Category Archives: A Behavioral Approach to Mental Disorders

Beyond Survival

Recently I came across a remarkable article From surviving to thriving: how does that happen. The authors are Mark Bertram and Sarah McDonald, and the piece was published in The Journal of Mental Health Training, Education and Practice, Vol 10, Iss 5, 2015. The work was conducted in the vocational service department of a large mental health center in London, UK.

The authors’ purpose was:

“…to explore what helped seven people in contact with secondary mental health services achieve their vocational goals, such as: employment, education, training and volunteering.”

Here are some quotes, interspersed with my observations and comments.

“It is widely recognised that people in contact with mental health services are one of the most excluded groups in society. The causes of this exclusion are complex, multifaceted and not completely understood, but the facts are stark. Employment rates have hit their highest since records began, yet the majority of service users are unemployed (Office National Statistics, Statistical Bulletin, 2015).”

“Current critiques of the care programme approach (CPA) and the care planning process state that the work of mental health services through CPA is generally not effective – in terms of helping people achieve their goals and enhancing their life experience. There are calls for a fundamental change to the nature of the relationship between service users and professionals – with an emphasis on partnership and collaboration (Rinaldi and Watkeys, 2014).”

In fact, psychiatric care is inherently disempowering. Telling people, falsely, that they have an incurable, disabling brain disease militates against the notion that they can pursue their goals and improve their situation.

“The role of the staff is collaborative – moving from doing to or trying to fix, to helping people find their own way forward by identifying the things people are able to do and encouraging choice and control within a trusting relationship. This has been described as hope inducing and promotes well-being (Rapp and Goscha, 2010).”

“There are continuous calls for new ways of working in mental health services and knowledge from service users to be given its rightful place (Basset, 2008; Beales, 2012; Faulkner and Basset, 2012). What remains less clear in the literature is what service users are actually saying? Specifically, what do service users say are the conditions that help them achieve their goals, increase their well-being and be included?”

. . . . . . . . . . . . . . . .

The authors invited the service users at their center to come forward and be interviewed, with the objective of developing answers to the following questions:

“1. What areas of life were you struggling with prior to engaging in the peer support or vocational service?

2. What mental health services were you using and how was your mental health and well-being?

3. How were you involved in the project, what worked for you and what life changes have occurred as a result of engaging in peer support or vocational services?

Data analysis

The data were transcribed, content analysed and categorised under the key emerging themes.  Validity checks involved giving the participants a copy of their interview with our  interpretations. Some minor adjustments were necessary. Overall, the participants agreed that these records were accurate versions of their interview.

We then combined the qualitative data from all the interviews and through further reflection and content analysis we began to see patterns emerging – similarities between the nature and impact of people’s struggles and the types of conditions that people were saying helped them in a process of change and growth. These were listed on five pages of A4 [letter size paper] and consisted of 50 themes. To try and make the data clearer and more concise, we explored the possibility of creating images to visually represent the themes. We hired a systems designer and she was able to construct initial tree designs. We were then able to embed the themes into roots, trunk, branches and fruits.

We shared these images with staff, peer supporters and service users and the response was enthusiastic and positive. People were saying these images and the themes represented their understanding of the invalidating conditions that cause distress and the validating conditions that facilitate a process of learning, change and growth. Gradually, a model of change – with all its inter-related parts and processes – emerged and this remained faithful to the insights people shared.”

Here are the tree images:

Under the heading Life Struggles, the authors pointed out:

“People were saying their main struggles with their mental health were related to problems with living and these difficult life experiences had created significant distress over a number of years. Consequently, everyone we spoke with had ended up in secondary mental health services for over five years. One person had been in services for 20 years, including 11 annual admissions to hospital. These were bleak, harrowing and painful situations that people arrived with.”

In their Conclusion section, the authors note:

“People were very clear and identified a wide range of life struggles that brought them into contact with services such as: income poverty, unemployment, trauma events, serious physical injuries, bullying, isolation, drug and alcohol problems, family losses, stigma, meaninglessness, hopelessness and a lack of sleep. It was the invalidating effects of these struggles that caused serious damage.”

This is in marked contrast to the standard psychiatric approach, which is to downplay the significance of these kinds of adverse events and circumstances, and to tell the client that he/she has a brain illness which needs to be treated with chemicals and/or high voltage electric shocks to the brain.

“However, all of the people we interviewed found their own way through and there are several important threads that bound their stories together. How people were perceived and treated was simply everything. It was the human, can do and co-productive approach within the vocational and peer support projects that shone through.”

Under the heading Recommendations:

“The evidence here reveals that the difficulties that bring people into contact with mental health services are multifaceted, but have common themes – problems with living and being invalidated. The challenge for all mental health services is to recognise and address the economic, psychological and social consequences of these life struggles. If these areas are not addressed then the demand on services will continue to increase because the direct causes of distress are not being resolved.” [Emphasis added]

How simple and clear. In my experience, people who are despondent are always able to explain in clear, simple terms why they are feeling despondent. And it always comes down to adverse events and/or abiding adverse circumstances. Psychiatry, however, self-servingly wedded as it is to spurious biological explanations, ignores this entire area, and focuses solely on “making the diagnosis”. So instead of asking open-ended questions and allowing the client to talk, they ask the questions on their inane, simplistic checklists: how often do you feel depressed?; are you less interested in doing things than formerly?; have you lost or gained weight recently?; are you having trouble sleeping?; are you sleeping excessively?; do you feel slow or sluggish?; do you feel worthless or guilty?; do you find it difficult to concentrate?; do you think about death or suicide?, etc.

And if the person answers yes to at least five of these questions, then voila, by the great miracle of psychiatric transformation, the hapless individual now has another serious problem: a life-threatening brain illness called major depressive disorder, which requires the ingestion of dangerous chemicals for life. What an unmitigated travesty!

And what a contrast to the simple, respectful, insightful, and entirely meaningful approach set out by Mark Bertram and Sarah McDonald in this paper.

“The wide range of current standardised approaches and pathology-laden practices in the mental health field need to be reviewed in the light of: the extent to which they invalidate or validate service users lived experiences.”

FINALLY

I cannot, in this short post, do justice to this paper. Besides its obvious merits, it offers a profound contrast to the drug-pushing, people-shriveling practices of psychiatry. Although the paper does not particularly promote anti-psychiatry, it does demonstrate that even people who have been drawn deeply into the disempowering maw of “mental health”, can still articulate their needs, and can still find fulfillment in productive activity and self-direction.

Mark Bertram and Sarah McDonald have demonstrated that when people are weighed down by life’s adversities, what they need is authentic, validating support, not facile pathologizing checklists, and not tranquilizing or stimulant drugs.

I strongly encourage readers to study this paper and pass it along.

Where Do We Go From Here?

At the risk of stating the obvious, the anti-psychiatry movement is rapidly gaining momentum. We are attracting an increasing number of supporters, and our message is being picked up increasingly by the mainstream media.

We have won the intellectual and moral battles hands down. We have demonstrated again and again that psychiatry is intellectually and morally bankrupt. We have shown that

  • psychiatry is a hoax;
  • that its “illnesses” are not illnesses;
  • that its “diagnoses” are nothing more than vague, arbitrarily delineated, disempowering and stigmatizing labels with no explanatory value;
  • that its “treatments” do more harm than good;
  • that its coercive drugging and electric shocks constitute torture;
  • and that its research is fraudulent.

Psychiatry has no valid or rational response to any of these criticisms. Instead, they continue to trot out the same tired and unproven assertions, marginalize their critics, lobby government agencies to defend and fund their business, and promote their own interests using the kind of PR tactics that one commonly associates with the makers of soft drinks and hair shampoo.

Psychiatry is a marketing hoax. They sell their “illnesses” and they sell their “cures”. In general, the way to neutralize a hoax is to expose it to the proper authorities. But with psychiatry this is not effective for three reasons.

1. There is an enormous credibility gap. For most people, it is simply inconceivable that a long-established medical profession could be so destructive, venal, and just plain wrong.

2. Psychiatry provides a “valuable” service to governments by promoting the false message that legitimate and appropriate responses to discriminatory and exploitative policies are symptoms of illness.

3. Psychiatry is the cornerstone of a multi-billion dollar world-wide drug cartel.

THE SILENT SKEPTICAL MAJORITY

Psychiatry’s fundamental concept – that these “sick” people need psychiatric care – has been widely accepted at all levels of society, including politicians and civil servants.

But alongside this widespread acceptance, there are very large numbers of skeptics: people who haven’t bought the lie, or who have reservations and concerns about the numbers of people being “diagnosed” and “medicated”. And most of these people have never heard of the anti-psychiatry movement. They’re puzzled; they’re skeptical; they’re concerned; but they distrust their own judgment.

And this, in my view, is the audience to which we should now direct our efforts. We need to spread the word to a much wider group. We need to connect with that silent skeptical majority, and deliver the message: your skepticism is well-founded; psychiatry is a destructive, disempowering, self-serving, drug-pushing hoax; your instincts are correct.

This is not to say that we should abandon our present directions. We still need to maintain a steady flow of essays and articles criticizing psychiatric concepts and practices. We need to identify and denounce the principal promoters of the hoax, and to expose their venal relationships with pharma as and when appropriate. We need to create and maintain an expectation in the minds of psychiatry’s so-called thought leaders, that their flawed and self-serving attempts to justify and expand their hoax will be picked up, dissected, and exposed by one or more members of the anti-psychiatry movement.

But we also need to strengthen our activities in other directions if we hope to connect with the silent skeptical majority mentioned earlier. Here are some of my thoughts on this matter.

NON-PSYCHIATRIST PROFESSIONALS

I know from my own experience during my career, and from the large number of emails that I receive today, that a great many non-psychiatrist professionals working in mental health centers, group homes, nursing homes, etc., see through the hoax, are dismayed by the damage being done, but are apprehensive about speaking out. This apprehension often stems from a fear of losing employment. But is also often a reflection of uncertainty and misplaced deference to the authority and dogma of “the doctor”.

All the non-psychiatrist professions are represented in this group: social workers, job coaches, case managers, psychologists, counselors, behavioral trainers, nurses, etc… There is, in my view, an enormous need for websites where these individuals could communicate, voice their concerns, share ideas, and provide mutual support and encouragement.

In addition, there is a major need for associations of social workers, counselors, case managers, job coaches, etc., to formally acknowledge the anti-psychiatry movement in their literature and websites, and to schedule regular sessions in their annual conferences and other venues to discuss the lack of validity and the dangers of psychiatry’s medical model.

LAWSUITS

There have been a great many successful lawsuits brought by aggrieved psychiatric victims. But when one considers the scale and range of psychiatric destruction, it is clear that only a tiny proportion of victims ever pursue legal remedies. It is almost axiomatic that pharma will get out of this business when the cost of the lawsuits exceeds the profits. And when pharma goes, psychiatry’s drug cartel will shrivel from lack of funding.

Considering the damage that psychiatry is doing, and psychiatry’s chronic neglect of informed consent requirements, this seems fertile ground for successful litigation. There are, of course, many attorneys working in this field, but it would be nice to see more. It would also be nice to see roadside billboards saying: “Have you been harmed by psychiatry? Call us now” etc.

SURVIVORS

Ultimately, it is the survivors who will turn this thing around. These are individuals who have escaped psychiatry’s web of deception, disempowerment, and destructiveness, and who are now actively exposing the hoax in which they were once ensnared. Survivor groups constitute a powerful source of inspiration for those who are trying to escape psychiatry’s cloying tentacles, and a source of support for those taking their first tentative steps to freedom and self-reliance. It would, I think, be an enormous step forward if there were a psychiatric survivor group in every town here in the US and overseas.

JOURNALISTS AND MAINSTREAM MEDIA

One professional journalist writing in a mainstream outlet can do more for our cause than ten amateurs such as myself writing on our websites. This is not to disparage our amateurish efforts, but simply to acknowledge that there is an art to catching readers’ attention, and presenting data persuasively to a wide audience. I encourage my readers to do two things: firstly, if you come across an article in a newspaper or other outlet that challenges or criticizes psychiatry’s practices, take the time to write to the journalist or the editor, expressing your appreciation; secondly, and conversely, if you come across a piece that promotes psychiatry, consider sending a letter pointing out that there is another side to the story. The mainstream media are beginning to recognize the validity of the anti-psychiatry perspective, and have displayed a willingness to publish our positions and our concerns.

PROTESTS

Even a dozen people carrying placards protesting peacefully outside a psychiatric facility will attract media attention, and will provide an opportunity to talk to the press about psychiatry’s spurious illnesses, and destructive “treatments”. It’s critically important to keep the protests peaceful and to have carefully-drafted written statements ready to give to the press.

CALL A SPADE A SPADE

In criticizing psychiatry, it is important not to endorse their concepts by using their terminology. Here are some common psychiatric terms with what I feel are more accurate descriptors:

mental illness:                problems of thinking, feeling or behaving

mental disorder:             problems of thinking, feeling or behaving

medication:                     mood-altering drugs; neurotoxic drugs

ECT:                                  high voltage electric shocks to the brain

psychiatric diagnosis:     psychiatric label

major depression:          profound sadness

psychiatric treatment:    drug pushing

anti-psychotics:               major tranquilizers or neuroleptics; chemical restraints

MISCELLANEOUS

The civil rights and anti-war protesters of the 60’s made use of slogans, songs, cartoons, etc., to carry and promote their message. I’m sure there are potential song-writers and poets in the anti-psychiatry movement who could do for our field what Bob Dylan and Joan Baez did for the protests of the 60’s.

Cartoons can also be helpful. Check out Auntie Psychiatry for examples of how a good cartoonist can express complex and profound ideas in a single picture.

I would love to see bumper stickers that said: “Psychiatry Kills”, “Depression is not an illness”, etc..

I think it would also be helpful to keep an eye on pending legislation within our respective jurisdictions. If you see a bill that promotes psychiatric concepts or “treatments”, consider writing a letter to your representatives.

We need to generate and maintain pressure on GPs with regards to their endorsement of psychiatry and their prescribing of psychiatric drugs. The appropriate response from a GP to a person complaining of depression is that this is not a medical problem, coupled with the suggestion that the individual discuss the matter with someone who can provide genuine help with the psycho-social-economic issues that led to, and sustain, the feelings of sadness. We need to point out continuously and vigorously that writing a prescription for a so-called antidepressant is nothing more or less than drug-pushing, and is a disgrace to the honor and traditions of genuine medical practice.

