What Is Cancer? What Causes Cancer?

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What Is Cancer? What Causes Cancer?

Cancer is a class of diseases characterized by out-of-control cell growth. There are over 100 different types of cancer, and each is classified by the type of cell that is initially affected.

Cancer harms the body when damaged cells divide uncontrollably to form lumps or masses of tissue called tumors (except in the case of leukemia where cancer prohibits normal blood function by abnormal cell division in the blood stream). Tumors can grow and interfere with the digestive, nervous, and circulatory systems, and they can release hormones that alter body function. Tumors that stay in one spot and demonstrate limited growth are generally considered to be benign.

More dangerous, or malignant, tumors form when two things occur:

1. a cancerous cell manages to move throughout the body using the blood or lymph systems, destroying healthy tissue in a process called invasion
2. that cell manages to divide and grow, making new blood vessels to feed itself in a process called angiogenesis.

When a tumor successfully spreads to other parts of the body and grows, invading and destroying other healthy tissues, it is said to have metastasized. This process itself is called metastasis, and the result is a serious condition that is very difficult to treat.

How cancer spreads - scientists reported in Nature Communications (October 2012 issue) that they have discovered an important clue as to why cancer cells spread. It has something to do with their adhesion (stickiness) properties.

Certain molecular interactions between cells and the scaffolding that holds them in place (extracellular matrix) cause them to become unstuck at the original tumor site, they become dislodged, move on and then reattach themselves at a new site.

The researchers say this discovery is important because cancer mortality is mainly due to metastatic tumors, those that grow from cells that have traveled from their original site to another part of the body. Only 10% of cancer deaths are caused by the primary tumors.

The scientists, from the Massachusetts Institute of Technology, say that finding a way to stop cancer cells from sticking to new sites could interfere with metastatic disease, and halt the growth of secondary tumors.

In 2007, cancer claimed the lives of about 7.6 million people in the world. Physicians and researchers who specialize in the study, diagnosis, treatment, and prevention of cancer are called oncologists.

Malignant cells are more agile than non-malignant ones - scientists from the Physical Sciences-Oncology Centers, USA, reported in the journal Scientific Reports (April 2013 issue) that malignant cells are much “nimbler” than non-malignant ones. Malignant cells can pass more easily through smaller gaps, as well as applying a much greater force on their environment compared to other cells.

Professor Robert Austin and team created a new catalogue of the physical and chemical features of cancerous cells with over 100 scientists from 20 different centers across the United States.
The authors believe their catalogue will help oncologists detect cancerous cells in patients early on, thus preventing the spread of the disease to other parts of the body.

Prof. Austin said "By bringing together different types of experimental expertise to systematically compare metastatic and non-metastatic cells, we have advanced our knowledge of how metastasis occurs."

What causes cancer?

Cancer is ultimately the result of cells that uncontrollably grow and do not die. Normal cells in the body follow an orderly path of growth, division, and death. Programmed cell death is called apoptosis, and when this process breaks down, cancer begins to form. Unlike regular cells, cancer cells do not experience programmatic death and instead continue to grow and divide. This leads to a mass of abnormal cells that grows out of control.

What is cancer? - Video

A short, 3D, animated introduction to cancer. This was originally created by BioDigital Systems and used in the Stand Up 2 Cancer telethon.

Genes - the DNA type

Cells can experience uncontrolled growth if there are damages or mutations to DNA, and therefore, damage to the genes involved in cell division. Four key types of gene are responsible for the cell division process: oncogenes tell cells when to divide, tumor suppressor genes tell cells when not to divide, suicide genes control apoptosis and tell the cell to kill itself if something goes wrong, and DNA-repair genes instruct a cell to repair damaged DNA.

Cancer occurs when a cell's gene mutations make the cell unable to correct DNA damage and unable to commit suicide. Similarly, cancer is a result of mutations that inhibit oncogene and tumor suppressor gene function, leading to uncontrollable cell growth.

Carcinogens

Carcinogens are a class of substances that are directly responsible for damaging DNA, promoting or aiding cancer. Tobacco, asbestos, arsenic, radiation such as gamma and x-rays, the sun, and compounds in car exhaust fumes are all examples of carcinogens. When our bodies are exposed to carcinogens, free radicals are formed that try to steal electrons from other molecules in the body. Theses free radicals damage cells and affect their ability to function normally.

