On March 16, Ronald Pies, MD, published an article in the Psychiatric Times. The article is titled The War on Psychiatric Diagnosis, and the sub-title synopsis on the pdf version reads: “A recent report that argues against descriptive diagnosis in medicine is historically ill-informed and medically naive, in the opinion of this psychiatrist.”
Dr. Pies is a very prestigious and eminent psychiatrist. He is a professor of psychiatry at both Syracuse and Tufts. He was the first editor of Psychiatric Times, which, by its own account, provides “News, Special Reports, and clinical content related to psychiatry” for “…psychiatrists and allied mental health professionals who treat mental disorders…Circulation of the monthly print publication is approximately 40,000.”
The report that Dr. Pies considers “historically ill-informed and medically naïve”, is the BPS November 2014 paper Understanding Psychosis and Schizophrenia, which has been widely discussed in recent weeks.
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There is much in Dr. Pies’ paper that warrants critical examination, but I would like to focus here on just one topic: the explanatory value of diagnoses.
Dr. Pies himself acknowledges the centrality of this matter, and writes:
“But there is a larger issue raised in the BPS report that goes to the very heart of psychiatric diagnosis, which the report tries to discredit with the following argument:
We normally expect medical diagnoses to tell us something about what has caused a certain problem, what the person can expect in future (‘prognosis’) and what is likely to help. However, this is not the case with mental health ‘diagnoses,’ which rather than being explanations are just ways of categorizing experiences based on what people tell clinicians. . . . For example, someone who says that they are hearing voices might be given a diagnosis of schizophrenia. Since this says nothing about cause, it makes little sense to say that the person hears the voices ‘because of ‘ the schizophrenia.
Actually, it makes a good deal of sense, in precisely the same way it makes sense to say, ‘Mr Jones has severe facial pain because he has tic douloureux;’ or ‘Smith has severe left-sided head pain and nausea because he has migraines.’ We still do not know the precise causes of these conditions; moreover, the diagnosis of tic douloureux (literally, ‘painful tic’) or migraine headache (etymologically, headache ‘in half the cranium’) is made almost entirely on the basis of ‘what people tell clinicians’—not on the basis of an abnormal laboratory value, x-ray film, or anatomical finding. (Of course, certain tests, such as a CT scan of the head, can help rule out other diagnostic possibilities, such as a brain tumor.)”
The essence of Dr. Pies’ contention here is that psychiatric diagnoses are just as valid as diagnoses in general medicine, and that, in particular, the absence of knowledge concerning causes does not diminish their status or usefulness.
It has long been my contention that psychiatric “diagnoses” have no explanatory value, and in fact constitute nothing more than vague, unreliable re-labeling of the presenting problems.
This is clearly demonstrated in the hypothetical conversation:
Client’s parent: Why is my son so paranoid? Why does he just sit in his room all day? Why won’t he do anything?
Psychiatrist: Because he has an illness called schizophrenia.
Parent: How do you know he has this illness?
Psychiatrist: Because he is so paranoid, sits in his room all day, and won’t do anything.
The only evidence, and I stress the only evidence, for the so-called illness is the very behavior that it purports to explain. The psychiatric explanation essentially comes down to: he is paranoid, sits in his room all day, and won’t do anything, because he’s paranoid, sits in his room all day, and won’t do anything. There is nothing more to it than that.
I realize that I’ve labored this matter to the point of tedium. But I’ve done so for two reasons. Firstly, because it is one of the core flaws in psychiatry. Its diagnoses have no explanatory value. They are nothing more than labels. Secondly, because psychiatry consistently fails to respond to this particular criticism, and with equal consistency presents these labels as if they did have explanatory value.
The present article by Dr. Pies is a perfect example of the second point, because although Dr. Pies appears to address the issue, he actually side-steps it.
Let’s go back to the quote from the BPS article.
We normally expect medical diagnoses to tell us something about what has caused a certain problem…
This is absolutely accurate. When a person consults a physician concerning a medical problem or concern, there is a general expectation that the diagnosis, if forthcoming, will provide an explanation of the problem. And in practice, this is normally the case. If a person reports exhaustion, pulmonary congestion, elevated temperature, pain in the chest, and nasty-looking phlegm, his diagnosis might be pneumonia. Pneumonia is a viral or bacterial infection of the lung tissue.
What is noteworthy here, in the present context, is that we have two distinct elements: the symptoms and the cause of the symptoms. The person consults a physician because of the symptoms, and, from the physician, he learns the cause of these symptoms. This is what diagnosis means: determining the cause and nature of a pathological condition. Wikipedia gives the following definition:
“Medical diagnosis…is the process of determining which disease or condition explains a person’s symptoms and signs.” [Emphasis added]
Another critical factor in this issue is that there has to be a clear logical link between the symptoms and the diagnosis. If, for instance, the physician’s diagnosis in the above scenario were “incorrect curvature of the spine”, there would, I suggest, be an enormous burden of proof as to how this particular pathology could cause these particular symptoms. But with a diagnosis of pneumonia, the logical link is clear: the infection causes exudation of blood and other fluid into the lung tissue; the immune system triggers an increase in temperature, etc..