FINALLY

My purpose in writing this post is to encourage readers to take steps to promote the anti-psychiatry movement. Psychiatry is a destroyer of life, and it destroys under the guise of benevolence – a veritable wolf in sheep’s clothing. But it can only survive as long as people are kept in ignorance of its true nature, its dismal outcomes, and its trailing wake of death and destruction.

There is absolutely nothing wholesome or good in psychiatry, and as such, it is an eminently worthy target for criticism and exposure. Please, if your circumstances permit, consider taking a step, even a small step, towards exposing and ultimately eradicating this hoax. We need to deliver our message to the silent, skeptical majority.

. . . . . . . . . . . . . . . .

Imagine if, twenty years from now, dictionary entries for the word “psychiatry” were along the lines:

…1. a medical specialty, now defunct, whose primary tenet was that all significant problems of thinking, feeling, and/or behaving were best conceptualized as illnesses, and best treated with mood-altering drugs and electric shocks to the brain. 2. (informal) an enormous hoax. 3. (informal) a shameful abuse of power and position.

SSRIs:  Minimal Effectiveness and High Risk

Last month (February 2017), the journal BMC Psychiatry published a study by James Christian  Jakobsen et al.  The study is titled Selective serotonin reuptake inhibitors versus placebo in patients with major depressive disorder. A systematic review with meta-analysis and Trial Sequential Analysis.

The research was a meta-analysis – i.e. it combined the findings from several earlier studies.  Here are the authors’ conclusions:

“SSRIs might have statistically significant effects on depressive symptoms, but all trials were at high risk of bias and the clinical significance seems questionable. SSRIs significantly increase the risk of both serious and non-serious adverse events. The potential small beneficial effects seem to be outweighed by harmful effects.”

The authors point out that there have been previous meta-analyses assessing “the effects of SSRIs in adults with major depressive disorder”, the general conclusions of which have been that SSRI’s have a statistically significant effect on depression.  But Jakobsen et al point out that the previous studies had a number of limitations, including one or more of the following:

  • failure to use predefined Cochrane methodology in the selection of studies;
  • only including subgroups of depressed individuals;
  • failure to search all relevant databases;
  • failure to systematically assess harmful effects;
  • failure to systematically assess risk of bias in the source studies.

The authors’ objective was:

“…to conduct a comprehensive systematic review assessing the beneficial and harmful effects of SSRIs versus placebo, ‘active’ placebo, or no intervention in adult participants with major depressive disorder using our eight-step procedure for assessing evidence in systematic reviews.”

The authors’ protocol, detailing the methodology to be used, was published in advance, and can be seen here.  “The methodology was not changed after the analysis of the review results began.”

. . . . . . . . . . . . . . . .

Here are some quotes from the article, interspersed with my comments/observations.

“Independent investigators searched for eligible trials published before January 2016 in The Cochrane Library’s CENTRAL, PubMed, EMBASE, PsychLIT, PsycINFO, clinicaltrials.gov., and Science Citation Index Expanded…Trials were included irrespective of language, publication status, publication year, and publication type. To identify unpublished trials, we searched clinical trial registers of Europe and USA, websites of pharmaceutical companies, websites of U.S. Food and Drug Administration (FDA) and European Medicines Agency, and we requested the  U.S. Food and Drug Administration (FDA) to provide all publicly releasable information about relevant clinical trials of SSRIs that were submitted for marketing approval.

Participants had to be 18 years or older and have a primary diagnosis of major depressive disorder based on standardised criteria, such as DSM III, DSM III-R, DSM IV, DSM V, or ICD 10.”

Obviously this was a very comprehensive search for source studies.

“Primary outcomes

  • Depressive symptoms measured on the 17-item or 21-item Hamilton Depression Rating Scale (HDRS), the Montgomery-Asberg Depression Rating Scale (MADRS), or the Beck’s Depression Inventory (BDI).
  • Remission (Hamilton <8 points; BDI <10 points; MADRS <10 points).
  • Adverse events during the intervention period which were classified as serious and non-serious adverse events. Serious adverse events were defined as medical events that were life threatening, resulted in death, disability, or significant loss of function, or caused hospital admission or prolonged hospitalization. The remaining events were classified as non-serious adverse events.

Secondary outcomes

  • Suicides, suicide attempts, and suicide ideation during the intervention period.
  • Quality of life (scale used by the trialists).

The time point of primary interest was end of treatment (defined by trialist). We also planned to report results assessed at maximum follow-up.”

. . . . . . . . . . . . . . . .

“Using our strict inclusion and exclusion criteria, a total of 195 publications/unpublished trials were identified and included. Due to multiple publications of single trials and lack of useful data, only 131 randomised clinical trials enrolling a total of 27,422 participants were included in our analyses.”

. . . . . . . . . . . . . . . .

“Estimating a meaningful threshold for clinical significance is difficult and an assessment of clinical significance should ideally not only include a threshold on an assessment scale.  Major depressive disorder affects daily functioning, increases the risk of suicidal behaviour, and decreases quality of life. Some adverse events might therefore be acceptable if SSRIs have clinically significant beneficial effects. We therefore both predefined a threshold for clinical significance and assessed the balance between beneficial and harmful effects.

As threshold for clinical significance, we chose a drug-placebo difference of 3 points on the 17-item HDRS (ranging from 0 to 52 points) or an effect size of 0.50 standardised mean difference. This has been recommended by the National Institute for Clinical Excellence (NICE) in England and has been chosen in other reviews. Nevertheless, these recommendations are not universally accepted and have been questioned. Others have suggested the following ‘rules of thumb’ regarding the standardised mean difference: 0.2 a small effect, 0.5 a moderate effect, and 0.8 a large effect. One study has shown that a SSRI-placebo mean difference of up to three points on the HDRS corresponds to ‘no clinical change’ [186]. Another valid study has shown that a SSRI-placebo difference of 3 points is undetectable by clinicians, and that a mean difference of 7 HDRS points, or a standardized mean effect size of 0.875, is required to correspond to a rating of ‘minimal improvement’[187]”

In studies of this kind, it is necessary to distinguish clinical significance from statistical significance.  This is well illustrated with a simple analogy.  Imagine a coin that has a 1% bias in favor of heads.  What this means essentially is that if one conducts a very large number of trials, each of 200 tosses, the average result per trial will be 101 heads and 99 tails: a discrepancy of 2 per 200, or 1%.  In ordinary practice, however, this coin could be considered fair for use in sporting events and other simple decision-making situations.  The 1% discrepancy is statistically significant (as opposed to a random fluctuation) but not practically significant.

Similarly, in clinical trails involving a large number of participants, a treatment effect might be statistically significant (i.e., probably not a random fluctuation), but may nevertheless be so small that it has no clinical significance.

For the purposes of the present meta-analysis, Jakobsen et al chose a 3-point difference on the 17-item Hamilton Depression Rating Scale as the threshold for clinical significance.  Their discussion of this in the above quote is self-explanatory.  Reference 187 in the above quote is to a 2015 paper by Joanna Moncrieff and Irving Kirsch.  The paper is a discussion of a 2013 study by Leucht et al, What does the HAMD mean?, which is reference 186 in the above quote.

The Leucht et al study was a meta-analysis embracing 7131 participants.  The methodology used was to compare the improvement scores that people obtained on the HDRS questionnaire with their improvement scores on the Clinical Global Impression scale (CGI-I).  The CGI is a rating scale based on a face-to-face interview and is used frequently by psychiatrists and other mental health workers in clinical and research settings to assess client improvement or deterioration.  Leucht et al found:

“The results were consistent for all assessment points examined.  A CGI-I score of 4 (‘no change’) corresponds with a slight reduction on the HAMD-17 of up to 3 points.” [Note:  the HAM-D and the HDRS are the same questionnaire.]

What this means essentially is that trained psychiatrists and other clinicians, conducting face-to-face assessments, could not detect an improvement of 3 points on the HDRS.  People who achieved an improvement of 3 points on the HDRS questionnaire were rated as “no change” on the face-to-face CGI-I.

Incidentally, five of the six authors of Leucht et al report close links to pharma.

“HF, MK and AS work full-time for Merck & Co, parent company of Organon, which provided the data for this study.  AS is also a shareholder with Merck & Co.  SL has received honoraria for consulting/advisory boards from Alkermes, Bristol-Myers Squibb, Eli Lilly, Janssen, Johnson & Johnson, Lundbeck, Medavante, Roche, lecture honoraria from AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Essex Pharma, Janssen, Johnson & Johnson, Lundbeck Institute, Pfizer, Sanofi-Aventis, and Eli Lilly has provided medication for a trial with SL as the primary investigator.  PL has received honoraria for educational talks on medical ethics from AstraZeneca and Eli Lilly.”

So it seems unlikely that they would be biased towards downplaying the efficacy of antidepressant drugs.

Also incidentally, here’s an interesting quote from a general discussion of this matter in the Moncrieff and Kirsch paper:

“The small differences detected between antidepressants and placebo may represent drug-induced mental alterations (such as sedation or emotional blunting) or amplified placebo effects rather than specific ‘antidepressant’ effects.”

. . . . . . . . . . . . . . . .

Primary Outcomes

“…meta-analysis of the results of all 92 trials [that used the HDRS] showed that SSRIs versus placebo significantly reduced the HDRS score (mean difference −2.25 points…).”

In other words, there was a statistically significant reduction in average depressive “symptoms” as measured by the HDRS, but the reduction was only 2.25 points, which as discussed above, is of no clinical significance, i.e., would be rated as “no change” on the CGI-I scale.

Risk of Bias

“All trials were at high risk of bias per several bias risk domains and especially the risk of incomplete outcome data, selective outcome reporting, and insufficient blinding bias may bias our review results. Our GRADE assessments show that due to the high risks of bias the quality of the evidence must be regarded as very low. The high risks of bias question the validity of our meta-analysis results as high risk of bias trials tend to overestimate benefits and underestimate harms.  The ‘true’ effect of SSRIs might not even be statistically significant.”

In other words, the small, but statistically significant results found in the meta-analysis may simply reflect various biases that were present in the source studies, and which would inevitably bias the results of the meta-analysis.

GRADE is a protocol developed by Cochrane Training for assessing the quality of a body of evidence.  Grading of Recommendations, Assessment, Development and Evaluation.

Incomplete outcome reporting is a particularly important source of bias in these kinds of trials.  Consider a drug vs. placebo trial in which the authors have gathered ten different pieces of outcome data on each participant.  Let’s say that four of these outcome measures favor the drug and six favor the placebo.  It is very tempting for the researchers, particularly those who have a vested interest in the drug, to report the four drug-favorable measures and omit the other six.

I leave it to the reader to decide whether psychiatric research might be prone to this kind of selective reporting.

Subgroup Analyses

In trials involving people with relatively higher levels of depression (HDRS score higher than 23 points), the improvement with SSRI’s was higher than in the trials involving lower levels of depression (less than or equal to 23 points).  The mean difference was 2.69 points for the SSRI group vs. 1.29 points for the placebo group, neither of which cross the threshold for clinical significance (3 points).

Other tests for sub-group differences showed no significant differences.  These tests were:

  • comparison of different SSRI’s
  • older vs. younger participants
  • trials with washout period vs. those without
  • trials with drug/alcohol dependent participants vs. those without
  • short “treatment” period (less than 8 weeks) vs. other trials
  • dose of SSRI, below median vs. equal to or above median

Long-term Follow-up

Only six of the 131 trials reported long-term follow-up results.  The meta-analysis of all six trials showed a mean difference of 1.30 HDRS points in favor of the SSRI participants.  This is a marginally significant result statistically.  The probability that it could have been a chance fluctuation is 7%.  Additionally it is considerably below the threshold for clinical significance.

The fact that the mean difference in long-term follow-up is lower than the short-term results suggests that whatever tenuous benefits came from the SSRIs were short-lived.  It is also interesting that only 6 of 131 trials pursued any kind of long-term follow-up.

Remission and No Response

Thirty-four of the 131 trials assessed participants for remission, and 70 trials assessed for no response.  Remission was usually defined as achieving a score below 8 on the HDRS.  Response was usually defined as a 50% reduction of HDRS score.  On each of these measures, the SSRI group had a better outcome.

Jakobsen et al, however, point out that the results on remission and response need to be interpreted cautiously for the following reasons:

“1) the assessments of remission and response were primarily based on single HDRS scores and it is questionable whether single HDRS scores are indications of full remission or adequate response to the intervention; 2) information is lost when continuous data are transformed to dichotomous data and the analysis results can be greatly influenced by the distribution of data and the choice of an arbitrary cut-point; 3) even though a larger proportion of participants cross the arbitrary cut-point in the SSRI group compared with the control group (often HDRS below 8 for remission and 50% HDRS reduction for response), the effect measured on HDRS might still be limited to a few HDRS points (e.g., 3 HDRS points) or less; 4) by only focusing on how many patients cross a certain line for benefit, investigators ignore how many patients are deteriorating at the same time. If results, e.g., show relatively large beneficial effects of SSRIs when remission and response are assessed but very small averaged effects (as our results show) – then it must be because similar proportions of the participants are harmed (increase on the HDRS compared to placebo) by SSRIs. Otherwise the averaged effect would not show small or no difference in effect. The clinical significance of our results on ‘no remission’ and ‘no response’ should therefore be questioned.”

Serious Adverse Events

Forty-four trials reported data on serious adverse events.  The meta-analysis odds ratio for the SSRI vs. the placebo group was 1.37.  What this means is that “31 per 1000 SSRI participants will experience a serious adverse event compared to 22 per 1000” in the placebo group:  an excess of about eleven serious adverse events per 1000 SSRI users.  And it should be stressed that in this study, serious adverse events were defined as “…medical events that were life threatening, resulted in death, disability, or significant loss of function, or caused hospital admission or prolonged hospitalisation.”

It should also be remembered that the great majority of the trials collected no long-term data.  The eleven-per-thousand excess serious adverse events occurred during the relatively brief period of “treatment” duration, and it is reasonable to suspect that such events would be more frequent with long-term use.

