Chapter Three

Post-Freudian Angst

Until Sigmund Freud came along, psychiatric conditions had been classified in purely descriptive terms. Some were named for a single symptom such as the various phobias. Claustrophobia, a fear of closed places, Agoraphobia, a fear of open places, are examples of such single symptoms.

Later, these conditions began to be named in general descriptive terms such as Behavior Disorder or Neurosis. This change came about because psychiatry was in the same primitive state of understanding as general medicine had been before Harvey discovered how the blood circulated.

Consider this, for example. Prior to Harvey’s discovery of blood circulation, there was a diagnosis called “dropsy” which consisted of two main symptoms commonly seen together, shortness of breath and swelling of the ankles. Once Harvey had spelled out how the circulation worked, doctors were able to understand how these two symptoms could be related to heart failure in one instance, to renal failure in another, and to starvation in yet a third. Once the organizing principle had emerged, one diagnosis became three, each of which provided a much clearer line to treatment that did the descriptive label “dropsy.”

Medical diagnosis has always marched along a continuum which has description at one end and cause -- or as we physicians call it, etiology -- at the other. The journey often multi-stepped and protracted, and it never ends.

Psychiatry has needed a Harvey to discover and explain some fundamental principle of mental function which could take us deeper into the heart of the psychological disabilities behind the symptoms our patients displayed. When Freud came along many thought psychiatry had found that principle.

Freud constructed a coherent system of psychological function and malfunction, based on three fundamental notions. The first of these was called the libido theory of psychosexual development. This was the notion that the child passed through phases during infancy when his or her psychological needs were dominated by oral, anal, or oedipal events, each of which phases might, or might not, be successfully navigated. The second fundamental notion was that these significant events of early childhood were pushed out of awareness by an active process Freud called repression. The third fundamental notion was that there was an unconscious mind where these developmental triumphs and traumas remained, and where they were capable of affecting the adult’s behavioral choices. Putting these three ideas together, Freud came up with the instinctual conflict theory of neurosis.

Just as Harvey’s principle had changed the concept of blood circulation, Freud's led to many new diagnoses. These were called dynamic diagnoses since they purported to explain how the symptoms were related to the underlying instinctual conflict. The names of many of these diagnoses reflected underlying oral, anal, or oedipal psychopathology.

For example, the school phobia child was seen to have displaced his unresolved castration anxiety onto some aspect of the school. By avoiding school he was actually protecting his psychological cojones.

When it came to treatment, the rationale became as follows: recover the repressed early conflict from the unconscious, vent the attached emotion, and forever free patients from its tyranny. Given Freud’s underlying premises, it all made perfect sense.

The fact that the treatment didn’t actually work was overlooked in the burgeoning enthusiasm. Soon everybody who was au courant was rushing to take part in the best parlor game to come along since charades. It was easy to diagnose your neighbor’s refusal to lend you his lawn mower as a manifestation of his anal retentive personality. It was just as easy to see your wife’s distaste for your late nights as repressed emotional angst about her father. And it was not just naive intellectuals, cab drivers, and bartenders who played this game. Novelists, playwrights, movie makers – everyone got into the act.

With the passage of time, things Freudian began to fall apart. The theoretical underpinnings of Freud's instinctual conflict theory of neurosis were, one by one, invalidated. Direct observation of developing children did not lead to a confirmation of Freud's libido stages. The notion of repression was discredited. The unconscious mind was seen to be a much different creature from the one Freud described. (I addressed this issue in “Some Observations Concerning Out of Awareness Mentation,” in Perspectives in Biology and Medicine 33, 2 (Winter 1990).)

Though Freud’s instinctual conflict theory of neurosis was discredited by all but a few die hard analysts, his contribution was, and remains, a considerable one. Freud opened an important door for psychiatrists. He taught us to look beyond symptoms into historical psychological events and he showed us how these events were in fact major determinants of our learned behavior.

Though psychoanalysis soon became defunct, dynamic psychiatry had come to stay. The new dimension to diagnosis was called psychosocial, which, viewed against where psychiatry had been prior to Freud, was change indeed.

Now we come to the angst bit.

The immediate post-Freudian era was not a good time to be a psychiatrist. The pendulum took a mighty swing. We psychiatrists soon found we had all been tarred with the oral-anal brush. People no longer saw us as wise and kindly men of great intelligence easily able to penetrate to the heart of bizarre syndromes such as those portrayed in the movies Spellbound and Vertigo.

Now psychiatrists were seen as Dr. Strangeloves, and our patients as feckless Woody Allen characters or spouse murderers working the Freudian con. Even our medical colleagues began looking at us with barely concealed misgivings.