So let’s see how our consultation conversation might run in this case.
Patient: Why am I so tired; why did my temperature spike; why am I spitting up such dreadful-looking phlegm?
Physician: Because you have pneumonia.
Patient: How do you know I have pneumonia?
Physician: Because I can hear characteristic sounds through the stethoscope; your chest X-ray shows large quantities of fluid in both lungs; your sputum labs are positive for pneumococcus; and because everything you have told me is consistent with this diagnosis. I can show you the X-rays if you like.
The difference between this kind of conversation and the psychiatric conversation is obvious. In the pneumonia case, the physician has progressed from the symptoms to the essential underlying nature of the illness. In psychiatry, no such progress has occurred or can occur. In psychiatry, the so-called symptoms are the essence of the problem. There is no underlying reality to which the symptoms point. The “symptoms” and the “illness” are identical.
Back to the BPS quote:
“For example, someone who says that they are hearing voices might be given a diagnosis of schizophrenia. Since this says nothing about cause, it makes little sense to say that the person hears the voices ‘because of ‘ the schizophrenia.”
Again, this is accurate. “Schizophrenia” is a label, not an underlying explanatory entity that enables us to understand the symptoms. The phrase “…because he has schizophrenia” is a form of words that looks like an explanation, but in fact isn’t.
To illustrate this, let’s consider another example. Imagine a small child running tearfully to his mother with the complaint that another child has been hitting him. Mother gathers the victim to her arms and soothes him.
Mother: It’s OK. I’ve got you. It’s OK. etc.
Child: Why does he keep hitting me?
Mother: Because he’s a bully. Don’t mind him.
The phrase “because he’s bully” looks like an explanation, and will be accepted by the child as an explanation, but in fact it has no explanatory value. All we have to do to see this is ask the question: “How do you know he’s a bully?”, and the only possible answer is “because he keeps hitting you”.
The statement “he beats you because he is a bully” is logically equivalent to the statement: “He beats you because he beats you.” It contains no explanatory insights into the aggressor’s action. And psychiatric explanations are exactly of this kind.
Now, please don’t misunderstand me. This is not a logical critique of mothers who try to comfort their children. As parents, we do what we can to comfort our children, and there is no great onus with regards to logic or science. But psychiatric concepts and assertions do need to pass the tests of logic and science.
The statement: “Your son hears voices because he has schizophrenia” is logically equivalent to “Your son hears voices because he hears voices.” Schizophrenia is nothing more than the label that psychiatry gives to that loose cluster of vaguely defined thoughts, feelings, and/or behaviors that are listed on page 99 of DSM-5. These are:
- Disorganized speech (e.g., frequent derailment or incoherence).
- Grossly disorganized or catatonic behavior.
- Negative symptoms (i.e., diminished emotional expression or avolition)
The simple fact of the matter is that the reasons underlying these thoughts, feelings, and behaviors are as varied as the individuals who experience them. But psychiatrists make no attempt to explore these reasons. Instead, they rely on the medical-sounding, but facile, “because-he-has-schizophrenia” form of words. As in so many areas, psychiatry has become intoxicated by its own rhetoric, and individual practitioners seem to believe that this form of words actually has some explanatory value.
Back to Dr. Pies:
“Actually, it makes a good deal of sense, in precisely the same way it makes sense to say, ‘Mr Jones has severe facial pain because he has tic douloureux;’ or ‘Smith has severe left-sided head pain and nausea because he has migraines.’ We still do not know the precise causes of these conditions; moreover, the diagnosis of tic douloureux (literally, ‘painful tic’) or migraine headache (etymologically, headache ‘in half the cranium’) is made almost entirely on the basis of ‘what people tell clinicians’—not on the basis of an abnormal laboratory value, x-ray film, or anatomical finding.”
So there is a fairly profound disagreement. The BPS say that the explanation “because he has schizophrenia” makes little sense. Dr. Pies says it makes a good deal of sense. Let’s take a closer look. First, let’s go back to the BPS statement which Dr. Pies quoted and which I reproduced above. Although there are no quotation marks around this passage, it is actually a verbatim quote from the BPS paper, but a crucial piece of the quote has been omitted. (The omission is indicated by an ellipsis in the regular online version, but there is no ellipsis in the pdf version.)
The omitted passage is:
“The Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) explicitly states that its categories say nothing about cause – in its own words it is ‘neutral with respect to theories of aetiology’.”