It is also noteworthy that only 44 of the 131 trials reported data on serious adverse events.

Non-Serious Adverse Events

“Meta-analyses showed that the participants randomized to SSRIs versus placebo had a significantly increased risk of several [non-serious] adverse events.”

These included:  abnormal ejaculation, tremor, anorexia, nausea, somnolence, sweating, asthenia, diarrhea, constipation, insomnia, dizziness, dry mouth, libido decreased, sexual dysfunction, appetite decreased, fatigue, vomiting or upset stomach, flu syndrome, drowsiness, blurred/abnormal vision or dry eyes, nervousness, headache, dyspepsia, weight loss, central or peripheral nervous system problems, lightheadedness/faint feeling, agitation, impotence, taste perversion, etc..

Suicides, Suicide Attempts, and Suicide Ideation

“There were almost no data on suicidal behaviour, quality of life, and long-term effects.”

The limited amount of information on these matters showed no significant differences between participants randomized to SSRI’s vs. placebo on number of suicides, number of suicide attempts, or suicidal ideation.  This is particularly noteworthy in that the prescription of antidepressants is routinely defended on the grounds that they provide protection against suicide.

Readers may find this no-difference­ result puzzling, given the accumulation of anecdotal information linking SSRI use to suicides and even murder-suicides.  But it has to be borne in mind that, compared to the enormous numbers of people taking SSRIs, suicide is still a very rare event and is unlikely to occur in sufficient numbers in short studies of this kind to provide useful comparative information.

General Points

“All trials used placebo as control intervention and due to the large number of adverse events, some patients might have figured out if they received an ‘active’ intervention or not, which might question the blinding of the trials.”

“Multiple previous reviews and meta-analyses have, as mentioned in our Background, assessed the effects of SSRIs and have generally concluded that SSRIs have significant effects on depressive symptoms. However, the estimated results (and not the conclusions the review authors made) of these reviews and meta-analyses actually are in agreement with our present results and show that SSRIs do not seem to benefit patients more than a few HDRS points. This increases the validity of our present results. Furthermore, we assessed in detail the risks of serious adverse events and of non-serious adverse events and found that both were significantly increased by SSRIs.”

“Our HDRS mean differences were averaged effects. Hence, it cannot be concluded that SSRIs do not have clinically significant effects on all depressed participants. E.g., certain severely depressed patients compared with lightly depressed patients… might benefit from SSRIs even though there is no evidence backing this hypothesis. However, any clinical research result will have this ‘limitation’. Specific patients might benefit from any given intervention even though valid research results have shown that this intervention ‘on average’ is ineffective or even harmful.”

In addition, it needs to be recognized that there is no way to identify in advance which individuals will be harmed by these drugs.  So, in prescribing these drugs, psychiatrists are effectively playing Russian Roulette with one essential difference:  they’re pointing the gun at someone else’s head.

“SSRIs versus placebo seem to have statistically significant effects on depressive symptoms, but the clinical significance of these effects seems questionable and all trials were at high risk of bias. Furthermore, SSRIs versus placebo significantly increase the risk of both serious and non-serious adverse events. Our results show that the harmful effects of SSRIs versus placebo for major depressive disorder seem to outweigh any potentially small beneficial effects.”

“Per our results, we now believe that there is valid evidence for a public concern regarding the effects of SSRIs. We agree with Andrews et al. that antidepressants seem to do more harm than good. We have clearly shown that SSRIs significantly increase the risks of both serious and several non-serious adverse events. The observed harmful effects seem to outweigh the potential small beneficial clinical effects of SSRIs, if they exist. Our results confirm the findings from other studies questioning the effects of SSRIs, but are in contrast to the results of other reviews concluding that SSRIs are effective interventions for depression. However, our present analyses represent the most comprehensive systematic review on the topic and we hope it may guide clinical practice.” [Hyperlink added]

. . . . . . . . . . . . . . . .

 DISCUSSION

 If psychiatry were a bona fide medical field, a meta-analysis of this quality yielding these results would send Richter 9 shock waves through the profession.  The prescription of SSRIs for depression is probably the single most frequent activity performed by psychiatrists in their day-to-day work.  The unambiguous revelation that this activity is doing more harm than good should be generating enormous concern for psychiatry’s leadership and for the rank and file.

But the publication of this study on February 8 generated no discernible concern within the profession.  This is because psychiatry has very little interest in the scientific assessment of its “treatments”.  Psychiatry is drug-pushing, pure and simple.  The primary criteria of success are customer retention, and volume of product sold.  As long as the “patients” keep coming back for more, psychiatrists can convince themselves that they are doing good.

The fact that the “patients” have been duped by unsubstantiated assertions of chemical imbalances, and are, in many cases, addicted to the pills, are inconvenient truths that can readily be eclipsed by self-deception and in-group mutual reassurance.

. . . . . . . . . . . . . . . .

AN INTERESTING “REBUTTAL”

On February 21, 2017, Emil Karlsson, who describes himself as “a debunker of pseudoscience and steamroller of miscellaneous nonsense”, critiqued the Jakobsen et al paper on the grounds that the HDRS 3-point cut-off for clinical significance is arbitrary and excessively high.  But in fact, as we saw earlier, the threshold is based on the empirical findings that a “minimal improvement” on the Clinical Global Impression scale corresponds to an improvement of about 7 on the HDRS, and a CGI rating of “no change” corresponds to a 3-point HDRS shift.  So the threshold of 3 points, far from being too high, is actually excessively generous.  Nevertheless, the average HDRS improvement in the trials reviewed by Jakobsen et al was only 2.25 points, and the improvement in those trials that contained long-term follow-up was only 1.30 points.

FUNDING

“The work was supported by The Copenhagen Trial Unit, Centre for Clinical Intervention Research, in Denmark.”

 

 

 

More on the Biological Evidence for “Mental Illness”

On January 10, 2017, I put up a post titled The Biological Evidence for “Mental Illness”.  It was published simultaneously on Mad in America.  The post was a response to an earlier comment from Carolina Partners in Mental Healthcare PLLC, which included the assertion “mental illnesses have a long history of biological evidence.”  In my January 10 article, I challenged this assertion and pointed out that no such evidence existed.  The article generated some comments, most of which were favorable.  There was one comment, however, from Michael, who asserted:

“Your rebuttal that there are no scientific studies to these cases can be dismissed with a quick google search.”

In my response to Michael, I asked him to cite me some references to support this assertion.  On  January 15, Michael wrote back citing three studies:  the first on the neurobiology of depression; the second on the neurobiology of “schizophrenia”; and the third on the neurobiology of “bipolar disorder”.

I examined these studies, and started to draft a response to Michael, but as I was writing, I realized that the subject matter warranted a wider audience and needed to be put up as a post.  This is not because the studies cited are particularly compelling.  As we shall see below, they are not. But rather, because what has happened here is something that occurs routinely in these debates.  Psychiatry proponents claim there is evidence to support their position that “mental illnesses” are caused by biological malfunctions – but when pressed for references, they either don’t respond at all, or they dish up the kind of references cited by Michael.

All three papers are literature reviews.

THE PAPER ON DEPRESSION

Maletic V, Robinson M, et al, Neurobiology of depression: an integrated view of key findings, Int J Clin Pract, 2007 Dec; 61(12): 2030–2040.

From the point of view of Carolina Partners and  Michael’s original assertion, this study is particularly easy to rebut.  In fact, the authors do it for us.  Here’s the conclusion:

“Major depressive disorder is an illness with significant neurobiological consequences involving structural, functional and molecular alterations in several areas of the brain. Antidepressant pharmacotherapy is associated with restoration of the underlying physiology. Clinicians are advised to intervene with MDD using an early, comprehensive treatment approach that has remission as the goal.” [Emphasis added]

Note that the authors are stating clearly that the structural, functional, and molecular neurobiological alterations are consequences of depression, not causes.

. . . . . . . . . . . . . . . .

But the article has many additional points of interest.  Here are some quotes:

“Although much information still needs to be attained, imaging and other methods have begun to elucidate the neurobiological abnormalities associated with MDD. In particular, several prefrontal and limbic structures and their interconnected circuits have been implicated in affective regulation (Figure 2). These neuroanatomical areas include the ventromedial prefrontal cortex (VMPFC), lateral orbital prefrontal cortex (LOPFC), dorsolateral prefrontal cortex (DLPFC), anterior cingulated cortex (ACC), ventral striatum (including nucleus accumbens), amygdala and the hippocampus. Abnormalities in these areas have been shown in patients with MDD compared with healthy controls and thus suggest a foundation for the symptomatic expression of MDD (24, 25). However, these deviations may be obscured or not present at the individual patient level and thus, these findings cannot necessarily be considered pathognomonic.” [Emphasis added]

Note the admissions that:

“…much information still needs to be attained…”
“…imaging and other methods have begun to elucidate…” [Emphasis added]
“…implicated in affective regular…” [implicated in is not synonymous with causative of]
“…suggest a foundation…” [Emphasis added]
“…deviations may be obscured or not present at the individual patient level…” [Emphasis added]

This doesn’t sound very definitive or convincing.

. . . . . . . . . . . . . . . .

“Combining the evidence from these genetic, cross-sectional, and clinical treatment studies suggests that morphological differences in the hippocampus may be a predisposing factor in MDD, but changes can also accumulate in the course of the disease and thereby create an obstacle to full recovery.”

Again, note the vagueness:

“Combining the evidence…suggests…” [Emphasis added]
“…differences in the hippocampus may…” [Emphasis added]
“…be a predisposing factor in MDD…”

The ever-present predisposing factor – not quite the same thing as a cause – but good enough to convey the impression of causality.

But look at the last phrase in the quote:

“…changes can also accumulate in the course of the disease and thereby create an obstacle to full recovery.”

What the authors are suggesting here is that depression  causes neurological pathology “in the course of the diseases” and that this pathology could create an obstacle to full recovery.  Of course the drugs and hi-voltage electric shocks to the brain that psychiatrists routinely use to “treat” depression also cause neurological pathology.

And lest it be feared that I’m cherry-picking quotes that are particularly vague and unconvincing, the word “may” occurs 21 times in the paper, e.g. “this abnormal activity pattern may be responsible for the manifestations of symptoms associated with MDD”; “Symptomatically, disruptions as a result of proinflammatory cytokines may be experienced as fatigue, loss of appetite and libido as well as hypersensitivity to pain.”  The word “could” occurs three times and the word “suggest(s)” ten times.

Here’s the final sentence of the study:

“Once remission is attained, maintenance of effect may become the more appropriate term, rather than relapse prevention, to emphasise the necessity for an ongoing collaboration between patient and physician in order to maintain neurobiological homeostasis.”

And what do you think is going to happen in this “…ongoing collaboration between patient and physician…”?

Here’s a clue:

“Disclosures
Vladimir Maletic has served on the Speaker’s Bureau or has been a consultant for Eli Lilly and Company and Cephalon.  He did not receive any financial compensation for his work on this manuscript. His co-authors are each employees and/or shareholders of Eli Lilly and Company”

And incidentally, according to Dollars for Docs, Dr. Maletic received $841,342 from pharmaceutical companies between August 2013 and December 2015.  In 2015 alone, he received 460 payments from pharma companies for a range of activities including promotional speaking, honoraria, consulting, education, food and lodging, etc.  According to his biography on Global Medical Education, he is a Professor of Neuropsychiatry and Behavioral Science at the University of South Carolina School of Medicine.

THE PAPER ON “SCHIZOPHRENIA”

Ross CA, Margolis RL, et al, Neurobiology of Schizophrenia,  Neuron, October 5, 2006, 52, 139–153

Here again, the authors themselves have provided the rebuttal of Michael’s assertion.  The final section of the paper is Conclusions and Possibilities for Future Research.  Here are the first two sentences.

“In conclusion, we now believe that the molecular genetics of schizophrenia are sufficiently advanced such that etiology-based studies of the neurobiology of schizophrenia are both justified and feasible. The field is still in its infancy, and we must struggle to integrate our rudimentary knowledge of schizophrenia genetics with our scarcely better developed understanding of normal human brain function.”

So, etiology-based studies of the neurobiology of “schizophrenia” are justified and feasible.  Which, of course, is a clear admission that the evidence is not to hand.

Later in the same section there’s this gem:

“The genes associated with schizophrenia may have a spectrum of different pathogenic effects, altering neuronal development, neuronal plasticity, and signal transduction. While undoubtedly a great oversimplification, it may be of heuristic value to postulate that variations in particular genes can affect particular neurobiological processes (Figure 6), in turn causing specific phenotypes.” [Emphasis added]

So the genes associated with “schizophrenia” may have a spectrum of different pathogenic effects.  This is very vague.  The use of the word “may” clearly implies that they also may not have such effects.  But in any event, the evidence for such effects is not adduced in the paper.

And the assertion “…it may be of heuristic value to postulate that variations in particular genes can affect particular neurobiological processes…in turn causing specific phenotypes”, simply means that the hypothesis that genetic variations affect neurobiological processes, which in turn cause psychiatric “symptoms” may have value in encouraging us to explore and learn, which isn’t particularly profound.  Any hypothesis can act as a stimulus to explore and learn.

Here are three more quotes from the section headed Neuropathology:

“Neuropathological investigations of schizophrenia…have not found any evidence of the usual features of neurodegenerative diseases, such as inclusion bodies, dystrophic neuritis, or reactive gliosis.  There is intriguing, though not always consistent, evidence of subtle cytoarchitectural anomalies in entorhinal gray matter…and in other corticolimbic regions, and an abnormally high frequency of aberrant neurons in the white matter underlying prefrontal cortex…temporal, and parahippocampal regions…While these findings remain open to various interpretations…together they provide suggestive evidence for subtle abnormalities in neurodevelopment in schizophrenia, such as disordered cortical neuronal migration, consistent with the observation of subtle behavioral, neurological, and morphologic abnormalities.” [Emphasis added]

“Gene expression array studies have compared the expression profiles, in a number of different brain regions, of schizophrenias and controls…These studies have yielded inconsistent results and still need to overcome the difficulties inherent in the usage of postmortem brain tissue.” [Emphasis added]

“These studies may allow us to reconceptualize our definitions of the psychiatric disorders, including schizophrenia, based on a better understanding of etiology and pathogenesis.”