Genes - the family type

Cancer can be the result of a genetic predisposition that is inherited from family members. It is possible to be born with certain genetic mutations or a fault in a gene that makes one statistically more likely to develop cancer later in life.

Other medical factors

As we age, there is an increase in the number of possible cancer-causing mutations in our DNA. This makes age an important risk factor for cancer. Several viruses have also been linked to cancer such as: human papillomavirus (a cause of cervical cancer), hepatitis B and C (causes of liver cancer), and Epstein-Barr virus (a cause of some childhood cancers). Human immunodeficiency virus (HIV) - and anything else that suppresses or weakens the immune system - inhibits the body's ability to fight infections and increases the chance of developing cancer.

What are the symptoms of cancer?

Cancer symptoms are quite varied and depend on where the cancer is located, where it has spread, and how big the tumor is. Some cancers can be felt or seen through the skin - a lump on the breast or testicle can be an indicator of cancer in those locations. Skin cancer (melanoma) is often noted by a change in a wart or mole on the skin. Some oral cancers present white patches inside the mouth or white spots on the tongue.

Other cancers have symptoms that are less physically apparent. Some brain tumors tend to present symptoms early in the disease as they affect important cognitive functions. Pancreas cancers are usually too small to cause symptoms until they cause pain by pushing against nearby nerves or interfere with liver function to cause a yellowing of the skin and eyes called jaundice. Symptoms also can be created as a tumor grows and pushes against organs and blood vessels. For example, colon cancers lead to symptoms such as constipation, diarrhea, and changes in stool size. Bladder or prostate cancers cause changes in bladder function such as more frequent or infrequent urination.

As cancer cells use the body's energy and interfere with normal hormone function, it is possible to present symptoms such as fever, fatigue, excessive sweating, anemia, and unexplained weight loss. However, these symptoms are common in several other maladies as well. For example, coughing and hoarseness can point to lung or throat cancer as well as several other conditions.

When cancer spreads, or metastasizes, additional symptoms can present themselves in the newly affected area. Swollen or enlarged lymph nodes are common and likely to be present early. If cancer spreads to the brain, patients may experience vertigo, headaches, or seizures. Spreading to the lungs may cause coughing and shortness of breath. In addition, the liver may become enlarged and cause jaundice and bones can become painful, brittle, and break easily. Symptoms of metastasis ultimately depend on the location to which the cancer has spread.

How is cancer classified?

There are five broad groups that are used to classify cancer.

1. Carcinomas are characterized by cells that cover internal and external parts of the body such as lung, breast, and colon cancer.
2. Sarcomas are characterized by cells that are located in bone, cartilage, fat, connective tissue, muscle, and other supportive tissues.
3. Lymphomas are cancers that begin in the lymph nodes and immune system tissues.
4. Leukemias are cancers that begin in the bone marrow and often accumulate in the bloodstream.
5. Adenomas are cancers that arise in the thyroid, the pituitary gland, the adrenal gland, and other glandular tissues.

Cancers are often referred to by terms that contain a prefix related to the cell type in which the cancer originated and a suffix such as -sarcoma, -carcinoma, or just -oma. Common prefixes include:

• Adeno- = gland
• Chondro- = cartilage
• Erythro- = red blood cell
• Hemangio- = blood vessels
• Hepato- = liver
• Lipo- = fat
• Lympho- = white blood cell
• Melano- = pigment cell
• Myelo- = bone marrow
• Myo- = muscle
• Osteo- = bone
• Uro- = bladder
• Retino- = eye
• Neuro- = brain

How is cancer diagnosed and staged?

Early detection of cancer can greatly improve the odds of successful treatment and survival. Physicians use information from symptoms and several other procedures to diagnose cancer. Imaging techniques such as X-rays, CT scans, MRI scans, PET scans, and ultrasound scans are used regularly in order to detect where a tumor is located and what organs may be affected by it. Doctors may also conduct an endoscopy, which is a procedure that uses a thin tube with a camera and light at one end, to look for abnormalities inside the body.

Extracting cancer cells and looking at them under a microscope is the only absolute way to diagnose cancer. This procedure is called a biopsy. Other types of molecular diagnostic tests are frequently employed as well. Physicians will analyze your body's sugars, fats, proteins, and DNA at the molecular level. For example, cancerous prostate cells release a higher level of a chemical called PSA (prostate-specific antigen) into the bloodstream that can be detected by a blood test. Molecular diagnostics, biopsies, and imaging techniques are all used together to diagnose cancer.