So a summary of the BPS passage might look something like this:
- medical diagnoses give us the cause or explanation of a problem
- psychiatric diagnoses, by contrast, do not give causes or explanations
- psychiatric diagnoses are just ways of categorizing clients’ reports
- the APA acknowledges that its diagnoses say nothing about cause
- therefore the label schizophrenia has no explanatory value
- so, to say that a person hears voices because he has schizophrenia makes little sense
What Dr. Pies has omitted is item 4 arguably the most important part of the passage. So Dr. Pies is accusing the BPS of leaping from
psychiatric diagnoses are just ways of categorizing clients’ reports
therefore the label schizophrenia has no explanatory value
and ignores the interim premise which is crucial to the issue. Dr. Pies then uses this distortion to make the point that some diagnoses in general medicine are based entirely on patient report but are nevertheless considered valid and useful. This, of course, is non-contentious. There are, indeed, genuine medical conditions which are diagnosed largely on the basis of patient report. Dr. Pies mentions tic douloureux as an example, and states that the precise cause of this illness is unknown. But he is, I suggest, being less than candid, because a great deal is known, and has been known for decades, about the cause of tic douloureux, which, incidentally, is now usually called trigeminal neuralgia. Here’s the entry for this illness in the 1963 edition of Taber’s Cyclopedic Medical Dictionary:
“Degeneration of or pressure on the trigeminal nerve, resulting in neuralgia of that nerve…The pain is excruciating. Usually occurs after forty. Pain is paroxysmal, radiating from angle of the jaw along one of the involved branches. If the first branch, a shocklike pain is felt along the eye and back over the forehead. If it is the middle fiber, the upper lip, nose, and cheek under the eye are affected. If it is the third branch, pain is in the lower lip and outer border of tongue on affected side. Pain is momentary but returns again and again.” (p T-30)
More up-to-date information is provided by drugs.com, a service of Harvard Health Publications:
“In some cases, the cause of trigeminal neuralgia is unknown. In many people, however, something seems to be irritating the trigeminal nerve, usually in the area of the nerve’s origin deep within the skull. In most cases, the irritation is believed to be caused by an abnormal blood vessel pressing on the nerve. Less often, the nerve is being irritated by a tumor in the brain or nerves. Sometimes, the problem is related to a rare type of stroke. In addition, up to 8% of patients who have multiple sclerosis (MS) eventually develop trigeminal neuralgia as a result of MS-related nerve damage.”
So, if a patient were to ask his physician why he is experiencing excruciating stabbing pains in his face, the response “because you have tic douloureux” is a perfectly logical explanation. It might, or might not, be correct – that is not the issue. But it is a coherent, valid explanation, and is not simply a relabeling of the presenting problems, which is the essential status of all psychiatric diagnoses, other than those specified as being “due to a general medical condition”.
What’s particularly interesting here is that the BPS document is in fact very clear on this matter. The sentence following the passage quoted by Dr. Pies reads:
“An analogy with physical medicine might be a label such as ‘idiopathic pain’, which merely means that a person is reporting pain, but a cause of that pain cannot be identified.”
Idiopathic means “of unknown cause, as a disease.” (Random House Webster’s College Dictionary, 1992). So if a patient were to ask a physician why he was experiencing severe facial pain, the response “because you have idiopathic pain” would simply be a restatement of the presenting problem, and would have no explanatory value. The point being made in the BPS report is that a relabeling of the presenting problem that entails no understanding of cause has no explanatory value. The phrase “because you have schizophrenia” is precisely on a par, logically, with “because you have idiopathic pain.” Dr. Pies’ introduction of, and comparison to, “because you have tic douloureux” is an enormous red herring. His use of the etymological annotation “painful tic” is also a red herring, in that etymology is a poor guide to current meaning. The etymology of the word “mortgage”, for instance, is “death pledge”, because the original meaning of a mortgage was a pledge that a debt would be repaid from one’s estate after one’s death. This is interesting, of course, but has no relevance to the current meaning of the term.
Certainly there are disease entities that general medicine has named, and can identify with reasonable accuracy, prior to establishing the etiology or cause of these illnesses. But this is fundamentally different to the situation that prevails in psychiatry. Firstly, in general medicine there are always prima facie reasons for believing that the condition is an organic pathology. Secondly, the quest of general medicine for explanations and causes has been remarkably successful.
Neither of these conditions exists in psychiatry. In fact, despite an enormous amount of highly motivated research in this area, no psychiatric “illness” has ever been reliably established to be the result of a specific neural pathology. Even Thomas Insel, MD, Director of NIMH, wrote on April 29, 2013:
“While DSM has been described as a ‘Bible’ for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been ‘reliability’ – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.”
Whilst I don’t agree with Dr. Insel in all areas, on this matter he has hit the nail squarely on the head.