They may indeed – but clearly the authors are not saying that the evidence is in.  In fact, in the Introduction to the article, they stated that:

“We argue in this review that a definitive study of the neurobiology of schizophrenia is now possible.”

The definitive study is “now possible”!  This paper is dated October 2006, more than ten years ago.  Why haven’t we seen the definitive study yet?  Could it be, could it possibly be, that psychiatry, driven by its own self-centered considerations, is barking up the wrong tree?

Under the ACKNOWLEDGEMENT heading, the paper states:

“NARSAD, Stanley Medical research institute, NIMH, NINDS, and Johns Hopkins Psychiatry provided support.”

AND INCIDENTALLY

The word suggests(s) occurs 26 times; may, 57 times; can, 28 times; might twice; and could seven times.

THE PAPER ON “BIPOLAR DISORDER”

Muneer A, The Neurobiology of Bipolar Disorder: An Integrated Approach, Chonnam Med J., 2016 Jan; 52(1):18-37

Once again, let’s start with the author’s own assessment of his paper.  The Conclusion section begins:

“A broad assessment of the current literature was done to bring to light the underpinnings of mood disorders in general and BD in particular. These are stress-related conditions with overt expression in individuals with an underlying genetic vulnerability. Modern neuroscience is utilizing animal models and conducting human research with increasingly sophisticated methods to unravel their pathophysiology. Significant strides have been made in understanding the neurobiology of affective illnesses, and in this regard new targets and biomarkers have been identified. Diverse biological systems act in concert in perpetuating the disorders. While obstacles in research remain in the basic scientific and clinical domains, there is no doubt that a representation is emerging that is providing a consolidated view regarding the development of these intractable conditions. It is hoped that new knowledge will translate into novel therapeutic measures that have both preventive and curative value for patients with bipolar spectrum disorders.”

Note:

“Modern neuroscience is [working]… to unravel their pathophysiology.”  The clear implication is that they haven’t unraveled it yet.

“Significant strides have been made in understanding the neurobiology of affective illnesses,”.  This is not what researchers say when they’ve made the great discovery.  They say Eureka!

“… new targets and biomarkers have been identified.”

Biomarkers sounds pretty good.  After all, it is widely claimed by psychiatry proponents that the identification of the elusive biomarkers is just around the corner.  It is widely promoted that the biomarkers, when discovered, will clinch the biological pathology issue once and for all.  So is that what the author is saying here?  Well, no.

It is clear from the text that what this author means by “biomarkers” is simply a biological factor that correlates to varying degrees with the bipolar label.  The author presents a few examples, but for illustrative purposes, let’s examine just one:  cortisol levels in the blood stream.

“Early in the trajectory of BD, episodes occur secondary to stress but there is blighted psychobiological resilience and defective coping that increase vulnerability to recurrent affective exacerbations with illness advancement.12  This impairment is principally provoked by the hypothalamic-pituitary-adrenal (HPA) axis, which does not function properly in patients with BD.13 Patients with BD have a hyperactive HPA axis, high levels of systemic cortisol, and nonsuppression of its circulating levels in the dexamethasone suppression test or the dexamethasone/corticotrophin-releasing hormone (DEX/CRF) test.14

This is a bit technical, but here’s the translation:

  1. In the early stages of those behaviors, thoughts, and feelings that psychiatrists label bipolar disorder, episodes of mania and depression occur in response to stress.
  1. But, as more episodes occur, there also occurs blighted psychobiological resilience, which presumably means reduced psychological resilience coupled with impairment in general health. These deteriorations are provoked by the HPA axis, “which does not function properly in patients with BD”.  Note the term provoked, which isn’t quite the same as caused.  Also note the cautious wording in the final clause:  “does not function properly in patients with BD”.  At first glance, this seems to be saying that the malfunctions cause the “BD”.  But when read more carefully, no such causal connection is stated or even implied.  All that’s being asserted is that HPA malfunction and being labeled BP are correlated.  The causation, if it exists at all, could go either way.
  1. People labeled BP have high cortisol levels as measured by the two tests mentioned.

From all of this, the author concludes:

“From this perspective, HPA axis irregularities seem to be a genetic attribute endowing vulnerability to mood disorders.”

Note the vagueness:  “seems to be” and “vulnerability”.  Not quite the same as cause.

But there’s more.  The evidence for the HPA “irregularities” is the elevated cortisol level, which, incidentally, is just an average figure.  In the study cited, several of the BD “patients” had cortisol levels in the same range as the controls.  But more importantly, it’s been common knowledge since the 50’s that high alcohol consumption is associated with high cortisol levels, and, according to DSM-IV:

“As the Manic Episode develops, there is often a substantial increase in the use of alcohol or stimulants which may exacerbate or prolong the episode.” (p 330)

This is echoed in DSM-5, which notes a

“…tendency for individuals with bipolar 1 disorder to overuse substances during an episode.” (p 131)

So the elevated cortisol may reflect nothing more than frequent heavy drinking.

. . . . . . . . . . . . . . . .

 In general, Dr. Muneer makes no claim that a biological cause to “BD” has been established.  Indeed, the paper is characterized by caution and guardedness in this matter.  For instance:

“…it is probable that most of the cortisol-GR [glucocorticoid receptor]-related mechanisms alluded to above are a sign of the putative genetic underpinning.” [Emphasis added]

Putative means assumed or believed to be the case.

“Given that the mechanisms of HPA axis dysregulation are incompletely known at present, as is its role in dictating the risk of the disease in vulnerable subjects, current work is beginning to unravel the molecular targets of illness development and progression in BD.” [Emphasis added]

“In bipolar patients, major mood episodes of either polarity result in an inflammatory response that has been convincingly shown in several studies.” [Emphasis added]

So the “episodes” cause the biological malfunction rather than the other way round.

Under the heading LIMITATIONS, the author states:

“The following caveats should be kept in mind while deducing any inferences with respect to the neurobiology of BD:
1) Not all predisposed individuals are afflicted by BD, which underscore the issues of genetic epistasis and hitherto little known mechanisms that mediate resiliency.
2) There are large gaps in knowledge due to the absence of good animal models replicating BD.
3) Technological advances are needed to reproduce findings from animal research in human samples.”

Note the truly exquisite optimism in item 1 above.  Not all the people who have the biological correlate in question go on to develop the thoughts, feelings, and actions which psychiatry labels BD.  So these individuals must have some as yet unknown “mechanisms” that confer resilience.  But the alternative perspective, that this is simply not a fruitful line of inquiry, isn’t even addressed.

SUMMARY

None of the three studies put forward by Michael as evidence that “mental illness” is biologically caused come even close to establishing this premise.  Indeed, in each case, the authors are quite clear that the evidence for this premise is not to hand.  The articles are essentially discussion papers which discuss the implications of previous research, and express the hope that more definitive findings will be available some time in the future.

Meanwhile, psychiatrists and their supporters continue to claim that “mental illnesses” are real illnesses caused by brain pathology, that need to be corrected by drugs and/or high voltage electric shocks.  These assertions remain unsubstantiated despite decades of highly motivated and lavishly funded research.  For these assertions to acquire even a semblance of validity, psychiatry needs to demonstrate convincingly that all (or at last the great majority) of the individuals “diagnosed” with a particular “mental illness” have a clear and identifiable neural pathology, and that the causation runs from the pathology to the problems of thinking, feeling, and/or behaving in question.  Weak correlations to neurophysiological processes or genetic variations are irrelevant, as I showed in the original article.

And while psychiatrists, for self-serving reasons, continue their inane efforts to “unravel” the neurobiological causes of these so-called illnesses, more obvious natural causes are studiously ignored and neglected.  Tampering irresponsibly with a person’s brain because he is depressed, while ignoring  those features of his lifestyle and recent history that have been known from time immemorial to precipitate depression, is reckless folly.

Psychiatry Interrogated, (ed. Bonnie Burstow), Palgrave Macmillan:  A Book Review

I have recently read Psychiatry Interrogated, subtitled “An Institutional Ethnography Anthology”Ethnography is the branch of anthropology that deals with the systematic study of individual cultures.  Institutional ethnography (IE), according to Wikipedia, is  “a method of social research [that]… explores the social relations that structure people’s everyday lives, specifically by looking at the ways that people interact with one another in the context of social institutions (school, marriage, work, for example) and understanding how those interactions are institutionalized…For the institutional ethnographer, ordinary daily activity becomes the site for an investigation of social organization.”

In the Introduction to Psychiatry Interrogated, Dr. Burstow writes:

“The suitability of IE as an approach for interrogating psychiatry is demonstrable for psychiatry routinely causes disjunctures – indeed, horrendous disjunctures in people’s everyday lives; it has both hegemonic and direct dictatorial power.  Behind what we might initially see – a doctor or a nurse – lies a vast army of functionaries, all of them activating texts that originate extra-locally.  The fact that IE as a method feels ready-made to unlock institutional psychiatry – and that’s what I am suggesting here – is not accidental.  Significantly, from early on, psychiatry was one of the primary regimes which Dorothy [Dorothy E. Smith, PhD, (1926- ) founder of IE] was theorizing as she went about developing her method.” (p 10)

Although IE studies begin with a disjuncture or disconnect in people’s everyday local lives, the focus is on the impact of non-local institutions and texts.

It should be clarified at this point that IE studies are not the kind of statistical analyses that we normally encounter and discuss in this arena.  Rather, they are qualitative descriptions of what’s going on in a situation with particular reference to relationships, power, and institutional oppression.  IE enquiries are “particularly aimed at ferreting out and making visible how institutions work”. (p 5)

. . . . . . . . . . . . . . . .

All the chapters of Psychiatry Interrogated, except the Introduction and the Afterword, describe a specific IE enquiry in which the institution psychiatry is examined.  In order to convey something of the flavor of the book, here is a brief outline of the disjunctures that initiated each enquiry, and some illustrative quotes.

Chapter 2 (B Burstow and S Adam):  In August 2012, the following ad appeared in the jobs etcetera section of the Toronto craigslist:

The authors point out that

“Under the category ‘Jobs Etc.’ CAMH had placed an ad on Craigslist that in essence functioned so as to lure those down on their luck to be participants in an electroshock study –  a study that involved them actually receiving ECT.  In the battle and research that followed, hitherto hidden truths come to light not only about psychiatric research processes but, every bit as important, about research oversight in general.” (p 16)

“At the same time as credible studies were establishing damage and disproving effectiveness, a mammoth ECT research industry devoted to demonstrating that the ‘procedure’ was safe and effective was moving into high gear – all overruling credible findings, all invisibilizing the everyday lives of shock survivors.  Moreover, books that functioned as boss texts…were spearheading a ‘safe and effective’ narrative.  By the same token, hospitals were making their reputation through ECT research.  It is in this context that we must understand the ECT study.” (p 28)

Chapter 3 (C Chapman, J Azevedo, R Ballen, J Poole):  Two nurses, who had practiced competently for years, lost their nursing certificates because they divulged a history of “mental illness”.

“It is the framing of Janet and Ikma as ‘mentally ill’ (conflated with ‘incompetent’) that enabled the CNO [College of Nurses of Ontario] to disregard their alternative accounts of events, their legitimate grievances, and assertions of their ‘competence.'” (p 58)

Chapter 4 (L Tenney in consultation with C Brown, K Cascio, A Cerio, B Grundfest-Frigeri):  The disjuncture for this study is the psychiatrization of people on the grounds of their nonhegemonic spiritual beliefs.

“My standpoint, my entry into the research, is as someone who 28 years ago was involuntarily institutionalized and drugged in New York, at least in part because of my spiritual experiences.  My ultimate disjuncture is precisely that psychiatrization.  The question that I am asking is how does psychiatry operate so that such disjunctures or violations occur?  That is, how does it turn people’s spiritual leanings into a warrant for both initial and ongoing psychiatrization?” (p 68)

Chapter 5 (MJ Hande, S Taylor, E Zorn) addresses the difficulties faced by parents of children “diagnosed with autism”, and examines how these parents, in their pursuit of assistance and resources, become unwitting agents of “the complex, multileveled ruling relationships that structure them”.

“At all levels of the process, parents can only access care and support through their child’s diagnosis and the texts that diagnosis has generated, thereby leading them to continually activate the DSM.” (p 90)

Chapter 6 (SL Jakubec, JM Rankin) examines how psychiatric expansionist goals can infiltrate, and even eclipse, the original goals of a helping organization.

“In our analysis we show how development practices (e.g., the exploration of indicators for measurement) and the dominant movement for global mental health (mGMH) – and goals of a rapid ‘scaling up’ of mental illness diagnosis, treatment and research – began to enter the way workers at the NGO understood and performed their work.” (104)

“The biomedical emphasis on ‘mental health’ has had an important impact on how ‘global mental health’ is being addressed. The mGMH’s premise is that what are called, for example, depression and schizophrenia, are biological disorders no different from HIV-AIDS or epilepsy, and that people living in poor countries have just as much right to access effective drug treatments for mental disorders as people in ‘developed’ countries…Despite the arguments of some experts claiming that drug treatments for psychiatric conditions are nowhere near as effective as believed…and are even harmful…those in the movement have relied on the appeal of equitable access to treatment to create the focus of the goals of the mGMH…What we see here is a conflation of human rights discourse and biological psychiatry discourse..” (p 108)

Chapter 7 (L Spring) begins with three disjunctures.  Firstly, increasing numbers of soldiers are killing themselves; secondly, soldiers who are experiencing problems of living are being labeled as “mentally ill”; and thirdly, the “treatment” these individuals receive often causes severe and permanent harm.

“…the question arises: Could some soldiers have killed themselves not in spite of the treatment they were receiving, but because of its effects?  Should not the fact that more than half of the CAF [Canadian Armed Forces] members who killed themselves in 2013 were receiving ‘the best care this country has to offer’ at the time of their suicides be an indication that the current system is not working?” (p 133-134)

“This chapter has traced how it has come to pass that a fictional disorder ‘essentially created by committees of doctors sitting around conference tables’…has gained so much traction in recent years.  I have traced how the ruling relations continually associate the idea of PTSD with soldiers’ suicides and how the language of the DSM is now regularly activated.  This is done not only by the media, the military, and the psychiatric system itself but also by services members, veterans, and those closest to them as they go about their daily lives.” (p 140)

Chapter 8 (J Tosh, S Golightley) presents two instances of bullying in UK colleges.  In one case the victim came to be labeled as “mentally ill”; in the other, the victim was bullied because of such a label.

