On December 23, I wrote a post called DSM-5 – Dimensional Diagnoses – More Conflicts of Interest? In the article I sketched out the role of David Kupfer, MD, in promoting the concept of dimensional assessment in DSM-5, and I speculated that at least part of his motivation in this regard might have stemmed from the fact that he is a major shareholder in a company that is developing a computerized assessment instrument. I ended the piece with a general criticism of psychiatry:
“There is only one agenda item in modern American psychiatry: the relentless expansion of psychiatric turf and drug sales. They’ve promoted categorical diagnoses and chemical imbalances strenuously for the past five decades. Now that these spurious notions are on the point of expiration, psychiatry is developing dimensional diagnoses and neurocircuitry malfunctions as the rallying points of the ‘new and improved’ psychiatry.
But the bottom line is always the same: turf and money. Something is truly rotten in the state of psychiatry.”
The article precipitated a fairly lengthy debate in the comments section. The discussion was wide ranging, and some of the issues addressed were fundamental to the entire psychiatric debate, in particular: whether or not psychiatry is based on valid science.
My own position is that the foundations of psychiatry are spurious, and the purpose of this post is to set out my position on this matter.
PSYCHIATRY’S USE OF THE TERM “ILLNESS”
Psychiatry’s most fundamental tenet is that virtually all significant problems of thinking, feeling, and/or behaving are illnesses that need to be studied and treated from a medical perspective. What’s not usually acknowledged, however, is that this is an arbitrary assumption.
In common speech and within the medical profession, the word “illness” indicates the presence of organic pathology: i.e. damage or malfunction in an organ. Historically, mental illnesses came into being, not because some scientist or group of scientists had recognized and established that problems of thinking, feeling, and/or behaving are caused by an organic malfunction, but rather because the APA had simply decided to extend the concept of illness to embrace these kinds of problems. For the record, some problems of thinking, feeling, and/or behaving are known to be caused by organic pathology, and I exclude those from the present discussion.
It is not superficially obvious that other problems of thinking, feeling, and/or behaving are actually illnesses, and there is a strong burden of proof on those who adopt this position. Psychiatry, however, has never proved this assertion, but nevertheless continues to expand its diagnostic net in the same way that it started – by fiat. A particular pattern of thinking, feeling and/or behaving becomes a mental illness/disorder because the APA says so!
Obviously I can’t dictate to psychiatrists how they should and should not use words. If they choose to call problems of this sort illnesses, then that’s their business. But they should also acknowledge that they are using the word illness in a distorted and misleading sense of the term.
They are also deviating from the ordinary standards and procedures of medical science. In the 1930′s, a German pathologist named Friederich Wegener discovered a “new” disease, which is now called Wegener’s Granulomatosis. He discovered this disease the old-fashioned way – by years of diligent post-mortem examinations and hundreds (thousands?) of microscope hours. The history of medical progress is the history of these kinds of discoveries.
By contrast, psychiatry produces their “diagnoses,” (e.g. ADHD, disruptive mood dysregulation disorder, conduct disorder, etc., etc.), simply by voting. They cling to the unacknowledged extended use of the term illness in these kinds of deliberations and decisions, whilst maintaining the pretense in their practices and promotional literature that the word is being used in its classical sense of organic pathology.
The reason that several psychoactive drugs have become blockbusters in recent years is that psychiatry has the advantage, unique in the medical field, that it can invent illnesses, and relax the criteria for these illnesses, more or less at will. Psychiatry, unlike other medical specialties, has no natural limits to its growth potential. They can continue to expand the diagnostic net until everybody in the world has a diagnosis. But it doesn’t even have to stop there. They can go for everybody having two, three, four, etc., diagnoses. If organized psychiatry votes an illness into being, there is no reality that can act as a brake or a check on this activity.