After a diagnosis is made, doctors find out how far the cancer has spread and determine the stage of the cancer. The stage determines which choices will be available for treatment and informs prognoses. The most common cancer staging method is called the TNM system. T (1-4) indicates the size and direct extent of the primary tumor, N (0-3) indicates the degree to which the cancer has spread to nearby lymph nodes, and M (0-1) indicates whether the cancer has metastasized to other organs in the body. A small tumor that has not spread to lymph nodes or distant organs may be staged as (T1, N0, M0), for example.
TNM descriptions then lead to a simpler categorization of stages, from 0 to 4, where lower numbers indicate that the cancer has spread less. While most Stage 1 tumors are curable, most Stage 4 tumors are inoperable or untreatable.

How is cancer treated?

Cancer treatment depends on the type of cancer, the stage of the cancer (how much it has spread), age, health status, and additional personal characteristics. There is no single treatment for cancer, and patients often receive a combination of therapies and palliative care. Treatments usually fall into one of the following categories: surgery, radiation, chemotherapy, immunotherapy, hormone therapy, or gene therapy.

Surgery

Surgery is the oldest known treatment for cancer. If a cancer has not metastasized, it is possible to completely cure a patient by surgically removing the cancer from the body. This is often seen in the removal of the prostate or a breast or testicle. After the disease has spread, however, it is nearly impossible to remove all of the cancer cells. Surgery may also be instrumental in helping to control symptoms such as bowel obstruction or spinal cord compression.

Innovations continue to be developed to aid the surgical process, such as the iKnife that "sniffs" out cancer. Currently, when a tumor is removed surgeons also take out a “margin” of healthy tissue to make sure no malignant cells are left behind. This usually means keeping the patients under general anesthetic for an extra 30 minutes while tissue samples are tested in the lab for “clear margins”. If there are no clear margins, the surgeon has to go back in and remove more tissue (if possible). Scientists from Imperial College London say the iKnife may remove the need for sending samples to the lab.

Radiation

Radiation treatment, also known as radiotherapy, destroys cancer by focusing high-energy rays on the cancer cells. This causes damage to the molecules that make up the cancer cells and leads them to commit suicide. Radiotherapy utilizes high-energy gamma-rays that are emitted from metals such as radium or high-energy x-rays that are created in a special machine. Early radiation treatments caused severe side-effects because the energy beams would damage normal, healthy tissue, but technologies have improved so that beams can be more accurately targeted. Radiotherapy is used as a standalone treatment to shrink a tumor or destroy cancer cells (including those associated with leukemia and lymphoma), and it is also used in combination with other cancer treatments.

Chemotherapy

Chemotherapy utilizes chemicals that interfere with the cell division process - damaging proteins or DNA - so that cancer cells will commit suicide. These treatments target any rapidly dividing cells (not necessarily just cancer cells), but normal cells usually can recover from any chemical-induced damage while cancer cells cannot. Chemotherapy is generally used to treat cancer that has spread or metastasized because the medicines travel throughout the entire body. It is a necessary treatment for some forms of leukemia and lymphoma. Chemotherapy treatment occurs in cycles so the body has time to heal between doses. However, there are still common side effects such as hair loss, nausea, fatigue, and vomiting. Combination therapies often include multiple types of chemotherapy or chemotherapy combined with other treatment options.

Immunotherapy

Immunotherapy aims to get the body's immune system to fight the tumor. Local immunotherapy injects a treatment into an affected area, for example, to cause inflammation that causes a tumor to shrink. Systemic immunotherapy treats the whole body by administering an agent such as the protein interferon alpha that can shrink tumors. Immunotherapy can also be considered non-specific if it improves cancer-fighting abilities by stimulating the entire immune system, and it can be considered targeted if the treatment specifically tells the immune system to destroy cancer cells. These therapies are relatively young, but researchers have had success with treatments that introduce antibodies to the body that inhibit the growth of breast cancer cells. Bone marrow transplantation (hematopoetic stem cell transplantation) can also be considered immunotherapy because the donor's immune cells will often attack the tumor or cancer cells that are present in the host.