That’s when a small group of American Psychiatric Association gurus, in the best American tradition, rode to the rescue. Pulling wagon loads of concrete nomenclature, they galloped in and undertook to restore psychiatry’s good name. Since the villain was a series of weird diagnoses that led to strange conclusions and haphazard predictions, these self-appointed salvationists decided to undertake a radical restructuring of diagnosis in psychiatry. (See a very interesting paper by Dr. Mitchell Wilson entitled “DSM III and the Transformation of American Psychiatry: A History” for more on this subject. It appeared in the American Journal of Psychiatry 150, 3 (March 1993).)

These doctors were determined to invent categories that were descriptive, medically based where possible, about which, they hoped, there could be no argument. Concrete description was in; etiology was out. As Robert Spitzer explained to a latter day critic, from the very beginning the task force was committed to a classification that avoided etiologic speculation. Thus, freshly equipped with sensible, straightforward categories, they reasoned, psychiatry would be restored to respect in the mainstream of medicine.

To develop their new diagnoses these doctors went back to what they considered to be first principles and spelled out the categories that would eventually make up the Diagnostic and Statistical Manual III. Spitzer’s lists had been born .

Not all psychiatrists were pleased with these efforts. Dr Theodore Lidz, a leading psychiatrist from New Haven, Connecticut, put it succinctly in a letter in the American Journal of Psychiatry, complaining that “they foisted DSM III on American Psychiatry despite strong opposition from many of the leaders in the field.”

DSM III constructs lists of symptoms, which in child psychiatry are usually behaviors, associated with a given diagnostic category. The manual then determines exactly how many of such behaviors need to be present for what period of time for the diagnosis to be made.

This entirely new approach to medical classification has become known as “check list diagnosing.” With DSM III the check list diagnosis is king. History taking and clinical interviewing now take a back seat. Sometimes, it seems, they have been kicked off the bus altogether.

The special appeal of check list diagnosing is that it is easy. Teachers, parents, and in fact anyone who can read and owns a pencil can make the diagnosis merely by checking items and counting them up. Later in this book I shall include the ADHD check list from DSM III and the reader can try his or her hand on the neighborhood children.

However, to name a category “Attention Deficit Disorder” does seem to suggest that the fourteen behaviors on the check list result from a deficit in the individual’s capacity to sustain his or her attention, does it not? Is this approach not implying an etiology – an actual cause of a disease?

What if the committee members elected to call their category “Pervasive Fidgeting Disorder”? Fidgeting is, by their account, the most statistically significant of their fourteen behavioral items. If their diagnosis is truly descriptive, why not name it for its most consistent symptom?

These doctors ignored this obvious choice, however, and chose to call their category “Attention Deficit Disorder,” a term with clear etiological implications. Why did they do this?

The Real Reason for the DSMs

For the explanation of this discrepancy we need to go back to Shrag and Divorky’s account of where the original diagnosis came from. As they point out in their book, “the cure preceded the ailment.” The cure they are speaking of is the drug Ritalin.

Before ADD, Ritalin was being used for children who were showing what was then called “functional behavior problems.” The term “functional” really means “we don't know the cause but think it’s nothing organic.”

Ritalin was seen to calm these children who exhibited “functional behavior problems.” But, some nascent gurus reasoned, Ritalin is a stimulant! How could a drug which was a known stimulant calm children? Clearly some fancy footwork was going to be needed to put this plus two and minus two together and come out four. (The old maid’s tale that coffee calms kids may have had something to do with the decision to experiment with stimulants for any calming properties they may contain.)

Not to worry. Clinical professors sharpen their teeth on challenges of this kind. The rationalization they constructed went like this. There has to be a brain center which enables the child to focus his or her attention on the environment, right? Let’s call this the Attention Center. Ritalin stimulates this center, which leads the child to pay better attention. Now that the child is focusing better, he or she copes better and, consequently, the behavior improves. Q.E.D. and all that stuff that makes it all sound precise and logical!

The next step was obvious. Since Ritalin stimulates this Attention Center and the child gets better, that center must not have been doing its job before. That means the child’s symptoms are caused by a deficit in his or her ability to attend. Voila! The child has an Attention Deficit Disorder!

You'd think, wouldn’t you, that if a man rode too long on an intellectual merry-go-round like this, he'd get dizzy? The diagnosis Attention Deficit Disorder has to be the first occasion in medical history where a diagnosis was named for a purely speculative rationalization, constructed to account for an unexplained drug effect.

Despite their horror of etiological implications creeping into their diagnostic nomenclature, the DSM gurus took this illegitimate orphan in, lock, stock, and barrel. With undaunted faith, hope, and charity, they have foisted it on the rest of us for nearly a decade now. And many swallowed it, hook, line, and sinker. Though it is becoming increasingly clear the Attention Deficit diagnosis doesn’t hold water, down at DSM HQ, they just change the check list and keep on trucking.

So, let’s now take a look at this famous check list.