The bottom line is this: if one doesn’t know the cause of something, then one can’t explain it. Explanation is the presentation of causes. And despite their frequent claims to the contrary, psychiatrists do not know the cause of the loose collection of thoughts, feelings, and/or behaviors that they call schizophrenia. They assume that any decade now they will discover this cause in the form of some neural pathology. Meanwhile, they go on telling their clients the falsehood that they have chemical imbalances, or neural circuitry anomalies or whatever is the latest fashion, and that these putative illnesses can be corrected by drugs or electric shocks to the brain. And they ignore the reality: that the best (indeed only) way to understand people is to talk to them patiently, compassionately, and with humility, and without the assumption that one already knows the source of their troubles. It is only in this way that we discover that people’s so-called symptoms are understandable within the context of each person’s unique history and current circumstances, and that the facile labels cataloged so conveniently by the APA are an irrelevant travesty.
And, indeed, Dr. Pies himself, even though he clings tenaciously to the need for psychiatric “diagnoses”, acknowledges the additional need to take the time to get to know clients:
“Finally, while diagnosis is a necessary first step in helping the patient with emotional, cognitive, or behavioral problems, it is far from sufficient. We must enter empathically into the patient’s ‘inner world,’ and provide a safe, trustworthy environment for the exploration of the patient’s troubles. This takes time—it can’t be done in 15 minutes!—and it requires what psychoanalyst Theodor Reik eloquently called, ‘listening with the third ear.’ “
But what Dr. Pies neglects to add is that the 15-minute med check has become standard practice in psychiatric care. Douglas Mossman, MD, Professor of Psychiatry at the University of Cincinnati, has written unambiguously:
“Even psychiatrists who deplore 15-minute med checks recognize that they have become standard care in psychiatry.”
Glen Gabbard, MD, a widely published professor of psychiatry at Baylor and Syracuse, has written on Psychiatric Times:
“There can be little doubt in our current era that the brief ‘med check’ is becoming standard practice in psychiatry.”
Dr. Pies himself, in an earlier paper (Psychiatrists, Physicians, and the Prescriptive Bond) has written:
“Unfortunately, many prescriptions for psychotropics are written in haste—often after the infamous ’15-minute med check’ – and without any real understanding of the patient’s inner life or psychopathology.”
Dr. Pies, incidentally, also failed to mention that Theodor Reik (1888-1969) was a psychologist, not a psychiatrist, and in fact, had to fight a lawsuit against the medical community in order to establish the principle that psychoanalysis could be practiced by non-physicians.
Nor does Dr. Pies seem to recognize that psychiatry’s contention, that the DSM entities are bona fide illnesses, is, in fact, the primary driving force behind the cursory treatment which he decries so ardently. After all, if people’s problems are caused by brain malfunctions, and if psychiatric drugs correct these malfunctions, what need is there for dialogue or understanding?
There is no factual or logical evidence that the loose collection of vaguely defined thoughts, feelings, and/or behaviors that psychiatrists call schizophrenia is a coherent entity, much less an illness. Nevertheless, psychiatrists continue, not only to make this groundless assertion, but also to prescribe neurotoxic chemicals to “treat” this pseudo-illness, often against the vehemently expressed wishes of the victims. This is not the practice of medicine. It is a travesty which no amount of Dr. Pies’ sophistry can mitigate.
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With regards to the title of his piece – The War on Psychiatric Diagnosis – Dr. Pies has this to say:
“If ‘war’ seems a somewhat overheated term in the title of this piece, I would recommend perusal of some of the anti-psychiatry Web sites, on which the ritual evisceration of psychiatry and psychiatrists is unapologetic and unrelenting.*”
The asterisk refers to a footnote:
“*In my view, the Web site of ‘Mad in America’ is particularly abusive toward psychiatrists, though it is far from the worst of the bunch”
Well, of course, there’s anger and vitriol on both sides of this issue, though I must say that MIA has always struck me as the epitome of civility and restraint. But it’s important in this, as in any human endeavor, to rise above the rhetoric, and deal honestly and squarely with the issues. And the issue on the table here is that psychiatric diagnoses – other than those clearly identified as “due to a general medical condition” – have no explanatory value, but are routinely and deceptively presented by psychiatrists as if they did.
And, Dr. Pies has not addressed that issue.
Psychiatry is under criticism because its concepts are spurious, and its treatments are destructive. The problems that psychiatry guards tenaciously as its turf are not medical in nature, but for the sake of that turf, are shoe-horned shamelessly into psychiatry’s bogus nomenclature, and are “treated” with neurotoxic drugs and electric shocks to the brain. Petulant complaining about the “ritual evisceration of psychiatry and psychiatrists”, is no substitute for rational, honest, and informed debate.