Hormone therapy

Several cancers have been linked to some types of hormones, most notably breast and prostate cancer. Hormone therapy is designed to alter hormone production in the body so that cancer cells stop growing or are killed completely. Breast cancer hormone therapies often focus on reducing estrogen levels (a common drug for this is tamoxifen) and prostate cancer hormone therapies often focus on reducing testosterone levels. In addition, some leukemia and lymphoma cases can be treated with the hormone cortisone.

Gene therapy

The goal of gene therapy is to replace damaged genes with ones that work to address a root cause of cancer: damage to DNA. For example, researchers are trying to replace the damaged gene that signals cells to stop dividing (the p53 gene) with a copy of a working gene. Other gene-based therapies focus on further damaging cancer cell DNA to the point where the cell commits suicide. Gene therapy is a very young field and has not yet resulted in any successful treatments.

Using cancer-specific immune system cells to treat cancer

Scientists from the RIKEN Research Centre for Allergy and Immunology in Yokohama, Japan, explained in the journal Cell Stem Cell (January 2013 issue) how they managed to make cancer-specific immune system cells from iPSCs (induced pluripotent stem cells) to destroy cancer cells.

The authors added that their study has shown that it is possible to clone versions of the patients’ own cells to enhance their immune system so that cancer cells could be destroyed naturally.

Hiroshi Kawamoto and team created cancer-specific killer T-lymphocytes from iPSCs. They started off with mature T-lymphocytes which were specific for a type of skin cancer and reprogrammed them into iPSCs with the help of “Yamanaka factors”. The iPSCs eventually turned into fully active, cancer-specific T-lymphocytes - in other words, cells that target and destroy cancer cells.

How can cancer be prevented?

Cancers that are closely linked to certain behaviors are the easiest to prevent. For example, choosing not to smoke tobacco or drink alcohol significantly lower the risk of several types of cancer - most notably lung, throat, mouth, and liver cancer. Even if you are a current tobacco user, quitting can still greatly reduce your chances of getting cancer.

Skin cancer can be prevented by staying in the shade, protecting yourself with a hat and shirt when in the sun, and using sunscreen. Diet is also an important part of cancer prevention since what we eat has been linked to the disease. Physicians recommend diets that are low in fat and rich in fresh fruits and vegetables and whole grains.

Certain vaccinations have been associated with the prevention of some cancers. For example, many women receive a vaccination for the human papillomavirus because of the virus's relationship with cervical cancer. Hepatitis B vaccines prevent the hepatitis B virus, which can cause liver cancer.

Some cancer prevention is based on systematic screening in order to detect small irregularities or tumors as early as possible even if there are no clear symptoms present. Breast self-examination, mammograms, testicular self-examination, and Pap smears are common screening methods for various cancers.

Researchers from Northwestern University Feinberg School of Medicine in Chicago reported in the journal Circulation that the 7 steps recommended for protection against heart disease can also reduce the risk of developing cancer,. They include being physically active, eating a healthy diet, controlling cholesterol, managing blood pressure, reducing blood sugar and not smoking.

Targeting cancers for new drug therapies

Researchers at The Institute of Cancer Research reported in the journal Nature Reviews Drug Discovery (January 2013 issue) that they have found a new way of rapidly prioritizing the best druggable targets online. They managed to identify 46 previously overlooked targets.

The researchers used the canSAR database together with a tool and were able to compare up to 500 drug targets in a matter of minutes. With this method, it is possible to analyze huge volumes of data to discover new drug targets, which can lead to the development of effective cancer medications.

The scientists analyzed 479 cancer genes to determine which ones were potential targets for medications. Their approach was effective - they found 46 new potentially “druggable” cancer proteins.

Not only will this approach lead to much more targeted cancer drugs, but also considerably cheaper ones, the authors added.

Cancer / Oncology news

Medical News Today is a leading resource for the latest news on cancer. You can find our cancer news section here.

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This what is cancer? information section was written by Peter Crosta for Medical News Today in September 2008 and was last updated in 19 July 2013. The contents may not be re-produced in any way without the permission of Medical News Today.

Business Day

Drug Shortages Persist in U.S., Harming Care

Chip Litherland for The New York Times

 

Jennifer Lacognata with her son Nic. Her doctor prescribed a liquid vitamin for her, but the manufacturer stopped making it.

By KATIE THOMAS

Published: November 16, 2012

Paul Davis, the chief of a rural ambulance squad in southern Ohio, was down to his last vial of morphine earlier this fall when a woman with a broken leg needed a ride to the hospital.

