On February 28, Awais Aftab, MD, a psychiatrist working in Qatar, published an interesting article on Psychiatric Times. The article, which is titled Mental Illness vs Brain Disorders: From Szasz to DSM-5, is an attempt to validate the concept of “mental illness” and, in particular, claims to refute the position of the late Thomas Szasz, MD, that mental illness is a spurious concept.
The validity or otherwise of the concept of mental illness is fundamental to psychiatry’s claim to legitimacy, and for this reason, Dr. Aftab’s article deserves close scrutiny.
Dr. Aftab opens with a veiled ad hominem attack on Dr. Szasz:
“Thomas Szasz was a lifelong ferocious critic of the institution of psychiatry.”
Dr. Szasz was indeed a critic of psychiatry, but the term “ferocious” conjures up images of irrationality and viciousness which were not characteristic of his presentation. In addition, by counterposing the term “ferocious” with the term “institution of psychiatry,” Dr. Aftab has managed to create the impression of a mad dog snapping at the heels of a benign old gentleman.
This is hardly an auspicious start to what purports to be a discussion of fundamental principles. But there’s more:
“Although most psychiatrists remain unconvinced of his arguments, Szasz has been very influential by virtue of being psychiatry’s arch-adversary.”
Here again, Dr. Aftab has sneaked in a significant falsehood and a subtle emotional distraction. The fact is that Dr. Szasz was, and posthumously still is, very influential, because he presented sound, logical arguments in a convincing manner. The impression that Dr. Aftab gives us, however, is that Dr. Szasz is influential just because he attacked psychiatry. And doesn’t the term “arch-adversary” have subtle overtones of Professor Moriarity – the evil nemesis of the rational and infallible Sherlock Holmes?
Dr. Aftab argues that Dr. Szasz’s rejection of the concept of mental illness is outdated, and therefore moot.
“Szasz’s argument goes awry when applied to our current understanding of mental disorders. First, the concept of disease is not restricted to the presence of a physical lesion; second, the term ‘mental disorder’ is now conceptualized in a manner that transcends mind-body-dualism.”
So essentially, Dr. Aftab is saying that Dr. Szasz’s challenge may have had some validity in the old mind-body dualism days, but that those days are gone, and psychiatry today is on a much firmer and more valid footing. This is because:
1. “the concept of disease is not restricted to the presence of a physical lesion”
2. the current concept of mental disorder “transcends” mind-body dualism.
This is uncomfortably vague, but Dr. Aftab elaborates:
“For the most part, disease is understood largely in terms of suffering and functional impairment, which may or may not be associated with a structural lesion. R. E. Kendell explains this view succinctly:…’For most of human history disease has been essentially an explanatory concept, invoked to account for suffering, incapacity, and premature death in the absence of obvious injury, and suffering and incapacity are still the must fundamental attributes of disease.’
Once we conceive of disease in terms of substantial or enduring states of suffering and incapacity, we are justified in applying it as a label to conditions in which disturbances in cognition, emotion, or behavior are associated with distress and impairment.”
This is the essential kernel of Dr. Aftab’s position. So let’s take a closer look.
“For the most part, disease is understood largely in terms of suffering and functional impairment, which may or may not be associated with a structure lesion.”
The first question that arises is: “understood” by whom? I suggest that for most people, including physicians, the presence of an underlying causative pathology is an essential component of disease. When physicians, other than psychiatrists, talk about disease, they are talking about underlying causative pathology. Certainly they are concerned with “suffering and functional impairment,” but when, after exhaustive investigation, they are unable to establish the presence of any organic lesion or pathology, they will frequently assert that the individual isn’t really ill. Usually in these cases, a referral is made to a psychiatrist, the clear implication being that psychiatrists treat people who aren’t really sick.
The notion that suffering and functional impairment, in and of themselves, constitute disease is the Ronald Pies argument, the details of which I’ve discussed and challenged elsewhere.
