March 30, 2009
A recent post at Furious Seasons on the spooky future of psychiatry prompted me to dig a little deeper into the origins of prodromal diagnoses.
A prodrome is “a symptom or group of symptoms that appears shortly before an acute attack of illness. The term comes from a Greek word that means “running ahead of.”” A spooky emerging trend in clinical psychiatry is the appropriation of this concept under the paradigm of “early intervention in psychosis” for “at risk” patients. Psychiatrists are preventively diagnosing mental illness and treating people prior to them exhibiting any behavioral symptoms.
Earlier diagnosis and early intervention. The past decade has witnessed a surge of progress in identifying individuals at high risk for psychosis or mood disorders. The “prodrome” has become a fertile area of research, with a focus on early “treatment” even before the clinical syndrome of schizophrenia or mania appears. The goal is to try to delay, modify, or ameliorate incipient serious mental illness by using both pharmacotherapy and psychotherapy.(“Psychiatry’s Future is Here“)
Instinctively, preventative health care seems like a good thing. Western medicine is often criticized for primarily responding to acute crises, instead of proactively promoting health and well-being. However, the reductionist flattening of minds into brains leads to categorical errors which pervert the Hippocratic principle to “do no harm”. Applying the medical paradigm of treating risks (instead of disorders) to mental conditions stretches the dangerously elastic diagnostic net beyond the breaking point.
Analogies between mental conditions and diseases of the body, such as the measles or heart failure, are often the point of departure for proponents of prodromal treatment. However, this rhetorical sleight of hand disguises many relevant disanalogies. The pathologization of diverse mental states remains controversial, unlike life threatening viruses or organ failures. Furthermore, there is currently no casual theory explaining why some people’s psychological experiences degenerate into crisis. Arguably, there can never be such a theory until we make significant progress towards resolving the mind/body problem, (a.k.a. the “hard problem” of consciousness). Without a causal theory explaining the transitions between mental states, all prodromal diagnoses of mental conditions are necessarily speculative correlations.
The roots of prodromal diagnosis of mental conditions can be traced back to work on the prodromal identification of schizophrenia.
What is needed is not the early diagnosis of schizophrenia, but the diagnosis of pre-psychotic schizophrenia. We must learn to recognize that state of mind which will develop into schizophrenia unless appropriate measures are taken to prevent deterioration.[*]
However, the identification of reliable predictors of schizophrenia has proven to be notoriously difficult and conceptually slippery:
Identifying symptoms or signs that reliably predict onset would obviously aid attempts to prevent mental disorders. Such specific predictors do not currently exist. In fact, one could argue that if any such risk factors were identified they would be conceptualized as early phenomena of the disorder itself… The nonspecific nature of these common features is notable. [*]
The Diganostic Statistical Manual is the psychiatric bible, effectively the working definition of insanity. The clinical gaze embodied in its pages is rooted in behaviorism – the symptoms it defines are all observable behaviors. The trend towards prodromal mental diagnoses is frightening precisely because it cedes even more power to an already cold and inhumane apparatus, which fails to listen to the voices of the people it claims to treat. The risks of preemptive discipline and prescriptive moral judgment reek of rhymes with eugenics, and are simply too great and horrifying for this practice to continue. Patients are being indicted on the basis of hereditary factors, thought crimes, and innocuous deviant behavior.
Furthermore, the psychopharmacological treatments prescribed for these prodromal diagnoses are physically dangerous and psychologically damaging. The atypical anti-psychotics that are often prescribed in these circumstances have been linked to excessive weight gain, metabolic disorders, and diabetes. The stigma attached to these diagnoses is also emotionally threatening. Advertising campaigns such as the award winning “Prescribe Early” poster have heightened the pressure to preventively prescribe dangerous medication, before it is too late. Children and teens often traverse defiant emotional terrain on their journey of self-discovery and becoming. Adult disapproval towards behaviors (smoking, drinking, inappropriateness, and irritability) and appearances (fashion, body piercings, hair style) has increasingly taken the form of chemical discipline,[*] with psychiatry’s permission and blessing.
That future of psychiatry is quite disturbed. Prodromal treatment is the latest progression in an ever constricting system of control. Preventative psychiatric treatment hints at forms of control that resonate with fears of omniscient surveillance, and we can begin to glimpse how grotesque these practices will become in an era of electronic medical records. Pathologizing the neurologically diverse is bad enough. Extending this attitude (and treatment) to those at risk of being neurologically diverse is downright evil.