The trip was 30 minutes, and the patient was in pain. But because of a nationwide shortage, his morphine supply had dwindled from four doses to just one, presenting Mr. Davis with a stark quandary. Should he treat the woman, who was clearly suffering? Or should he save it for a patient who might need it more? 

In the end, he opted not to give her the morphine, a decision that haunts him still. “I just feel like I’m not doing my job,” said Mr. Davis, who is chief of the rescue squad in Vernon, Ohio. He has since refilled his supply. “I shouldn’t have to make those kinds of decisions.” 

From rural ambulance squads to prestigious hospitals, health care workers are struggling to keep vital medicines in stock because of a drug shortage crisis that is proving to be stubbornly difficult to fix. Rationing is just one example of the extraordinary lengths being taken to address the shortage, which health care workers say has ceased to be a temporary emergency and is now a fact of life. In desperation, they are resorting to treating patients with less effective alternative medicines and using expired drugs. The Cleveland Clinic has hired a pharmacist whose only job is to track down hard-to-find drugs. 

Caused largely by an array of manufacturing problems, the shortage has prompted Congressional hearings, a presidential order and pledges by generic drug makers to communicate better with federal regulators. 

The problem peaked in 2011, when a record 251 drugs were declared in short supply. This year, slightly more than 100 were placed on the list, and workers say the battle to keep pharmacy shelves stocked continues unabated. The list of hard-to-find medicines ranges from basic drugs like the heart medicine nitroglycerin to a lidocaine injection, which is used to numb tissue before surgery. 

A deadly meningitis outbreak caused by contamination at a large drug producer could worsen the situation, federal officials have warned. The Food and Drug Administration said that shortages of six drugs — medicines used during surgery and to treat conditions like congestive heart failure — could get worse after a big compounding pharmacy closed over concerns about drug safety. The pharmacy, Ameridose, shares some management with the New England Compounding Center, which is at the center of a meningitis outbreak that has claimed 33 lives. 

“When you can’t treat basic things — cardiac arrest, pain management, seizures — you’re in trouble,” said Dr. Carol Cunningham, the state medical director for the Ohio Department of Public Safety’s emergency services division. “When you only have five tools in your toolbox and three of them are gone, what do you do?” 

Dr. Margaret A. Hamburg, the F.D.A. commissioner, said in an interview this week that she was “guardedly optimistic” that the shortage crisis was abating. “I think there’s been an enormous amount of progress,” she said. “We’re seeing real change in the number of shortages that we’re able to recognize early.” More than 150 new shortages have been prevented this year, according to the agency.

But Erin Fox, who tracks supply levels for a broader range of drugs at the University of Utah, said once a drug became scarce, it tended to stay scarce. The university’s Drug Information Service was actively tracking 282 hard-to-find products by the end of the third quarter of this year, a record. 

“The shortages we have aren’t going away — they’re not resolving,” she said. “But the good news is we’re not piling more shortages on top.” 

In 2011, prompted by emotional pleas by cancer patients and others who said the drug shortage was threatening lives, President Obama issued an executive order requiring drug makers to notify the F.D.A. when a shortage appeared imminent. The agency also loosened some restrictions on importing drugs, and sped up approvals by other manufacturers to make certain medicines. 

A law passed this summer contains several provisions aimed at improving the situation, including expediting approval of new generic medicines and requiring the agency’s enforcement unit to better coordinate with its drug-shortage officials before it takes action against a manufacturer. 

Ralph G. Neas, the chief executive of the Generic Pharmaceutical Association, said fixing the drug shortage was complex and would take time, but was a top priority. “One shortage is one shortage too many,” he said. “One patient not getting a critical drug is one patient too many.” 

Federal drug officials trace much of the drug shortage crisis to delays at plants that make sterile injectable drugs, which account for about 80 percent of the scarce medicines. Nearly a third of the industry’s manufacturing capacity is not running because of plant closings or shutdowns to fix serious quality issues. Other shortages have been caused by supply disruptions of the raw ingredients used to make the drugs, or by manufacturers exiting the market. 