Interestingly, Dr. Aftab’s article, as mentioned earlier, is published in Psychiatric Times, which has until recently been edited by Dr. Pies. Neither Dr. Pies or Dr. Aftab presents any argument in support of the notion – they simply assert it to be so. Habitual thoughts, feelings, or behaviors that result in suffering and functional impairment are illnesses – because we say so. To which I suppose there’s the implied rider: And we’re psychiatrists, so it must be true.
Dr. Aftab seems to believe that the passage from the late Dr. Kendell clinches the matter. So let’s take a look at the quote: Disease, Dr. Kendell tells us, is an explanatory concept. In other words, it provides us a way of understanding suffering, incapacity, and premature death in the absence of obvious injury. None of this is contentious. If a person is extremely tired and is coughing up dreadful-looking stuff, a physician might listen to his lungs, run some tests, perhaps take an X-ray, and diagnose pneumonia. Pneumonia – an infection of the lung – explains the suffering and the incapacity. Similarly, exhaustion, accompanied by edema and elevated creatinine and electrolytic levels, might be the result of kidney failure. The point is that the pathology (i.e. the lung infection and the kidney failure) cause the symptoms.
This conceptual framework is the very paradigm of modern medicine. Certainly there are cases in which the treating physicians are unable to ascertain a cause, but that in no way detracts from the general notion that the discovery and amelioration of underlying pathology is the defining feature of successful medicine.
But back to Dr. Kendell’s quote: “…suffering and incapacity are still the most fundamental attributes of disease.” He began by stating that disease (and presumably specific diseases) are explanatory concepts, i.e. they explain suffering and incapacity. But, he continues, suffering and incapacity “are still the most fundamental attributes of disease.” This is simply contradictory. Take the pneumonia example. The symptoms are caused by the pathology. That’s what we mean when we say that the diagnosis has explanatory value. By any ordinary use of the terms, the pathology is more fundamental than the symptoms. The symptoms may be more obvious. They may be the paramount consideration from the sick person’s perspective, but they are emphatically not “the most fundamental attributes” of a disease. A cause is, by definition, more fundamental than its effect.
Nevertheless, Dr. Aftab concludes from this false and contradictory statement:
“Once we conceive of disease in terms of substantial or enduring states of suffering and incapacity, we are justified in applying it as a label to conditions in which disturbance in cognition, emotion, or behavior are associated with distress and impairment.”
In other words, we (psychiatrists) have decided that the essential meaning of the word disease is an habitual thought, feeling, or behavior that causes distress and impairment. And because we say so – therefore it must be so. And therefore, all the problems that we address are illnesses.
And that’s all there is to it. All significant problems of thinking, feeling, and/or behaving are illnesses, because we say so. Ultimately it always comes down to this. Psychiatrists routinely dress this kind of spurious nonsense in confusing verbiage, but if you cut away the chaff, the kernel is always the same.
Dr. Aftab seems to be under the impression that calling problems of thinking, feeling, and/or behaving illnesses has some explanatory value. The “logic” presumably goes like this: any kind of suffering and functional impairment, even in the absence of organic pathology, is an illness. So if a person so afflicted asks why he is suffering and functionally impaired, the correct answer (i.e. the explanation) is: because you have an illness. But the only justification for conceptualizing the suffering as an illness is because psychiatrists, including Dr. Aftab, have arbitrarily and, I suggest, misleadingly chosen to call these problems illnesses. The notion that one can explain human emotions and actions by assigning labels makes a mockery of genuine scientific enquiry.
Imagine, by way of analogy, that a physicist, asked why it is that light can pass through glass, replied: because glass is transparent! That is psychiatric logic.
Having “established” that mental illnesses are real illnesses (because psychiatrists say so), Dr. Aftab continues his narrative:
“Although the terms ‘mental illness’ and ‘mental disorder’ are still used, the manner in which they are understood is very different from the old psychoanalytic view (and for that reason many psychiatrists argue that the terms should be abandoned). The notion of mental illness as distinct and divorced from the notion of a biological disorder reflects a dualistic understanding of the mind-body relationship, a dualism that has become increasingly untenable given the advances of neuroscience. While it may be true that in the 1950s, when Szasz came up with his critique, this particular dualistic understanding of mental illness was in fashion, psychiatrists have long abandoned such a view. Szasz failed to appreciate that in his critique and held on to his original position until his death in 2012.”