“These two case studies illustrate how labels of ‘mental illness’ can be used to silence those who speak out against oppression and pathologization within those professions where such interventions are sorely needed.  In one case, violence and bullying was dismissed, ignored, and perpetuated by labeling the victim as ‘mentally ill.’  In doing so, her accusations of bullying and her competency regarding her job became discredited and disbelieved.  Her actions and words were constantly interpreted and viewed through the lens of sanism and used as further justification for abuse.” (p 156)

“In the other case, the label of ‘mental illness’ was framed as a ‘danger’ and a ‘risk’ in addition to a ‘vulnerability.’  However, rather than provide the assistance that was initially requested, her label of mental illness was used in attempts to disrupt her training, much like how Olivia was ‘pushed out’ of her job.  This, in addition to the increased surveillance in both cases, shows how ‘reasonable adjustments’ manifested as restrictions framed within a discourse of ‘help’ and doing what was ‘best’ for those with a ‘mental illness.'” (p 156)

Chapter 9 (R Wipond, S Jakubec) examines the development of workplace “mental health” and the reframing of social problems as psychiatric issues.

“…the dominant Western mental health system is itself a deeply contested space characterized by polarized power relationships between the providers and the people actually receiving the ‘treatments’ or services.  In addition, profound political tensions are built into federal, provincial, and state laws that allow assertive, coercive, and forced ‘mental health care.'” (p 163)

“…extremely divergent opinions and struggles for power emerge in the scientifically unvalidated diagnostic methods and the often unreliable, ineffective, and demonstrably dangerous treatment practices…” (p 163)

These observations prompt the authors to ask:

“…could importing principles, policies, and practices from the mental health system into workplaces truly, as suggested, ‘create and continually improve a psychologically healthy and safe workplace?'” (p 163)

Chapter 10 (A Doll) examines the system by which people being adjudicated for involuntary psychiatric admission are afforded legal representation in Poland.  The study begins with three disjunctures that will be familiar to anyone who has had contact with these matters.  Firstly, the lawyers are poorly compensated for their work; secondly, they are mandated to perform this work; and thirdly, “it is almost impossible to challenge” psychiatric assertions in a legal context.

“All of which – even for those lawyers committed to their legal aid duties – only adds to the already burdensome nature of the work.  The key issue here is that the involuntarily admitted – that is, the very persons who need spirited lawyering – may not receive appropriate advocacy.  In this context, a right to representation, a key guarantee of ‘due process’ under the inherently coercive procedure of involuntary admission, may be nothing more than a formalistic legal institution with no substantive meaning.” (p 184) [Emphasis in original]

Chapter 11 (E Gold):  The disjuncture that prompted this study was the author’s observation that the torture experiments conducted in the 60’s by John Zubek, PhD at the University of Manitoba, were funded, not only by the military, but also by the US National Institute of Mental Health.

“It was argued earlier that Zubek’s experiments meet the criteria of definition of torture.  Students were knowingly and purposefully placed into experimental conditions that caused them pain and suffering.  These experiments were sanctioned by the University of Manitoba, and the ethical regulatory body for the field of psychology, the CPA, never stepped in, thus creating the illusion that Zubek’s work met ethical standards.  Zubek’s research was directly linked to military torture through one nagging question that he could never escape – if not torture, what was the DRB’s [Defense Research Board] interest in funding this research?” (p 219)

“Nevertheless, little research has questioned the interests of Zubek’s other major funder – the US National Institute of Mental Health.  We now know that this research was linked to the development of current military torture techniques – methods that cause pain and suffering without inflicting direct physical violence on the victim.  It seems worthwhile to ask here:  What is the overlap between the development of military torture and the burgeoning field of mental health?  If not torture, what was the NIMH’s interest in funding this research?” (p 219)

“Recalling the actual experiments, the National Institute of Mental Health primarily funded the immobilization branch – the most intolerable condition in Zubek’s repertoire.  Although most research has focused on the sensory deprivation aspect of the experiments, it was the immobilization that most subjects were simply unable to bear.  This condition – having one’s head and limbs strapped while in a recumbent position, even with normal levels of sensory input – was experienced as excruciating, with only one-fifth of the research subjects continuing their participation until the end.  Not only was this condition intolerable to most participants, but it also produced intellectual stunting, a loss of contact with reality, and severe distortions in participants’ perceptions…It is worth noting that Zubek’s immobilization condition bears a striking and eerie resemblance to the common practice of physical restraint in mental health settings.” (p 219-220)

“Unlike Zubek’s subjects, however, individuals who are being forcibly restrained in a psychiatric context do not enjoy the option of deciding whether they consent to being restrained and how long this period of restraint should last.” (p 220)

In conclusion, the author poses the troubling question:

“Are we as a society going about our everyday lives while complicit in everyday atrocities disguised as ‘help’?” (p 224)

THE SIGNIFICANCE OF IE FOR ANTI-PSYCHIATRY

Psychiatry routinely presents itself as a legitimate medical specialty differing from the other specialties only in the kinds of illnesses treated.  But, in fact, this is not accurate.  Firstly, the problems that psychiatry purports to treat are not illnesses in any ordinary sense of the term; and secondly, psychiatry’s treatments are nothing more than legalized drug-pushing, more akin to the street-corner activity than medical care.  But there is another important difference between psychiatry and real medicine.  Psychiatry’s core concepts are embedded formally and informally in our legal, social, educational, and workplace institutions in ways that the other medical specialties are not.

The term “mental illness”, for instance, which most of us in the anti-psychiatry movement consider spurious, is written into the laws and regulations of every US state, and probably most other countries.  In addition, virtually every county in the US is “served” by a publicly-funded community mental health center, charged with “treating mental illness”, educating the community on matters pertaining to “mental health”, and forcibly committing people to psychiatric facilities.  Residents of nursing homes are required by federal law to be screened for “mental illness” on admission, and to be afforded “treatment” if this is indicated.  Schools are legally required to provide special accommodation for some children who have been assigned spurious psychiatric labels (e.g. ADHD), and additional funding is provided for these activities.  And at the present time, psychiatry is pushing hard for integration of its “services” into primary care.

Those of us who would like to see an end to psychiatry are aware of its widespread tentacles, and the extent to which its core concepts and practices are embedded in the very fabric of our society.  But that awareness tends to be of the dull-and-persistent-ache variety, rather than the sharp-stone-in-the-shoe.

We win the intellectual and moral battles hands down, but we are understandably daunted at the prospect of persuading fifty legislatures that the term “mental illness” has no validity, and that psychiatric “treatment” is essentially on a par with street-corner drug-pushing.

We are daunted by the exportation of mental illness concepts and practices to all parts of the globe.  We are daunted by the wholesale adoption of pathologizing and disempowering psychiatric ideas by the military services here in the US and abroad.

We touch on these, and related, issues frequently, of course, in our individual writings, but up till now, we have lacked a formal methodology to focus on these matters, and to lay bare the disjunctures, the intricacies, the details, and the damage done.

And it is in this regard that the value of Psychiatry Interrogated needs to be recognized.  Psychiatry Interrogated does, of course, critique psychiatry, but it also does more:  it provides and  demonstrates a formal methodology (IE) by means of which these kinds of concerns can be systematically studied and credibly exposed in a wide variety of situations and contexts.  Psychiatry Interrogated is a cardinal work in the literal sense of the term:  a turning point on which new developments can hinge, find support, and thrive.

SUMMARY

Psychiatry Interrogated is a powerful and compelling work, that demonstrates how common reactions of the how-can-that-happen? variety can serve as springboards to unraveling and exposing the complex, repressive, and inherently destructive nature of psychiatry.  Each chapter has an extensive reference list for those who wish to pursue any of the topics in greater depth.

The book is dedicated to “everyone everywhere who has ever fallen prey to institutional psychiatry.”

DISCLAIMER

I have no financial interest in this book or any book/product that I mention in these writings.

Mental Health First Aid: Another Psychiatric Expansionist Tool

On December 25, 2016, the Baltimore Sun published an excellent article titled Drug companies prey on children, by Patrick D. Hahn, PhD.  Dr. Hahn is an affiliate professor of biology at Loyola University, Maryland.  Here are some quotes:

“I recently attended Youth Mental Health First Aid Training at a local public school. It was an eye-opening experience.”

“Youth Mental Health First Aid Training, sponsored by the National Council for Behavioral Health, is intended to enable teachers, parents and others in contact with young people to identify potential ‘mental illnesses’ in order to facilitate early detection and treatment by our mental health care system. My fellow attendees were surprisingly open about their own experiences with that system. One mentioned that her son became manic after being diagnosed for ADHD. Another said that both she and her roommate became bipolar after being diagnosed for depression. Neither our facilitators nor anyone else present pointed out that mania and bipolar disorder are toxic effects of medications commonly prescribed for ADHD and depression.”

“Our training manual didn’t say anything about this either, although it did claim that depression is caused by a deficiency of serotonin — a fable that by now has become as discredited as the phlogiston theory of chemistry. It also stated that mental health interventions are ‘evidence-based’ and ‘scientifically tested’ — neglecting to mention that much of that evidence is put forth by drug companies who have a fiduciary duty to do everything they can to maximize sales of their products.”

“So is all this a scheme to push more drugs to more kids? The 2013/2014 annual report for the National Council for Behavioral Health, titled ‘A Legacy of Excellence and Impact,’ gives us a hint. It lists the organization’s supporters as including the Pharmaceutical Research and Manufacturers of America (PhRMA) along with no fewer than 12 different drug companies. Would these folks be ponying up the cash if they weren’t confident this program would increase sales? And do the parents and teachers who attend the council’s training program — no doubt with the best intentions in the world — realize that they are essentially sitting through an eight-hour infomercial bought and paid for by the drugmakers?”

“One out of 13 American children between the ages of 6 and 17 has taken a psychotropic medication within the last six months, according to the Centers for Disease Control. Meanwhile, youth suicide rates are at their peak going back at least as far back as 1999, while the number of children receiving disability benefits for mental illness is at an all-time high.”

Please take a look at Dr. Hahn’s article, and pass it on.  Mental Health First Aid is not a good thing.  Rather, it is just another psychiatric expansionist tool.

MENTAL HEALTH FIRST AID

For readers who are not familiar with the term, Mental Health First Aid, according to its own website, is “…an 8-hour course that teaches you how to identify, understand and respond to signs of mental illnesses and substance use disorders.”

From its FAQ page:

“The evidence behind the program demonstrates that it does build mental health literacy, helping the public identify, understand, and respond to signs of mental illness.”

Incidentally, I Googled the term “mental health literacy” and got 28.8 million results!  There’s also a Wikipedia article on mental health literacy.  Here’s a quote from the opening paragraph:

Mental health literacy has been defined as ‘knowledge and beliefs about mental disorders which aid their recognition, management or prevention. Mental health literacy includes the ability to recognize specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking.1‘”

So mental health literacy doesn’t just mean the acquisition of some information and skills; it also means accepting the psychiatric hoax:  “attitudes that promote recognition and appropriate help-seeking”.  The goal is not just the dissemination of psychiatry-friendly information, but also the active conversion of skeptics to the psychiatric cause.

Reference # 1 in the above quote refers to Jorm et al “Mental health literacy”: a survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment, Med J Aust. 1997 Feb 17;166(4):182-6.  The survey in question was conducted in Australia in 1995 and sheds particular light on the present discussion.  Here’s the abstract of the article:

“OBJECTIVES:
To assess the public’s recognition of mental disorders and their beliefs about the effectiveness of various treatments (‘mental health literacy’).

DESIGN:
A cross-sectional survey, in 1995, with structured interviews using vignettes of a person with either depression or schizophrenia.

PARTICIPANTS:
A representative national sample of 2031 individuals aged 18-74 years; 1010 participants were questioned about the depression vignette and 1021 about the schizophrenia vignette.

RESULTS:
Most of the participants recognised the presence of some sort of mental disorder: 72% for the depression vignette (correctly labelled as depression by 39%) and 84% for the schizophrenia vignette (correctly labelled by 27%). When various people were rated as likely to be helpful or harmful for the person described in the vignette for depression, general practitioners (83%) and counsellors (74%) were most often rated as helpful, with psychiatrists (51%) and psychologists (49%) less so. Corresponding data for the schizophrenia vignette were: counsellors (81%), GPs (74%), psychiatrists (71%) and psychologists (62%). Many standard psychiatric treatments (antidepressants, antipsychotics, electroconvulsive therapy, admission to a psychiatric ward) were more often rated as harmful than helpful, and some nonstandard treatments were rated highly (increased physical or social activity, relaxation and stress management, reading about people with similar problems). Vitamins and special diets were more often rated as helpful than were antidepressants and antipsychotics.

CONCLUSION:
If mental disorders are to be recognised early in the community and appropriate intervention sought, the level of mental health literacy needs to be raised. Further, public understanding of psychiatric treatments can be considerably improved.”

So, in 1995, the general public in Australia, as represented by the sample of 2031 individuals in this study, had some interesting views concerning psychiatry.

  1. They rated GP’s and counselors as more helpful than psychiatrists and psychologists for problems of “depression” and “schizophrenia”.
  1. They rated many “standard psychiatric treatments” (antidepressants, neuroleptics, electric shocks, and psychiatric wards) harmful, more often than helpful.
  1. They rated some “nonstandard treatments” (increased physical or social activity, relaxation, stress management, reading about people with similar problems) highly.
  1. They rated vitamins and special diets helpful more often than antidepressant and neuroleptic drugs.

At the risk of stating the obvious, those of us on this side of the issue would consider the general public’s beliefs, as reflected in this survey, to be accurate, and grounded in common sense.  But from the aspect of psychiatry – and particularly psychiatry’s expansionist agenda – these findings are cause for particular concern.  And so, as the authors state:  “…the level of mental health literacy needs to be raised…”

Here’s an interesting quote from the study’s Introduction:

“The lifetime risk of developing a mental disorder is so high (nearly 50%)2 that almost the whole population will at some time have direct experience of such a disorder, either in themselves or in someone close. A high public level of mental health literacy would make early recognition of and appropriate intervention in these disorders more likely.”