Some people have accused the F.D.A. of causing the shortages, saying overzealous enforcement and poor communication have led plants to close needlessly or to slow production. Others have cited economic factors, like market pressures and reimbursement policies that have set prices so low that some companies have stopped making certain drugs. Earlier this week, several Democratic members of Congress asked the Government Accountability Office to investigate whether the practices of so-called group purchasing organizations, which buy drugs on behalf of hospitals, was contributing to the shortage. 

Regardless of the cause, the drug shortage has forced the F.D.A. to make some tough choices, including allowing manufacturers to sell drugs that, if it were not for the crisis, most likely would have been recalled. Last year, for example, the agency allowed the manufacturer American Regent to sell a drug used during chemotherapy that was found to contain glass particles. Doctors and nurses were instructed to filter the drug, sodium thiosulfate, before administering it to patients. 

“If there wasn’t a shortage, we would never allow a company to continue marketing” in such cases, Dr. Sandra Kweder, deputy director of the F.D.A.’s office of new drugs, said. But “patients need it.” 

Dr. Hamburg said drug manufacturers had invested significantly in improving their facilities, upgrades that will ultimately help ease the crisis but that in the near term are making some shortages difficult to resolve. “It’s not going to happen overnight, but we’re in the midst of a period of really, very significant change that offers great promise for the future,” she said. 

Patients like Jennifer Lacognata, a mother of two in suburban Florida, say they cannot afford to wait. She has debilitating night blindness, skin lesions and other health problems because she cannot absorb vitamin A through her diet, a rare side effect of weight-loss surgery she had years ago. In 2011, her doctor prescribed Aquasol A, a liquid form of the vitamin, to be injected into her shoulder. 

But Hospira has temporarily stopped selling Aquasol A after it decided to move manufacturing of the product from an outside company to one of its plants. The company recently decided to abort the plan, citing complex technical challenges, and now has a deal with another company to begin making the vitamin.

Ms. Lacognata sued Hospira unsuccessfully to try to compel the company to make it again. 

A company spokeswoman said Hospira recognized the critical need for Aquasol A and was “working diligently” to return it to the market, but declined to provide an estimate of when. 

Given that the delays have stretched for more than a year, Ms. Lacognata said she was not holding her breath. “If they don’t get their act together and do this, they’re not going to suffer,” she said. “They’re still going to be making millions of dollars. It’s the little guy in the end who ends up with nothing.”

A version of this article appeared in print on November 17, 2012, on page A1 of the New York edition with the headline: Drug Shortages Persist in U.S., Harming Care.

A mad world: A diagnosis of mental illness is more common than ever – did psychiatrists create the problem, or just recognise it?

Aeon Magazine 

A mad world

A diagnosis of mental illness is more common than ever – did psychiatrists create the problem, or just recognise it?

by Joseph Pierre 

When a psychiatrist meets people at a party and reveals what he or she does for a living, two responses are typical. People either say, ‘I’d better be careful what I say around you,’ and then clam up, or they say, ‘I could talk to you for hours,’ and then launch into a litany of complaints and diagnostic questions, usually about one or another family member, in-law, co-worker, or other acquaintance. It seems that people are quick to acknowledge the ubiquity of those who might benefit from a psychiatrist’s attention, while expressing a deep reluctance ever to seek it out themselves.

That reluctance is understandable. Although most of us crave support, understanding, and human connection, we also worry that if we reveal our true selves, we’ll be judged, criticised, or rejected in some way. And even worse – perhaps calling upon antiquated myths – some worry that, if we were to reveal our inner selves to a psychiatrist, we might be labelled crazy, locked up in an asylum, medicated into oblivion, or put into a straitjacket. Of course, such fears are the accompaniment of the very idiosyncrasies, foibles, and life struggles that keep us from unattainably perfect mental health.

As a psychiatrist, I see this as the biggest challenge facing psychiatry today. A large part of the population – perhaps even the majority – might benefit from some form of mental health care, but too many fear that modern psychiatry is on a mission to pathologise normal individuals with some dystopian plan fuelled by the greed of the pharmaceutical industry, all in order to put the populace on mind-numbing medications. Debates about psychiatric overdiagnosis have amplified in the wake of last year’s release of the newest edition of theDiagnostic and Statistical Manual of Mental Disorders (DSM-5), the so-called ‘bible of psychiatry’, with some particularly vocal critics coming from within the profession.