PSYCHIATRY AND SCIENCE
Despite this confusion in terminology, psychiatry routinely contends that its diagnoses are based on science. In the Introduction to DSM-IV, the APA wrote:
“More than any other nomenclature of mental disorders, DSM-IV is grounded in empirical evidence.” (p xvi)
And, of course, an enormous number of studies had been done. But, to the best of my knowledge, there wasn’t a single study on any “diagnosis” that addressed the fundamental question: is there any logical reason why this particular problem of thinking, feeling, and/or behaving should be conceptualized as an illness? This, in every case, was simply assumed, despite the fact that there are better, more productive, more parsimonious, and more logically sound ways to conceptualize these problems.
As a companion to DSM-IV, the APA published a five-volume sourcebook of references. There were prevalence studies, correlation studies, data re-analyses, field trials, etc… All of which was wonderful. But on the fundamental question: is there any rational reason for conceptualizing these conditions as illnesses? – there was nothing. Which was not surprising, because there had been nothing along those lines in the earlier manuals.
THE CHANGE FROM DSM-I TO DSM-II
And speaking of the earlier manuals, it needs to be noted that a major shift in underlying theory occurred between DSM-I and DSM-II. In DSM-I, most of the diagnostic terms contained the word “reaction” (e.g. schizophrenic reaction), the implication being that the problem in question was to be conceptualized as a reaction to something. In DSM-II, the word reaction was dropped. In the Foreword to DSM-II the drafting committee stated that the purpose of this change was to avoid terms that implied any particular causal theory. This notion was repeated in the Introduction to DSM-III-R:
“The use of the term reaction throughout the classification [in DSM-I] reflected the influence of Adolf Meyer’s psychobiologic view that mental disorders represented reactions of the personality to psychological, social, and biological factors.” (Adolf Meyer was an eminent Swiss-American psychiatrist, 1866-1950)
“The DSM-II classification did not use the term reaction, and except for the use of the term neuroses, used the diagnostic terms that, by and large, did not imply a particular theoretical framework for understanding the nonorganic mental disorders.” (p xviii)
All of this sounds fairly reasonable, but ignores the fact that the omission of the term “reaction” inevitably conveys the impression that the categories listed are to be conceptualized as primary illness entities. Despite their proffered justification for the claim, it is more plausible that the term was dropped in a deliberate attempt to oust Adolf Meyer’s notion of mental disorders as reactions to biopsychosocial stressors, especially his reformulation of schizophrenia as a cluster of maladaptive habits acquired in response to such stressors. It is also plausible that it was an attempt to return psychiatry to a Kraepelinian nosology of biologically-specifiable illnesses. In any event, that is exactly what has happened.
Many eminent psychiatrists today refer to the DSM as a psychiatric nosology. These include:
- Jordan W. Smoller, MD (Harvard and Mass General), Disorders and borders: psychiatric genetics and nosology, 2013
- Daniel S. Pine, MD (NIMH Intramural Research Program): A 60-Year Climb on the Mountain of Nosology, 2013
- Jeffrey Lieberman, MD (President of the APA, and Professor of Psychiatry at Columbia University): Psychiatric Diagnosis in the Lab: How Far Off Are We? in a presentation on Medscape, (2011). In this presentation, Dr. Lieberman refers to the DSM as “the ‘Bible of psychiatric nosology”.
The word nosology (from the Greek word nosos, meaning disease) means classification of illnesses, and by using this term in this context, psychiatrists are implying, without valid reason, that all significant problems of thinking, feeling, and/or behaving are illnesses, even though there is no evidence that this is a valid or helpful stance. In fact, as we’ve seen above, an alternative perspective (Adolf Meyer’s “reactions”) actually constituted psychiatric orthodoxy from 1952 to 1968. What is also clear and noteworthy in this matter is that Adolf Meyer’s theoretical/explanatory concepts were not abandoned on the grounds that they had been scientifically discredited or disproven. They were abandoned as part of an arbitrary decision by the DSM-II committee to medicalize problems of thinking, feeling, and/or behaving.
DSM-II’s decision to drop the word “reaction” was not, as claimed, a move to an atheoretical classification. Rather, it replaced a genuinely biopsychosocial causal framework with one that was purely biological: i.e. that all problems of thinking, feeling, and/or behaving are by definition primary disease entities. Under the present DSM system, psychiatry doesn’t have to prove that a problem is an illness, because that assertion is built into their definitions. If the DSM is a nosology, then every item listed must be an illness. This is not science. It is intellectual chicanery.