Incidentally, the survey was conducted by the Australian Bureau of Statistics, presumably at public expense.

Three years later, Dr. Jorm, the lead author, and his wife Betty Kitchener, founded Mental Health First Aid.  According to his biography on the University of Melbourne site, Dr. Jorm is a highly cited mental health researcher whose work “…focuses on building the community’s capacity for prevention and early intervention with mental disorders.”

The MHFA program spread rapidly in Australia, and by 2015, 350,000 people had received the training.

And Dr. Jorm has been busy promoting mental health literacy in other venues.  In 2000, he published a paper in the British Journal of Psychiatry, the stated aims of which were:

“To introduce the concept of mental health literacy to a wider audience, to bring together diverse research relevant to the topic and to identify gaps in the area.”

And in 2012, he and Nicola Reavley published a paper Public recognition of mental disorders and beliefs about treatment: changes in Australia over 16 years, also in the British Journal of Psychiatry.  The conclusions of this paper were:

“Although beliefs about effective medications and interventions have moved closer to those of health professionals since the previous surveys, there is still potential for mental health literacy gains in the areas of recognition and treatment beliefs for mental disorders. This is particularly the case for schizophrenia.”

THE SCOPE OF THE MENTAL HEALTH FIRST AID PROGRAM

Here’s another quote from MHFA’s FAQ page:

“Mental Health First Aid is intended for all people and organizations that make up the fabric of a community. The course is presented to chambers of commerce, professional associations, hospitals, nursing homes, rotary clubs, parent organizations, social clubs, and other groups. Professionals who regularly interact with a lot of people (such as police officers, human resource directors, and primary care workers), school and college leadership, faith communities, friends and family of individuals with mental illness or addiction, or anyone interested in learning more about mental illness and addiction should get trained.”

And so the tentacles of psychiatric destruction, disempowerment, and, ultimately, despair, are spread to all parts and segments of our society, and people of all ages and all walks of life are shoveled indiscriminately into the insatiable maw of psychiatric dependency and premature death.

Mental Health First Aid (USA) lists on its website 109 organizations across the US (including 45 NAMI chapters) that offer MHFA training.

MHFA AND THE APA

Not surprisingly, the APA has enthusiastically endorsed the program.  Here are some quotes from Mental Health First Aid:  Training for Communities and Families, which you can find on the APA website:

“Mental Health Fist Aid (MHFA) is an eight-hour, in-person training that teaches how to help a person struggling with a mental illness or in a crisis. It provides a basic understanding of mental illness and addiction, signs of addiction and mental illness, the impact of mental and substance use disorders, what helps individuals experiencing these challenges get well and local resources for help.”

Note the emphasis on “mental illness” and “mental disorders”, and the notion that individuals “experiencing these challenges” need to “get well” by accessing “local resources for help”.

“Trainees are taught a five-step action plan and how to apply it in a variety of situations such as helping someone experiencing psychosis, engaging with someone who may be suicidal, or assisting an individual who has overdosed. The training uses role play and demonstrations to convey the information.”

“Five-Step Action Plan – ALGEE

  1. Assess for risk of suicide or harm
  2. Listen nonjudgmentally
  3. Give reassurance and Information
  4. Encourage appropriate professional help
  5. Encourage self-help and other support strategies”

Note:  “encourage appropriate professional help”, conveniently ignoring the reality that the most common form of “professional help” (psychiatric drugging) is causally implicated in the creation of the problems.

“More than 250,000 people have been trained in Mental Health First Aid in the U.S. by 5,200 certified instructors. Twenty-one states have legislation to support Mental Health First Aid, and federal grants support training in some communities.”

So American psychiatry has effectively recruited 250,000 volunteer sales reps, and has managed to get state and federal money to support this enterprise.

“A recent national study of the training concluded that MHFA improves confidence about being able to recognize someone who may be dealing with a mental health problem or crisis and to actively and compassionately listen to someone in distress. Researchers surveyed more than 35,000 people who had completed the training for the study published in the APA journal Psychiatric Services.”

The study mentioned is Crisanti AS, Luo L, McFaul M, et al. Impact of Mental Health First Aid on confidence relation to mental health literacy: a national study with a focus on race-ethnicity. Psychiatric Services in Advance. Published online Nov. 2, 2015.

Here’s the abstract:

“OBJECTIVE:
Low mental health literacy (MHL) is widespread in the general population and even more so among racial and ethnic minority groups. Mental Health First Aid (MHFA) aims to improve MHL. The objective of this study was to determine the impact of MHFA on perceptions of confidence about MHL in a large national sample and by racial and ethnic subgroup.

METHODS:
The self-perceived impact of MHFA on 36,263 people who completed the 12-hour training and a feedback form was examined.

RESULTS:
A multiple regression analysis showed that MHFA resulted in high ratings of confidence in being able to apply various skills and knowledge related to MHL. Perceived impact of MHFA training differed among some racial and ethnic groups, but the differences were small to trivial.

CONCLUSIONS:
Future research on MHFA should examine changes in MHL pre-post training and the extent to which perceived increases in MHL confidence among trainees translate into action.”

In other words, people who take the Mental Health First Aid course expressed confidence that they could apply the skills and knowledge acquired to actual situations.  The implication is that this is important because “Low mental health literacy (MHL) is widespread in the general population and even more so among racial and ethnic minority groups.”

Note that the term “mental health literacy” has now been reified into a desirable commodity, the lack of which can be identified, measured, decried, researched, funded, etc., in the interests of bringing more and more people into psychiatry’s insatiable clutches.  Mental health literacy means the extent to which one has bought the psychiatric hoax.  Those of us who are active in the anti-psychiatry movement are, of course, by implication, mental health illiterates.

There are absolutely no limits to psychiatry’s expansionist agenda.  Despite the well-established destructiveness of their “treatments”, they will never voluntarily curtail their relentless drive for more victims.

And they will not commission, or even call for, a formal, comprehensive study to examine the now blatantly obvious link between psychiatric drugs and the murder-suicides that have become commonplace in our communities.  Psychiatry is intellectually and morally bankrupt.  They have no valid response to their critics, but instead resort to spin and tawdry marketing tactics to shore up their crumbling sand castle.  But just as the tide cleans the foreshore, so the light of logic and truth, and the outspoken protests of its survivors, will one day wash the world of the blight known as psychiatry.

Book Review: The Power of the Double Circle

I have recently read The Power of the Double Circle by Philip Springer, MD, and Shelby Havens, DNP.  It’s a small book (91 pages), but it sets out an idea that might have some value in support/self-help and other kinds of groups.

Dr. Springer is a retired psychiatrist, and Dr. Havens is a psychiatric nurse practitioner, but their position as set out in the book is something close to anti-psychiatry.

For instance:

“What is worth considering is that you may get more help from someone sitting next to you on a bus than from a professional.  At least you are assured that it is likely that you are next to a peer on the bus and someone who has some of the same experiences.  The professional, on the other hand, may only have faint recollections of a bus ride.  This is in part because of the dropping of the shield on the bus, while holding tightly to your secrets in the professional office.” (p xxi)

“What we can do is to set the record straight as to how we have come to trust knowledge from the experts too much and trust knowledge and experience from each other too little.” (p xxiii)

“In a 15-minute medication visit by a psychiatrist, nothing will be accomplished except that the psychiatrist must use words of caution concerning the medication because of fear of being sued.  He or she does not have time to concern himself with the patient’s true nature or true concerns but has plugged the patient into a diagnosis for which no real explanation is given to the individual.  It is a dreadful impasse to say the least.  It is not that there is or has been a true conspiracy but it turned out that the drug companies and insurance companies shared a common desire.  Both wanted to have a fixed diagnosis for which to render their brand of psychiatric servicing. As time has gone on, it has gotten only worse.” (p 19)

The book’s sub-title is:  “A Guide to the Supportive Person Group Process,” and this is the notion that was new to me and caught my attention.

The idea here is that small groups have enormous potential in terms of mutual support, learning, communication, encouragement, etc., but that sometimes individual members feel overwhelmed and find it difficult to participate or express themselves.

So, in a double circle group, each group member has a supportive person who sits behind him or her and is allowed to interject or clarify the individual’s position to a degree, and within parameters, agreed earlier by the two individuals.  “The outer circle person should rarely speak spontaneously, but may be invited to speak on behalf of the inner circle person.”

So there are two circles:  the group participants in the inner circle, and the supportive persons in the outer.

Then – and this is the interesting part – after a designated interval, the participants and the support persons switch roles.  The people in the outer circle move to the inner and vice versa.

Here are some quotes from the text:

“Although our stories and experiences are all different, people have many common themes that describe what it means to be human.” (p 36)

“Humans are naturally social creatures.  We’re hard wired for relatedness, and our energy comes from connecting with others.  When creating a connection, it can seem frightening at first, but it is our relationships with one another that help us grow and develop a rich, meaningful life.  We want to be seen, welcomed, and appreciated in an environment of safety, acceptance, and loving kindness.  We want to be able to speak our truth to one another.” (p 36)

“Each time the circles reverse, a new portal of perspective opens.  What had not been seen before is now seen with great clarity.” (p 38)

. . . . . . . . . . . . . . . .

In my view, the most significant development to arise from the anti-psychiatry effort is the increasing number of self-help/support groups. This is the great grass-roots movement that can ultimately make psychiatry redundant.  In that context, it occurred to me that the ideas set out in The Power of the Double Circle might be of interest to some groups.

Besides the Supportive Person idea, the book contains a range of related and tangential issues, which will inevitably elicit varying degrees of agreement from readers.  But the Double Circle and the Supportive Person are the core concepts, and are definitely worth examining.

The book is available from doublecircle.net or from Amazon.

. . . . . . . . . . . . . . . .

 DISCLOSURE

I have no financial interests in this book or in any books or products that I mention in these writings.

Allen Frances and the “Overdiagnosing” of Children

On October 31, 2016, the very eminent psychiatrist Allen Frances, MD, architect of DSM-IV, published an article on his Psychology Today blog, Saving Normal.  The article is titled DSM-5 Diagnoses In Kids Should Always Be Written In Pencil.  (The piece also appeared on the Huffington Post Blog on the same date.)  The subheading is “Mislabelling children and adolescents is frequent and can haunt them for life”

As in many of Dr. Frances’s recent articles, the bulk of the text is written by someone else, and Dr. Frances provides an introduction and a summary/conclusion.  In this case, the core of the article is written. by Juan Vasen and Gisela Untoiglich of Forum Infancias, an Argentine organization of mental health workers dedicated to the “proper diagnosis and treatment of children and adolescents”.

The material written by Drs. Vasen and Untoiglich is basically sound, e.g. “Children and adolescents vary dramatically in the way they develop and in the chronology of their developmental milestones. Individuality and immaturity should not be confused with disease”, but there is also the implication that ADHD is a real disease entity which can be identified with careful and painstaking assessment.

“Accurate diagnosis in children and adolescents takes a great deal of time in each session and often many sessions over a number of months.”

Dr. Frances opens the article by lamenting what he describes as the “three most harmful fads in psychiatric diagnosis, during the past 20 years,”  These are:

“Rates of Attention Deficit Disorder have tripled and rates of Autism and childhood Bipolar Disorder have multiplied an incredible 40 times.”

Dr. Frances goes on to write that “Powerful external factors have contributed greatly to this massive mislabelling of kids.”  From the general context it is clear that what Dr. Frances calls “massive mislabeling” is not the assignment of psychiatry’s spurious labels as such, but rather what he calls the overuse of these labels.

He then takes his usual shot at pharma:

“For ADHD and kiddie Bipolar, drug companies misleadingly and aggressively sold the ill to peddle their expensive and profitable pills. Their marketing strategy was based on the cynical assumption that starting a kid early on pills might make him a customer for life.”

Dr. Frances frequently blames pharma, while ignoring the role that psychiatry, and he himself personally, played in the proliferation of psychiatry’s so-called diagnoses and the progressive relaxation of the criteria for these diagnoses.  I have spelled out in an earlier post how the criteria for ADHD were markedly relaxed in Dr. Frances’s own DSM-IV.

The widespread application of the “bipolar diagnosis” to children was the brainchild of the Harvard psychiatrist Joseph Biederman, MD, but some of the groundwork for this had been laid in DSM-IV.

The earlier edition of the manual (DSM-III-R) had stated that the age of onset of manic episodes

“…is in the early 20s.  However, some studies indicate that a sizable number of new cases appear after age 50.” (p 216)

The corresponding statement in DSM-IV reads:

“The mean age at onset for a first manic episode is the early 20s, but some cases start in adolescence and others start after 50 years.” (p 331) [Emphasis added]

So it was Dr. Frances’s own DSM-IV that first legitimized the notion that this so-called diagnosis could be applied to children.

Certainly, pharma played its part, but psychiatry was hand-in-glove with its generous benefactor, as it has been since the 60’s-70’s.

. . . . . . . . . . . . . . . .

The explosion of Autism resulted from the combination of two things: the DSM-IV introduction of a much milder form (Asperger’s) and the far too close linkage of the diagnosis to eligibility for enhanced school services. DSM diagnoses developed for clinical purposes are inappropriate gatekeepers for allocating educational resources. Educational decisions should be based on the child’s educational need, as assessed by educators, using educational tools.”

The reference to Asperger’s disorder is probably accurate, and represents an honest admission on the part of Dr. Frances, but the statement:

“DSM diagnoses developed for clinical purposes are inappropriate gatekeepers for allocating educational resources. Educational decisions should be based on the child’s educational need, as assessed by educators, using educational tools.”

is extremely misleading.

The issue here is that, in general, public schools are required by federal law to make accommodation for children with disabilities.  It is also required that these children be taught, not in special education settings, but rather in regular classrooms, whenever possible.

Disability is obviously a complex, and difficult-to-define concept.  But for practical purposes, the Social Security Administration (SSA) has two broad criteria.  Firstly, the child must have a confirmed illness; and secondly, he must have confirmed illness-related functional limitations.  Both autistic disorder and attention deficit hyperactivity disorder have been accepted by the SSA as covered illnesses.  Evidence of functional limitations is usually gathered from the child’s treatment providers, supplemented as needed by reports from outside consultants.