Here again, there’s a lot of convoluted language which needs to be unraveled. What Dr. Aftab is saying is that Dr. Szasz’s rejection of the term “mental illness” was based on a mind-body dualism philosophy that was current in the 50’s. But, he tells us, psychiatry moved away from this antiquated thinking long ago, so Dr. Szasz’s criticisms no longer apply. And poor, naïve Dr. Szasz flogged away at this dead horse for the remainder of his days.
But, as was the case in the earlier passage quoted, it is Dr. Aftab who is missing the point.
“Mind” is a spurious concept with no explanatory value. It was adduced by the ancients to explain the phenomenon of thinking. Their “logic” can be exemplified in the following hypothetical conversation:
Q: Why is it that man can think?
A: Because he has a mind.
Q: How do you know he has a mind?
A: Because he can think.
We use the term “mind” in common speech to refer to cognitive and emotional activities, but there have been very few serious thinkers in modern times who have attached any ontological or explanatory significance to the concept.
And this includes the psychoanalysts! Freud believed that he was treating repressed emotions; Adler, feelings of inferiority; Harry Stack Sullivan, interpersonal relationships, Karen Horney, parental indifference; etc. Even the first DSM (1952) betrays no adherence to a mind-body dualism. For instance, under the heading “Definition of Terms” it states:
“…a psychotic reaction may be defined as one in which the personality, in its struggle for adjustment to internal and external stresses, utilizes severe affective disturbance, profound autism and withdrawal from reality, and/or formation of delusions or hallucinations.” (p 12)
There is no hint of mind-body dualism in this definition. So the notion that Dr. Szasz was tilting at a long-dead ghost is simply not factually accurate.
Indeed, Dr. Aftab’s own words contradict this assertion:
“If the conditions we call mental illnesses are not diseases, then what are they? Szasz argues that they are in fact problems in living, human conflicts, and unwanted behaviors. ‘Psychiatrists are not concerned with mental illnesses and their treatments. In actual practice they deal with personal, social, and ethical problems in living.'”
What could be clearer? The quote from Dr. Szasz above refers to personal, social, and ethical problems in living. Here again, there is no hint of anything mystical or nebulous – nothing that could be remotely construed as stemming from dualistic philosophy. And yet, a few paragraphs later, Dr. Aftab writes:
“Szasz treats the concept of mental illness very literally as being purely a disease of the mind (and thereby an impossibility).”
This notion, that we mental illness deniers are arguing from a dualistic framework, is a common theme among psychiatric polemicists. I have written on it here, here, and here. But let me restate the matter yet again.
Psychiatry’s decision to call all significant problems of thinking, feeling, and/or behaving illnesses is arbitrary. It is a labeling process with no ontological underpinning and no explanatory value. It is also misleading, because the term “illness” already had a perfectly clear meaning before psychiatry commandeered it for its own purpose. The reason for the commandeering was to convey the false impression that the subject matter of psychiatry is in fact real illness – “just like diabetes.” The spurious medicalization of these problems is also used to justify the prescription of neurotoxic chemicals and neurotoxic electric shock treatment.
There is no suggestion of mind-body dualism in any of this. On the contrary, it’s just Logic 101: identification and criticism of spurious reasoning. And the object of our criticism – the spurious medicalization of all significant problems of thinking, feeling, and/or behaving is, if anything, more pronounced and widespread today than it was during the 1950s.
Dr. Aftab continues by trotting out all the usual DSM pre-emptive disclaimers: no definition of a mental disorder can be entirely satisfactory; the distinction between mental and physical is not tenable; there is much mental in physical and physical in mental; boundaries between specific diagnoses are difficult to specify, etc…
Then he throws out the gem:
“‘Mental disorder’ continues to be used because there is no appropriate substitute for it.”