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It’s true that the scope of psychiatry has greatly expanded over the past century. A hundred years ago, the profession had a near-exclusive focus on the custodial care of severely ill asylum patients. Now, psychiatric practice includes the office-based management of the ‘worried well’. The advent of psychotherapy, starting with the arrival of Sigmund Freud’s psychoanalysis at the turn of the 20th century, drove the shift. The ability to treat less severe forms of psychopathology – such as anxiety and so-called adjustment disorders related to life stressors – with the talking cure has had profound effects on mental health care in the United States.

Early forms of psychotherapy paved the way for the Mental Hygiene Movement that lasted from about 1910 through the 1950s. This public health model rejected hard boundaries of mental illness in favour of a view that acknowledged the potential for some degree of mental disorder to exist in nearly everyone. Interventions were recommended not just within a psychiatrist’s office, but broadly within society at large; schools and other community settings were all involved in providing support and help.

A new abundance of ‘neurotic’ symptoms stemming from the trauma experienced by veterans of the First and Second World Wars reinforced a view that mental health and illness existed on a continuous spectrum. And by the time DSM was first published in 1952, psychiatrists were treating a much wider swath of the population than ever before. From the first DSM through to the most recent revision, inclusiveness and clinical usefulness have been guiding principles, with the profession erring on the side of capturing all of the conditions that bring people to psychiatric care in order to facilitate evaluation and treatment.

In the modern era, psychotherapy has steered away from traditional psychoanalysis in favour of more practical, shorter-term therapies: for instance, psychodynamic therapy explores unconscious conflicts and underlying distress on a weekly basis for as little as a few months’ duration, and goal-directed cognitive therapy uses behavioural techniques to correct disruptive distortions in thinking. These streamlined psychotherapeutic techniques have widened the potential consumer base for psychiatric intervention; they have also expanded the range of clinicians who can perform therapy to include not only psychiatrists, but primary care doctors, psychologists, social workers, and marriage and family therapists.

In a similar fashion, newer medications with fewer side effects are more likely to be offered to people with less clear-cut psychiatric illnesses. Such medications can be prescribed by a family physician or, in some states, a psychologist or nurse practitioner.

Viewed through the lens of the DSM, it is easy to see how extending psychiatry’s helping hand deeper into the population is often interpreted as evidence that psychiatrists think more and more people are mentally ill. Recent epidemiological studies based upon DSMcriteria have suggested that half or more of the US population will meet the threshold for mental disorder at some point in their lives. To many, the idea that it might be normal to have a mental illness sounds oxymoronic at best and conspiratorially threatening at worst. Yet the widening scope of psychiatry has been driven by a belief – on the parts of both mental health consumers and clinicians alike – that psychiatry can help with an increasingly large range of issues.

The diagnostic creep of psychiatry becomes more understandable by conceptualising mental illness, like most things in nature, on a continuum. Many forms of psychiatric disorder, such as schizophrenia or severe dementia, are so severe – that is to say, divergent from normality – that whether they represent illness is rarely debated. Other syndromes, such as generalised anxiety disorder, might more closely resemble what seems, to some, like normal worry. And patients might even complain of isolated symptoms such as insomnia or lack of energy that arise in the absence of any fully formed disorder. In this way, a continuous view of mental illness extends into areas that might actually be normal, but still detract from optimal, day-to-day function.

While a continuous view of mental illness probably reflects underlying reality, it inevitably results in grey areas where ‘caseness’ (whether someone does or does not have a mental disorder) must be decided based on judgment calls made by experienced clinicians. In psychiatry, those calls usually depend on whether a patient’s complaints are associated with significant distress or impaired functioning. Unlike medical disorders where morbidity is often determined by physical limitations or the threat of impending death, the distress and disruption of social functioning associated with mental illness can be fairly subjective. Even those on the softer, less severe end of the mental illness spectrum can experience considerable suffering and impairment. For example, someone with mild depression might not be on the verge of suicide, but could really be struggling with work due to anxiety and poor concentration. Many people might experience sub-clinical conditions that fall short of the threshold for a mental disorder, but still might benefit from intervention.

The truth is that while psychiatric diagnosis is helpful in understanding what ails a patient and formulating a treatment plan, psychiatrists don’t waste a lot of time fretting over whether a patient can be neatly categorised in DSM, or even whether or not that patient truly has a mental disorder at all. A patient comes in with a complaint of suffering, and the clinician tries to relieve that suffering independent of such exacting distinctions. If anything, such details become most important for insurance billing, where clinicians might err on the side of making a diagnosis to obtain reimbursement for a patient who might not otherwise be able to receive care.