So – and this is the critical point – “DSM diagnoses” are not being used as gatekeepers for allocating educational resources.  Rather, they are being used as the first stage in disability determination (i.e., the presence of illness).  And it is the disability determination that in turn drives the educational decisions, and, in some cases, channels additional funding to the school.

So Dr. Frances is, in effect, lamenting the use of “DSM diagnoses” to determine the presence of psychiatric “illness”, which seems a major about-face for someone who routinely asserts the validity and usefulness of these “diagnoses” for precisely these purposes.  The point is this:  Once the APA invented the ADHD illness, the door was opened for this illness to become disability-eligible.

And, incidentally, the plot thickens.  In 1985 the SSA contracted with the APA to conduct a major study of the standards and guidelines for the assessment of mental impairment.  The study lasted two years.  The APA made some minor recommendations, but “All recommendations were made on the premise that the basic construct of the SSA’s medical standards and guidelines for the evaluation of claims based on mental impairment should be retained.” [Italic emphasis in original]   So whatever criticism Dr. Frances has of the present system, he needs, I suggest, to acknowledge the part his own profession played in the creation of this state of affairs.

But the plot thickens even more.  Most of the details involved in the education of disabled children are set out in the Individuals with Disabilities Education Act (IDEA), 1990.  When this bill was being drafted, there was considerable controversy over whether ADHD should be included as a covered “illness”.  Opposition came from teacher organizations and the NAACP.  The original act (1990) did not include ADHD.  However, in 1991 the Department of Education issued a clarificatory memo stating that “ADHD” is a covered disability under IDEA.  This amendment was the result of intensive lobbying by CHADD and others.  And organized psychiatry has been a long-time supporter of CHADD. At the present time there is a downloadable document titled ADHD: Parents Medication Guide on the APA website.  CHADD is mentioned five times and is recommended as a source of information.  The document was prepared by the American Academy of Child and Adolescent Psychiatry and the APA.

“OVER-DIAGNOSIS”

Dr. Frances continues:

“It is long past time to tame the wild DSM over-diagnosis of kids.”

Then, after the material written by Drs. Vasen and Untoiglich:

“Thanks so much, Juan and Giselle, for poetically cautioning clinicians to be conservative, never careless or creative, in diagnosing kids. Mislabelling has serious and often longstanding consequences on how the child sees himself, how the family sees the child, and on the misuse of medication. Diagnosis should never be taken lightly.”

and

“Accurate diagnosis in kids is really tough and time consuming. Misdiagnosis in kids is really easy and can be done in 10 minutes. Accurate diagnosis in kids leads to helpful interventions that can greatly improve future life. Misdiagnosis in kids often leads to harmful medication and haunting stigma.”

and

“The stakes are high and the harms sometimes permanent. The best way to protect our children is to respect their difference and to accept uncertainty. I really love the idea of writing psychiatric diagnoses in pencil.”

This notion of conservative, careful and accurate diagnosis is a common theme in Dr. Frances’s writing, but in fact, it’s an empty exhortation, because the criteria are inherently vague and ill-defined.

Let’s consider the first criterion in the APA’s list:

1(a) “often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities” (DSM-IV, p 83)

The DSM-5 wording is almost identical, but adds two examples:  (e.g. overlooks or misses details, work is inaccurate).

To illustrate the problem, let’s imagine a conversation between two experienced psychiatrists, Dr. I. Druggem and Dr. Ak Curate.

Dr. Curate:      You’re diagnosing too many children with ADHD.
Dr. Druggem:  No, I’m not.  I always make sure that they meet the requisite number of criterion items.
Dr. Curate:      But you’re interpreting the criteria too loosely.
Dr. Druggem:  You’re interpreting them too tightly.
Dr. Curate:      Well consider that six-year-old boy you diagnosed last week.  Which criteria did he meet?
Dr. Druggem:  Inattention criteria a, b, c, d, and e.  He also met four of the hyperactivity-impulsivity criteria.
Dr. Curate:      So he met criterion 1(a) – “often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities”?
Dr. Druggem:  Yes, absolutely.
Dr. Curate:      How do you know?
Dr. Druggem:  Because I had his teacher fill out a checklist, and she checked that item.
Dr. Curate:      So the teacher said that he met this criterion.  Did she say how often is often?
Dr. Druggem:  No, of course not.
Dr. Curate:      How often is often?
Dr. Druggem:  I don’t know; I suppose two or three times a day.
Dr. Curate:      I think it would be perfectly normal for a six-year-old boy to make careless mistakes or lose his attention ten or even fifteen times a day.
Dr. Druggem:  No way.
Dr. Curate:      Yes way.

And the critical point here is that there is nothing in the DSM, or indeed in any psychiatric guideline, that can resolve this disagreement.  There is no way to say which psychiatrist is correct.  And the problem is compounded when we recognize that similar definitional difficulties arise when we ask what constitutes close attention versus not-so close; or careless mistakes versus other kinds of mistakes.  And when we recognize that the same difficulties arise with all 18 criteria, it is clear that the term “accurate diagnosis of ADHD” is a logical absurdity.  If one invents illnesses with no identifiable pathology, to be diagnosed on the basis of inherently vague checklists, the concept of true prevalence is meaningless.

So what psychiatry has created is a loose algorithm that can be expanded and contracted at will, without any blame or censure being assigned to the “diagnosing” psychiatrist.  But it’s even worse than that, because this arbitrarily flexible “diagnosing” is being conducted in a context where there are enormous incentives to make the “diagnosis”, and considerable penalties for declining to “diagnose”.

First in this regard are the pharma companies whose revenue correlates with the number of children “diagnosed”.  Secondly, the parents are off the hook with regards to the need to discipline or train their children effectively.  Thirdly, the “diagnosis” may entitle the child (or rather his parents) to a disability income.  Fourthly, the school may be eligible for additional funding.  Fifthly, the psychiatrists stand a very good chance of acquiring a long-term repeat customer.

So everybody wins – except, of course, the child, who loses, especially in the long term.  This is the monster that psychiatry has created.  And Dr. Frances played a cardinal role.

The problem is not over-diagnosing.  The problem is the spurious medicalization of problems that are not medical in nature.  And this was psychiatry’s contribution to the great psychiatry-pharma hoax, which they entered with eyes wide open.  The deal was simple.  We (psychiatrists) invent and legitimize the illnesses, and write the prescriptions; you (pharma) send lots of money, validations, and business our way.  And Dr. Frances is very knowledgeable about this matter.  In 1995, he and his partners John Docherty, MD and David Kahn, MD, wrote:

“We are also committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.”

This was a reference to The Expert Consensus Guideline Series: Treatment of Schizophrenia produced by Drs. Frances, Docherty, and Kahn (The Journal of Clinical Psychiatry, 1996, Vol 57, Supplement 12B) with a generous grant from Johnson & Johnson (owners of Janssen).  The quote is from an expert witness report by David Rothman, PhD, professor of Social Medicine at Columbia University College of Physicians and Surgeons, p 15-16.  The entire issue has been covered in great depth by Paula Caplan, PhD, here, and to the best of my knowledge, Dr. Frances has never publicly acknowledged any wrongdoing or issued any apology with regards to the matter.

FINALLY

Dr. Frances was a key player in the promotion of the psychiatric hoax.  As architect of DSM-IV, he had the opportunity to reverse the trend begun by Robert Spitzer, MD, with DSM-III, but instead, Dr. Frances not only stayed on the proliferation/expansionist track, but actually accelerated the pace.  His present hand-wringing concerning the mislabeling and over-drugging of children is not convincing.

. . . . . . . . . . . . . . . .

 ADHD is not something a child has.  It is something a child does.

 

Narcissistic Personality Disorder and the President-Elect

CLARIFICATION

This post is a critique of psychiatry’s spurious personality disorder diagnoses.  It is neither a defense, nor a condemnation, of Mr. Trump.  In my view, it is right and proper that we the people should comment freely on, and criticize, our political leaders, as we deem appropriate.  But assigning spurious psychiatric labels is problematic for two reasons.  Firstly, it adds nothing useful to the discussion.  Secondly, it affords unwarranted validity and reliability to what are nothing more than loose collections of inherently vague thoughts, feelings, and behaviors, with no explanatory significance.

The point is not whether Mr. Trump “has narcissistic personality disorder”, but rather that there is no such thing as narcissistic personality disorder.

. . . . . . . . . . . . . . . .

On December 17, Richard Greene, a Communication Strategist, posted an article on the Huffington Post titled Is Donald Trump Mentally Ill? 3 Professors Of Psychiatry Ask President Obama To Conduct A Full Medical And Neuropsychiatric Evaluation.

In this article, Mr. Greene reproduces (with the authors’ permission) a letter that was sent to President Barack Obama on November 29, 2016. Here’s the text of the letter:

“President Barack Obama
The White House
1600 Pennsylvania Avenue NW
Washington, DC 20500
November 29, 2016

Dear President Obama,

We are writing to express our grave concern regarding the mental stability of our President-Elect. Professional standards do not permit us to venture a diagnosis for a public figure whom we have not evaluated personally. Nevertheless, his widely reported symptoms of mental instability including grandiosity, impulsivity, hypersensitivity to slights or criticism, and an apparent inability to distinguish between fantasy and reality lead us to question his fitness for the immense responsibilities of the office. We strongly recommend that, in preparation for assuming these responsibilities, he receive a full medical and neuropsychiatric evaluation by an impartial team of investigators.

Sincerely,

Judith Herman, M.D.
Professor of Psychiatry
Harvard Medical School

Nanette Gartrell, M.D.
Associate Clinical Professor of Psychiatry
University of California, San Francisco (1988-2011)
Assistant Professor of Psychiatry, Harvard Medical School (1983-87)

Dee Mosbacher, M.D., Ph.D.
Assistant Clinical Professor
Department of Community Health Systems
University of California, San Francisco (2005-2013)”

Mr. Greene’s article contains a link to an interview given by Lynne Meyer, PhD, whom Mr. Greene describes as “a Psychologist specializing in personality disorders, brilliantly explaining how such a disorder might help us understand Mr. Trumps comments and behaviors and the challenges that likely lie ahead for our country.”

Mr. Greene then lists the DSM-5 criteria for narcissistic personality disorder.

Then:

“If someone does have ‘Narcissistic Personality Disorder’ they can, indeed, wake up, see a Tweet or a news report from a foreign leader criticizing him, mocking him, calling him ‘weak’ or threatening his ego in any way and order some kind of impulsive, vindictive, punishing, immediate response that could include an unhinged order to attack that foreign leader or foreign country with military force, even including the authorization of nuclear weapons.

It is extremely likely that there would be some kind of impulsive, angry diplomatic response.

Because someone afflicted with this incurable and progressive ‘Narcissistic Personality Disorder’ simply cant help himself.”

Note that the APA’s pseudo-diagnosis narcissistic personality disorder is being presented here as a valid entity, an incurable and progressive affliction. Note also the contention that if a person has this disorder, he simply can’t help himself.

Earlier in the article Mr. Greene had stated that he had been interviewing psychiatrists and psychologists about Donald Trump’s alleged “Narcissistic Personality Disorder”, and that:

“Virtually every mental health professional I interviewed told me that they believed, with 100% certainty, that Mr. Trump satisfied the DSM criteria of this incurable illness and that, as a result, he is a serious danger to the country and the world.”

Mr. Greene continues his article with a summary of the psychological and behavioral characteristics of “people with NPD”, and a summary of the concerns expressed by the mental health professionals that he had interviewed.

The article closes with an extended quote from “a clinical psychologist”, essentially endorsing and expanding on the points made by Dr. Meyer in the earlier interviews. These anonymous comments are fairly extreme, e.g.:

“The point about him getting worse in the future also cannot be overstated. An increasing paranoia combined with growing sadistic vindictiveness is pretty much a given. We have seen it consistently in other leaders, past and present, with this character defect.”

. . . . . . . . . . . . . . . .

But the essential core of the article is the second (and longer) video interview with Dr. Meyer. As mentioned earlier, Dr. Meyer is a psychologist, but it is clear from her comments that she endorses the psychiatric “diagnostic” system and the ontological and explanatory status of this so-called diagnosis. It should also be noted that Dr. Meyer couches her responses in hypothetical terms and does not state or imply that Mr. Trump meets the criteria for this “disorder”.

Here’s an extended quote from the interview. The interviewer is presumably Mr. Greene.

Q. I’d like you to share whether narcissistic personality disorder is the same thing as someone being a bit egotistical or quote unquote narcissistic.

A. Well to answer that question, no. When you have a trait that is a little bit narcissistic, that is not a diagnosis. So in order to make a diagnosis, you’d have to have five or more criteria, and that would be about one percent of the population which have NPD, which is narcissistic personality disorder. And when you have this diagnosis, it’s a pervasive disorder, it’s hardwired in the brain. And with narcissistic personality disorder it’s very highly untreatable, it’s very difficult to treat because narcissists don’t like to have anybody have an opinion that is not theirs, they don’t like interpretations, and in fact they are very fragile. They are the most unlikely people to seek out psychotherapy because of their grandiosity, sense of self-importance. And they actually create a world around them that’s a little bit delusional, they lose track of reality, especially if they have people around them feeding their sense of self-importance.

Q. So if someone were hypothetically the President of the United States and the Commander in Chief with sole and exclusive and unfettered access to thousands of nuclear weapons and the entirety of the United States military, would that be a problem if they were suffering from narcissistic personality disorder?

A. If they had the true diagnosis, the concern would be their lack of stability and especially their impulsivity and they’re quick to anger. So I would be very concerned that in a moment of rage or impulsivity, they would react because they are reactive, they’re thin-skinned, and they would do something destructive.

Q. So it’s not outside of the realm of possibility, without being totally paranoid here, that if someone were the Commander in Chief and they had narcissistic personality disorder which is not just a trait, it’s as you said an actual diagnosis. And if a foreign leader said something very negative about them, criticized them for not being strong enough, for being weak, for whatever, that they could go into some sort of impulsive reaction and potentially use or misuse their power over the military and over the release of weapons and even nuclear weapons. Is that completely out of the question?

A. No it’s absolutely in the realm of possibility that they would use their power to punish or be destructive and without thinking they would react, because they are wounded. We have a concept called narcissistic rage which is when you go against the narcissist they usually retaliate, and that’s part of the condition. They can be retaliatory.

