos­tic label like para­noid schiz­o­phre­nia meant the same thing in the Unit­ed States as it did in oth­er coun­tries. To achieve these goals, the task force decid­ed to base the diag­noses in the DSM-III on plain-lan­guage descrip­tions of the patient’s symp­toms and signs of ill­ness. In oth­er words, psy­chi­a­trists were sup­posed to base their diag­noses on what they could real­ly observe, not on what they imag­ined was going on in the patient’s sub­con­scious.

Unfor­tu­nate­ly, the APA kept two of the diag­noses that break this rule: con­ver­sion dis­or­der and som­a­ti­za­tion dis­or­der. They appeared in the DSM-III and DSM-IV. They are like­ly to appear in DSM-5, which is due to be pub­lished in 2013. These two diag­noses mean that the psy­chi­a­trist thinks that the patient’s phys­i­cal symp­toms are the result of some psy­cho­log­i­cal prob­lem. How­ev­er, the psy­cho­log­i­cal prob­lem might not be some­thing that any­one can observe. It might not even exist. If the symp­toms look like symp­toms of a neu­ro­log­i­cal dis­ease, the patient gets the diag­no­sis of con­ver­sion dis­or­der. If the symp­toms look like some oth­er kind of prob­lem, the diag­no­sis is som­a­ti­za­tion. As I explain at length in my arti­cle in Med­ical Hypothe­ses, there’s no valid way to estab­lish the cause in these cas­es. Thus, doc­tors can’t make these diag­noses with­out mak­ing an error in rea­son­ing.

Con­ver­sion dis­or­der and som­a­ti­za­tion dis­or­der are waste­bas­ket diag­noses that doc­tors use when they can’t fig­ure out what is real­ly wrong. Doc­tors diag­nose con­ver­sion or som­a­ti­za­tion dis­or­der when the patient’s symp­toms seem gen­uine but the doc­tor can’t explain them. These diag­noses are the doctor’s way of say­ing “You are men­tal­ly ill” instead of admit­ting “I don’t know why you are sick.” This kind of fake diag­no­sis is obnox­ious, unpro­duc­tive, and in my opin­ion uneth­i­cal. It has no place in med­ical prac­tice and should be delet­ed from the DSM.

Instead of dis­miss­ing symp­toms as psy­cho­so­mat­ic, doc­tors should work on improv­ing their abil­i­ty to make cor­rect diag­noses. In par­tic­u­lar, they need to learn to lis­ten bet­ter to their patients and to do a bet­ter phys­i­cal exam­i­na­tion. Often, the vital clues are right there in the exam­in­ing room. If the patient has any mys­te­ri­ous chron­ic ill­ness, the patient should be referred to a reg­is­tered dietit­ian for an elim­i­na­tion diet pro­to­col. A low-fat, high-fiber diet that excludes all ani­mal foods and a few of the most com­mon­ly trou­ble­some plant foods (such as wheat) can often solve the prob­lem.

Why are women far more like­ly than men to be told that their ill­ness is “all in their head”? There are two pos­si­ble rea­sons. One is that the autoim­mune dis­or­ders that are hard to diag­nose are far more com­mon in women than in men. Anoth­er pos­si­ble rea­son is sex­ism. Even in the 21st cen­tu­ry, some med­ical doc­tors evi­dent­ly still believe that “The aver­age unmar­ried [or mar­ried] female/basically insecure/due to some long frus­tra­tion may react/with psy­cho­so­mat­ic symptoms/difficult to endure.”

Update: I for­ward­ed a copy of my Med­ical Hypothe­ses arti­cle to Dr. Allen Frances, who chaired the com­mit­tee that com­piled the DSM-IV. He agreed with my analy­sis. Nev­er­the­less, those diag­noses are includ­ed in the DSM-5. I am hope­ful that they will exclud­ed from DSM-6!

narcissists-cover-01Although I take issue with som­a­ti­za­tion and con­ver­sion dis­or­der, I think that the APA’s clas­si­fi­ca­tions for the per­son­al­i­ty dis­or­ders make a great deal of sense. I explain them in detail in my book Don’t Feed the Nar­cis­sists! The Mythol­o­gy and Sci­ence of Men­tal Health.

2 thoughts on “American Medicine Is Still Stuck in the 1950s!”

  1. This is almost word for word my expe­ri­ence yes­ter­day at the neu­rol­o­gist. He was extreme­ly sex­est in telling my hus­band that he need­ed to pay very good atten­tion because I sim­ply wasn’t going to under­stand. He then pre­ceed­ed to tell me I am a pic­ture of health so i must have sur­pressed issues from my child­hood cau­se­ing these prob­lems. Even though before he ran every test he told me with­out ques­tion I had a neu­ro­log­ic prob­lem and defi­nate signs of nerve dam­age. After the tests can back nor­mal he said my issues where psy­cho­so­mat­ic. I then asked if he thought is would make a dif­fer­ence redo­ing my MRI with con­trast (as we only did them w/o) and he told me he new I was going to be argumentitive…He then sug­gest­ed I go to ther­a­py. I explained to him that I am a very hap­py per­son do not suf­fer from depression/ anx­i­ety and don’t feel in any way emo­tion­al­ly com­prim­issed in any areas of my life. I explained I and a children’s pas­tor and and very strong in my faith. To which he replyed ” that is your prob­lem and it has been my expe­ri­ence that faith ruins most lives.” I knew then and there I want­ed noth­ing more to do with this doc­tor. The ques­tion now…where to go from here? Thank you for this arti­cle.

  2. It has been my expe­ri­ence that incom­pe­tent doc­tors ruin lives.

    The first thing is to take care of your health. The first thing to do is talk to a reg­is­tered dietit­ian for an elim­i­na­tion diet. Here’s the elim­i­na­tion diet pro­to­col that Dr. McDougall rec­om­mends: It elim­i­nates all of the foods that are known to be com­mon trig­gers of ill­ness and is good for your gen­er­al health. If you need some Bible vers­es to sus­tain you dur­ing the elim­i­na­tion diet, I’d rec­om­mend the first chap­ter of Daniel.

    Anoth­er pos­si­bil­i­ty is that your prob­lem might be due to the pinch­ing of a cra­nial nerve. Some­times a good den­tist can fix that prob­lem in a jiffy. Check this out:

    You real­ly ought to report your doc­tor to your local med­ical soci­ety. Send them a copy of my Med­ical Hypothe­ses arti­cle, along with a let­ter explain­ing how your doc­tor not only failed to diag­nose your ill­ness but he insult­ed your reli­gion, which is an extreme­ly unpro­fes­sion­al thing to do. You might also ask the high­er-ups in your denom­i­na­tion to com­plain to the med­ical soci­ety on your behalf. You don’t have to take abuse from peo­ple, even if they’re MDs.

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