Though many object to psychiatry’s perceived encroachment into normality, we rarely hear such complaints about the rest of medicine. Few lament that nearly all of us, at some point in our lives, seek care from a physician and take all manner of medications, most without need of a prescription, for one physical ailment or another. If we can accept that it is completely normal to be medically sick, not only with transient conditions such as coughs and colds, but also chronic disorders such as farsightedness, lower back pain, high blood pressure or diabetes, why can’t we accept that it might also be normal to be psychiatrically ill at various points in our lives?

The answer seems to be that psychiatric disorders carry a much greater degree of stigma compared with medical conditions. People worry that psychiatrists think everyone is crazy because they make the mistake of equating any form of psychiatric illness with being crazy. But that’s like equating a cough with tuberculosis or lung cancer. To be less stigmatising, psychiatry must support a continuous model of mental health instead of maintaining an exclusive focus on the mental disorders that make up the DSM. If general medicine can work within a continuous view of physical health and illness, there is no reason why psychiatry can’t as well.

Criticism of this view comes from concern over the type of intervention offered at the healthier end of the continuum. If the scope of psychiatry widens, will psychiatric medications be vastly overprescribed, as is already claimed with stimulants such as methylphenidate (Ritalin) for attention deficit hyperactivity disorder (ADHD)? This concern is well worth fretting over, given the uncertain effectiveness of medications for patients who don’t quite meet DSMcriteria. For example, a 2008 study by the Harvard psychologist Irving Kirsch published in PLOS Medicine found that, for milder forms of depression, antidepressants are often no better than placebos. Likewise, recent research suggests that children at risk of developing psychosis – but not diagnosable just yet – might benefit more from fish oil or psychotherapy than antipsychotic drugs.

In the end, implementing pharmacotherapy for a given condition requires solid evidence from peer-reviewed research studies. Although by definition the benefit of medications decreases at the healthier end of a mental health continuum (if one isn’t as sick, the degree of improvement will be less), we need not reject all pharmacotherapy at the healthier end of the spectrum, provided medications are safe and effective. Of course, medications aren’t candy – most have a long list of potential side effects ranging from trivial to life-threatening. There’s a reason such medications require a prescription from a physician and why many psychiatrists are sceptical of proposals to grant prescribing privileges to health practitioners with far less medical training.

People worry that psychiatrists think everyone is crazy because they make the mistake of equating any form of psychiatric illness with being crazy. But that’s like equating a cough with tuberculosis or lung cancer

Pharmacotherapy for healthier individuals is likely to increase in the future as safer medications are developed, just as happened after selective serotonin re-uptake inhibitors (SSRIs) supplanted tricyclic antidepressants (TCAs) during the 1990s. In turn, the shift to medicating the healthier end of the continuum paves a path towards not only maximising wellness but enhancing normal functioning through ‘cosmetic’ intervention. Ultimately, availability of medications that enhance brain function or make us feel better than normal will be driven by consumer demand, not the Machiavellian plans of psychiatrists. The legal use of drugs to alter our moods is already nearly ubiquitous. We take Ritalin, modafinil (Provigil), or just our daily cup of caffeine to help us focus, stay awake, and make that deadline at work; then we reach for our diazepam (Valium), alcohol, or marijuana to unwind at the end of the day. If a kind of anabolic steroid for the brain were created, say a pill that could increase IQ by an average of 10 points with a minimum of side effects, is there any question that the public would clamour for it? Cosmetic psychiatry is a very real prospect for the future, with myriad moral and ethical implications involved.

In the final analysis, psychiatrists don’t think that everyone is crazy, nor are we necessarily guilty of pathologising normal existence and foisting medications upon the populace as pawns of the drug companies. Instead, we are just doing what we can to relieve the suffering of those coming for help, rather than turning those people away.

The good news for mental health consumers is that clinicians worth their mettle (and you might have to shop around to find one) don’t rely on the DSM as a bible in the way that many imagine, checking off symptoms like a computer might and trying to ‘shrink’ people into the confines of a diagnostic label. A good psychiatrist draws upon clinical experience to gain empathic understanding of each patient’s story, and then offers a tailored range of interventions to ease the suffering, whether it represents a disorder or is part of normal life.

19 March 2014