Having demonstrated that they could do this without much opposition in DSM-II, the APA solidified the arrangement in DSM-III, and expanded it to the point of travesty in DSM-IV and 5. In fact, in DSM-5, the disease notion is injected even more explicitly and more clearly than in the earlier manuals. In the Introduction chapter, following a discussion on the value of dimensional assessment, the APA states:
“These findings mean that DSM, like other medical disease-classifications, should accommodate ways to introduce dimensional approaches…” (p 5) [emphasis added]
EXPLANATORY VALUE OF PSYCHIATRIC DIAGNOSES
The notion that all problems of thinking, feeling, and/or behaving are illnesses has no explanatory value. Consider the following conversation.
Client’s daughter: “Why is my mother so depressed?”
Psychiatrist: “Because she has an illness called major depression.”
Client’s daughter: “How do you know she has this illness?
Psychiatrist: “Because she is so depressed.”
The only evidence for the illness is the very behavior it purports to explain. Unlike diagnoses in real medicine, there is no actual illness behind the DSM symptom lists to provide genuine explanatory value. Those of us on this side of the debate have been pointing out this kind of circular reasoning for decades, but I have never seen or heard a convincing response from psychiatry. Instead, they continue to promote their “diagnoses” to their clients, the media, and the general public as if they had explanatory value – when in fact they have none.
Psychiatry sometimes counters this particular criticism by denying that they ever promoted mental illnesses as causes or explanations of the symptoms. But in fact, causative language permeates DSM-III, IV, and 5. In almost every section of DSM-5, one can find exclusion clauses like: “The disturbance is not better explained by another mental disorder,” the clear implication being that mental disorders are being presented as explanations of the problems listed in the criteria sets. Additionally, the notion of a disorder/illness as the cause of its symptoms is standard in general medicine. For instance, the illness pneumonia causes the symptoms of coughing, weakness, etc.,. By using this kind of language in DSM, the APA is promoting the notion that their putative illnesses are indeed the causes of the symptoms. For instance, the behavior of running around the classroom and failing to pay attention to the teacher is routinely presented by psychiatry as being caused by the “illness” ADHD, and this is precisely how the notion of “mental illness” is perceived by clients, the media, and the general public. If it is not psychiatry’s intention to create this impression, then they need to make a concerted effort to correct the misunderstanding. I am not aware of any moves in this direction by the APA or by psychiatric opinion leaders.
THE IMPORTANCE OF VALID THEORIES
Organized psychiatry tends to dismiss this entire issue of the ontological status of the “mental illnesses” as academic or philosophical, and as having no real bearing on practice. But imagine how different psychiatry would be today if it had retained Adolf Meyer’s formulations. Research would probably not have been hijacked by pharma, and would be focused on social and environmental factors rather than on drug responses. Psychiatrists would take detailed histories in an attempt to understand their clients, rather than gathering just enough information to clinch the “diagnosis.” There would be no fifteen-minute med checks, and social skills training would be the dominant treatment modality.
Causal theories are not ivory tower abstractions. In any systematic human activity, they are the pillars that support and drive practice. And when they are spurious, as in the case of psychiatry, practices and procedures inevitably drift into error. The legitimacy of a profession depends on the validity and adequacy of its underlying causal theories. Indeed, the theories are the formal expression of the knowledge accumulated by the science at a given point in time. This applies particularly to those concepts that are very basic and fundamental. A shipping industry, for instance, that was working on the assumption that the Earth is flat, other things being equal, would probably not be noted for excellence of service. Similarly, a geo-centered astronomy would be a shaky foundation for the development of space travel. Human endeavors that are based on valid theories are more likely to yield success than those based on invalid theories.