This is almost a straight quote from DSM-IV, p xxi:
“…the term [mental disorder] persists in the title of DSM-IV because we have not found an appropriate substitute.”
And this is the great psychiatric falsehood. There is a perfectly acceptable substitute. Significant problems of thinking, feeling, and/or behaving could be called: significant problems of thinking, feeling, and/or behaving. If the APA, or Dr. Aftab, were sincerely looking for a label that accurately reflected the subject matter, that, or something similar, would work perfectly well.
The reason they don’t do that, however, is because they cling – like drowning men to life rings – to the spurious notion that these problems are illnesses – medical entities –because it is only through that absurdly transparent ruse that they can continue to claim competence in the field and go on justifying the destructive and ineffective treatments that they inflict on the people who come to them for help. The only thing that psychiatrists know how to do is dish out drugs. So they need a conceptual framework to justify this activity and to maintain the fiction that it is fundamentally different from ordinary street-corner drug-pushing.
Dr. Aftab draws his paper to a close by scrutinizing the DSM-5 definition of a mental disorder. This definition, incidentally, is essentially the same as DSM-IV’s, with two important differences. Firstly, the newer definition allows the possibility that the problem may have a biological underpinning (something that was not included in the DSM-IV definition). And secondly, the definition is markedly broadened, in that, while the earlier one required either distress, disability, or risk of significant loss, the DSM-5 definition merely states that the problem is usually associated with these kinds of adversities.
Dr. Aftab now focuses this new definition of mental illness on the condition known as schizophrenia. He contends that this condition is now known to have many neurobiological abnormalities. He points out that Dr. Szasz had frequently made the obvious point that if a problem of living were found to be caused by neural pathology, then it would be a brain illness. Dr. Aftab then poses the question: now that we know that schizophrenia is caused by neurobiological abnormalities (a spurious contention, incidentally, but one which for our present purposes, we can let go), should it cease to be regarded as a mental illness and become, simply, a neurological illness.
And this is where we descend into tragi-comedy. We can, Dr, Aftab assures us, confidently continue to conceptualize schizophrenia as a mental illness “…because the conception of mental disorder has expanded to include biological dysfunction within its scope.” (This is a reference to the possibility of a biological underpinning in the DSM-5 definition mentioned above.)
But what Dr. Aftab doesn’t seem to appreciate, even slightly, is that the reason for this expansion of scope is that David Kupfer, MD, and his interest-vested DSM-5 cronies wrote it this way. This is tablets-of-stone thinking stripped even of a semblance of disguise. If Dr. Kupfer et al had written that the Earth was flat, would that have made it so?
The definition of a mental illness/disorder is not some kind of reality that the DSM-5 work group wrested from nature’s grudging bosom in the manner of real science, and which can now be used as a reliable yardstick by which these kinds of matters can be gauged. Rather, it was a decision, made by Dr. Kupfer and his committees. The only reality that they had to observe was that the definition would be acceptable to the APA membership. The fact that Dr. Aftab would adduce this document as proof that schizophrenia, or indeed any of psychiatry’s so-called diagnoses, is an illness is beyond comprehension.
For at least the past sixty years psychiatry’s concepts and practices have been criticized as invalid and ineffective. Until recently they have, with the help of pharma money, been able to deflect these criticisms, and they have created a drug-pushing empire that makes the cartels look like amateurs. Then three things happened: 1. the survivors started to speak out about the damage they had incurred at the hands of psychiatry; 2. critics began to realize the potential of the Internet; and 3. a mainstream journalist named Robert Whitaker saw through the travesty and threw the power of his pen and his personal energy into the debate. On all fronts, psychiatry is being exposed as the intellectually and morally bankrupt institution that it has been for at least the last fifty years. They continue to insist that they are real doctors, treating real illnesses. But the arguments that they adduce to support this contention always boil down to the same four words: because we say so.