To guard against misunderstanding, I’m not saying that good theories are sufficient. One also needs techniques, tools, skills, etc… But working without valid theories, or worse, working with invalid theories, inevitably leads practitioners astray. Which is exactly what has happened in the case of psychiatry. By assuming that all significant problems of thinking, feeling, and/or behaving are illnesses, they have, very naturally, been drawn into seeing these problems as entities that they (the physicians) have to fix by means of medical-type techniques, and seeing the owners of the problems as “patients” – i.e. people who have to be fixed. The illness theory also, because it conveys the false impression that the matter has been explained, has a dampening effect on practitioners’ curiosity as to genuine explanations.
Modern psychiatry has been plugging away at its so-called nosology for more than a hundred years, and the APA, in their successive revisions of the DSM, assure us that the classifications are scientific. Thought leaders and individual psychiatrists, with few exceptions, assure us that the “illnesses” listed in the manuals are scientifically established, ontologically valid entities that provide the framework for understanding and ameliorating problems of thinking, feeling, and/or behaving. But seldom is it acknowledged that this stance is nothing more than an assumption, the purpose of which was to establish psychiatric turf in a non-medical field.
“PSYCHIATRY IS VALID BECAUSE ITS TREATMENTS WORK”
It is sometimes argued that psychiatry derives validity and legitimacy from the fact that its treatments (i.e. drugs) work. In rebuttal, many writers on this side of the debate have pointed out that small quantities of alcohol help a person overcome shyness, but that nobody would conclude from this either that shyness is an illness, or that alcohol is a medicine. Drugs, whether they’re of the street, liquor store, or pharmaceutical variety, alter people’s thoughts, feelings, and/or behaviors. In some cases, the users of these products and their families express themselves pleased with the alteration.
I have known a good many marijuana users who maintained, with, I think, good credibility, that pot helped them control their anger – made them mellow. Over the years I have worked with several women who always kept a twelve-pack of beer in the refrigerator in case their husbands became angry or upset. In these cases, the pot and the alcohol “worked” in the sense that they forestalled the anger and rage. And psychopharmaceutical products sometimes “work” in this same pragmatic use of the term. But there is no evidence that any psychopharmaceutical product fixes or alleviates any pathological process. Indeed, what seems to be the case is that these drugs “work” by producing abnormal neurological states. From a pragmatic point of view the abnormal state may seem better to the client, and/or his family, and/or the authorities. But this does not establish that the original condition was an illness or that the drug is a medicine.
Obviously the problems listed in the DSM are real. That’s not the issue. What’s being challenged here is the contention that the clusters of problems set out in the manual can be validly conceptualized as symptoms of medical disease entities. It is my position that such a conceptualization does violence to the subject matter, and has led psychiatry seriously astray.
For instance, at the present time there is a great deal of concern in professional and official circles about the rapidly increasing use of neuroleptic drugs to “treat” childhood temper tantrums and aggression. What’s not usually acknowledged, however, is that these practices are a direct consequence of the spurious notion that all problems of thinking, feeling, and/or behaving are illnesses that warrant medical intervention. In the “old days” parents who brought a child to a physician for temper tantrums or aggression would have been told that this, in the absence of some very obvious and compelling indications to the contrary, was not a medical problem. Today it is a medical problem, not because there has been some breakthrough medical discovery, but simply because the APA says so, and because psychiatrists prescribe neurotoxic drugs that act as chemical strait-jackets and dampen the problem behavior. Contrary to the congratulatory self-talk of Dr. Lieberman and his like-minded “opinion leaders,” this is not medical progress.
A SECOND CLARIFICATION
Again, to guard against misunderstanding, let me state very clearly that if psychiatry could produce convincing evidence that the myriad problems of thinking, feeling, and/or behaving listed in the DSM are in fact caused by specific illnesses/diseases of the brain or other organs, then my objections are moot. And if that day comes, as I’ve said many times, I will fold my tent, apologize to all concerned, and end my days writing poetry, growing vegetables, and playing with my grandchildren. In the meantime, I will continue to state as vigorously and as frequently as I can, that psychiatry’s most fundamental tenet is nothing more than a self-serving assumption which despite decades of highly motivated research, numerous premature, yet confidently asserted, eurekas, and virtually endless promises that the definitive evidence is just around the proverbial corner, remains nothing more than a false and destructive assumption.