DISCUSSION

The central problem here is that the “diagnosis” of narcissistic personality disorder is being presented as a reality something “hardwired into the brain” which has both explanatory significance, and predictive validity. In fact, the criteria for this disorder, like all DSM entries, are merely a loose collection of vaguely defined thoughts, feelings, and behaviors. There is no evidence that these activities even if they could be reliably identified in specific individuals constitute a coherent entity. In fact, the polythetic aspect of the “diagnosis” (five out of nine) virtually guarantees that the “diagnosis” is not a coherent entity. Individuals who score “yes” on items 1, 2, 3, 4, and 5 will inevitably differ markedly from those scoring “yes” on items 5, 6, 7, 8, and 9. And that’s even conceding that these items can be applied in a reliable and consistent fashion, which they can’t.

Let’s look at some of the DSM-5 criteria for this so-called disorder.

“Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.” (p 669)

It is obvious that this criterion cannot be rated against a simple yes or no standard. What does preoccupied mean? What is unlimited success? How can we even know other people’s fantasies?

Here are two more criteria:

“Requires excessive admiration.”

“Believes that he or she is ‘special’ and unique and can only be understood by, or should associate with, other special or high-status people (or institutions).”

In effect, the “diagnoser” must shoe-horn his/her assessment of the individual into a yes or no judgment, then count the yeses. So essentially we have five (or more) pieces of garbage data, which through the mindless alchemy of psychiatry become an incurable illness, “hardwired in the brain”.

The fact that a “diagnosis of narcissistic personality disorder” has no explanatory usefulness is highlighted by the following hypothetical conversation.

Wife: Why is my husband so self-important; why does he have such a sense of entitlement?
Psychiatrist: Because he has an illness called narcissistic personality disorder.
Wife: How do you know he has this illness?
Psychiatrist: Because he is so self-important and has such a sense of entitlement.

Narcissistic personality disorder is just a label. It explains nothing. The only evidence for the “illness” is the very behavior it purports to explain.

. . . . . . . . . . . . . . . .

DSM-5’s general definition of a personality disorder is:

“an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” (p 645)

The reality, however, borne out by decades of research, indicates clearly that behavior is “enduring” only when the circumstances and context that maintain the behavior are equally enduring. When our circumstances change, our perceptions and our actions change, and this general adaptability usually outweighs any tendencies that might exist to stay mired in the habits of the past. Although we are usually willing servants to our habits, we are not their slaves.

In his book Personality and Assessment, (1968, reprinted 1996), Walter Mischel, PhD, having reviewed two decades of research on this matter, concludes:

“Global traits and states are excessively crude, gross units to encompass adequately the extraordinary complexity and subtlety of the discriminations that people constantly make. Traditional trait-state conceptions of man have depicted him as victimized by his infantile history, as possessed by unchanging rigid trait attributes, and as driven inexorably by unconscious irrational forces. This conceptualization of man, besides being philosophically unappetizing, is contradicted by massive experimental data. The traditional trait-state conceptualizations of personality, while often paying lip service to man’s complexity and to the uniqueness of each person, in fact lead to a grossly over-simplified view that misses both the richness and the uniqueness of individual lives. A more adequate conceptualization must take full account of man’s extraordinary adaptiveness and capacities for discrimination, awareness, and self-regulation; it must also recognize that men can and do reconceptualize themselves and change, and that an understanding of how humans can constructively modify their behavior in systematic ways is the core of a truly dynamic personality psychology.” (p 301)

There is no evidence that the individuals to whom psychiatry attaches the label narcissistic personality disorder are somehow exceptions to this general finding. There is no evidence that these individuals’ brains are “hardwired” for inflexibility. But psychiatrists, busy and preoccupied as they have been in the invention and promotion of spurious, but medical-sounding, diagnoses, have chosen to ignore this large corpus of psychosocial research, and to provide instead a medical façade to the long-standing human activity of name-calling.

The point of all this is that psychiatry’s “personality disorders” are not valid ways to conceptualize or categorize behavior. They have an appearance of face validity, but the labels add nothing to our understanding of the thoughts, feelings, and behaviors in question. And in fact, the personality disorder labels have two very negative effects. Firstly, they create the impression that the behaviors in question have been explained. In mental health case discussion, for instance, one often hears statements like: he’s arrogant and demanding because he has narcissistic personality disorder; or he keeps very much to himself because he has schizoid personality disorder; etc. In fact, narcissistic personality disorder and schizoid personality disorder are just labels which explain nothing. Genuine understanding of human actions requires a detailed knowledge of the individual obtained through lengthy and painstaking dialogue, in a context of mutual trust and respect. It is definitely not something that can be derived from fifteen-minute “med checks” four times a year. Nor is it something that can be obtained by someone who views people through the distorting lens of psychiatric “diagnoses”.

AND INCIDENTALLY

Seven months ago, on June 9, 2016, the eminent psychiatrist Allen Frances, MD, architect of DSM-IV, stated categorically that Donald Trump did not have narcissistic personality disorder, or for that matter any personality disorder. So much for the reliability of psychiatric diagnoses.

 

The Biological Evidence for “Mental Illness”

On January 2, 2017, I published a short post titled Carrie Fisher Dead at Age 60 on Behaviorism and Mental Health.  The article was published simultaneously on Mad in America.

On January 4, a response from Carolina Partners was entered into the comments string on both sites.

Carolina Partners in Mental Healthcare, PLLC, is a large psychiatric group practice based in North Carolina.  According to their website, they comprise 14 psychiatrists, 7 psychologists, 34 Advanced Practice Nurse Practitioners/Physicians Assistants, and 43 Therapists and Counselors.  They have 27 North Carolina locations.

Partners’ comment consists essentially of unsubstantiated assertions, non sequiturs, and appeals to psychiatric authority.  As such, it is fairly typical of the kind of “rebuttals” that psychiatry’s adherents routinely direct towards those of us on this side of the issue.  For this reason, and also because it comes from, and presumably represents the views of, an extremely large psychiatric practice, it warrants a close look.

I will discuss each paragraph in turn.

“We strongly disagree with this article, which neglects a lot of important information and uses selective hearing to distort what Carrie Fisher was about and also to distort the evidence for mental illness as a real disorder.”

My Carrie Fisher article was brief (566 words), and was intended as a counterpoint to the very widespread obituaries that lionized her as a champion of “bipolar disorder”.  The essential point of my article was that Ms. Fisher had been a victim of psychiatry, and like a great many such victims, died prematurely.  Obviously I neglected a lot of important information.  I could have gone into great length as to the recklessness of psychiatry assigning the bipolar label, with all its implications of helplessness, disempowerment, and “chemical imbalance” to a young woman who by her own account was, at the time, using any drugs she could get her hands on.  But I felt that a brief and respectful statement of the facts was all that was needed.

. . . . . . . . . . . . . . . .

“Mental illnesses have a long history of biological evidence. For example, researchers have demonstrated that people with depression have an overactive area of the brain, called Brodmann area 25. Schizophrenia has been linked to specific genes, as PTSD and autism have been linked to specific brain abnormalities. Suicide has been linked to a decreased concentration of serotonin in the brain. OCD has been linked to increased activity in the basal ganglia region of the brain.”

Brodmann area 25 (BA25)
Partners did not provide a specific reference in support of this contention, but my best guess is that the reference is Mayberg, HS, et al (1999) Reciprocal Limbic-Cortical Function and Negative Mood: Converging PET Findings in Depression and Normal Sadness (Am J Psychiatry 1999; 156:675–682).  Here’s the study’s primary conclusion:

“Reciprocal changes involving subgenual cingulate [which includes Brodmann area 25] and right prefrontal cortex occur with both transient and chronic changes in negative mood.”

What this means essentially is that negative mood, whether transient or enduring, is correlated with changes in both the subgenual cingulate (Brodmann area 25) and the right pre-frontal cortex, and that when the depression is relieved, the changes are reversed.

This, of course, is an interesting finding, but provides no evidence that depression, mild or severe, transient or enduring, is caused by a biological pathology.

The reality is that all human activity is triggered by brain activity.  Every thought, every feeling, every action has its origins in the brain.  I cannot lift a finger, blink an eye,  scratch my head, or recall my childhood home without a characteristic brain function initiating and maintaining the action in question.  Without stimuli from the brain, my heart will stop beating, my respiratory apparatus will shut down, and I will die, unless these functions are maintained by machines.

So there is absolutely no surprise in the discovery that sadness and despondency have similar neural triggers and maintainers.  It would be amazing if they didn’t.  But – and this is the critical point – this does not warrant the conclusion that sadness which crosses arbitrary and vaguely-defined thresholds of severity, duration, and frequency is best conceptualized as an illness caused by pathological or excessive activity in BA 25.

Depression is a normal state.  It is the normal human reaction to significant loss and/or living in sub-optimal conditions/circumstances.  It is also an adaptive mechanism, the purpose of which is to encourage us to take action to restore the loss and/or improve the conditions.

All consciously-felt human drives stem from unpleasant feelings.  Thirst drives us to seek water; hunger, food; hypothermia, warmth; hyperthermia, coolness; danger, safety, etc.  Sadness and despondency are no exceptions.  They drive us to seek change, and have been serving the species well since prehistoric times.

But – as is the case with all the above examples – when a drive is not acted upon, for whatever reason, the unpleasant feelings worsen.  Just as unrequited hunger and thirst increase in strength, so the depression drive when not requited deepens.

The reality is that most people deal with depression in appropriate, naturalistic, and time-honored ways.  If the source of the depression is the loss of a job, they start job-hunting.  If the source is an abusive relationship, they seek ways to exit or remediate the situation.  If the source is a shortage of money, they seek ways to budget more sensibly, or increase their earnings; etc.

Depression, either mild or severe, transient or lasting, is not a pathological condition.  It is the natural, appropriate, and adaptive response when a feeling-capable organism confronts an adverse event or circumstance.  And the only sensible and effective way to ameliorate depression is to deal appropriately and constructively with the depressing situation.  Misguided tampering with the person’s feeling apparatus is analogous to deliberately damaging a person’s hearing because he is upset by the noise pollution in his neighborhood, or damaging his eyesight because of complaints about litter in the street.

Our feeling apparatus is as valuable and adaptive as our other senses.  But psychiatry routinely numbs, and in many cases permanently damages, this apparatus to sell drugs and to promote the fiction that they are real doctors.  Their justification for this blatantly destructive activity hinges on the false notion that depression becomes a diagnosable illness when its severity crosses arbitrary and vaguely-defined thresholds.  But deep despondency is no more an illness than mild despondency.  The latter is the appropriate and adaptive response to minor losses and adversity.  The former is the appropriate and natural response to more profound or more enduring adversity.  Though, of course, what constitutes profound adversity will vary enormously from person to person.  An individual, for instance, raised to the expectation of stable and permanent employment may be truly heartbroken at the loss of a job.  Another individual, raised to the notion that there’s always another job “around the corner” will, other things being equal, be less affected.  And so on.

In this regard, it’s noteworthy that Partners’ comment refers to overactivity in BA 25.  The use of the prefix over implies pathology, but in reality there is no yardstick to determine what would be a correct amount of activity for BA 25.  All that can be said, on the basis of Mayberg et al’s findings, and subsequent BA 25 research, is that when a person is sad, there is more activity than when he is happy.  So the use of the term “overactivity” is deceptive – sneaking in the notion of pathology without any genuine or valid reasons to consider it so.  The “reasoning” here is:

–  depression is an illness
–  depression is correlated with high activity in BA 25
–  therefore high activity in BA 25 is pathological

In other words, the contention of pathology rests on the assumption that depression is an illness.  To turn around and use this falsely inferred pathology to prove that depression is an illness is obviously fallacious.  It is also typical of the kind of circular reasoning that permeates psychiatric contentions.  In reality, there is nothing in Mayberg et al or in subsequent research that warrants the conclusion that the increased activity in BA 25 is pathological or excessive.

. . . . . . . . . . . . . . . .

Schizophrenia linked to specific genes
This assertion, that schizophrenia is linked to specific genes, is frequently adduced in these debates, as evidence that “schizophrenia” is a real illness with a biological pathology.  Here again, Partners do not provide any references in support of this assertion, but there have been a number of studies in the past fifteen years or so that have found links of this kind.  However, in all cases, the correlations have been small.  In other words, there are always a great many individuals who have been assigned the “schizophrenia” label, but who do not have the gene variant in question; and there are a great many who have the gene variant, but who do not acquire the label “schizophrenia”.  To date, no genetic test has been found helpful in confirming or refuting a “diagnosis of schizophrenia”.

An additional problem arises here, in that the assertion that “schizophrenia has been linked to specific genes” is often interpreted as meaning that “schizophrenia” is a genetic disease, which it emphatically is not.  To illustrate this, let’s look briefly at a real genetic illness:  polycystic kidney disease (PKD).  This is a well established genetic illness caused by cysts in the kidneys.  The cysts progressively block the flow of blood through the kidneys, causing tissue death.

Most cases of PKD are caused by the defective gene (PKD-1).  In polycystic kidney disease, the pathology occurs because the PKD-1 gene causes the nephrons to be made from cyst wall epithelium rather than nephron epithelium.  And cyst wall epithelium produces fluid which accumulates in, and ultimately destroys, the nephrons and the kidney.

So the gene determines the structure of the nephron wall.  This is the primary genetic effect.  This structure causes the wall to produce fluid.  As the nephrons become increasingly blocked, the kidneys produce less urine.  So, reduced urination is a secondary effect of the gene PKD-1.  Symptoms of PKD don’t usually emerge until adulthood, but about 25% of children with PKD1 experience pain and other symptoms.  So a child growing up with polycystic kidney disease may feel sick much of the time.  Such a child, other things being equal, is likely to be fussier and more distressed than other children, and it is entirely possible that one could find a weak correlational link between gene PKD-1 and childhood fussiness, though, of course, any search for such a correlation will be confounded by the obvious fact that children can be habitually fussy for other reasons.  The fussiness would be a tertiary effect of the gene PKD1.

And from there the causal chain could continue in various ever-weakening directions.  For instance, the child might become somewhat sad and despondent.  Or it could be that the child received extra attention and comforting from his parents and was fairly content, and so on.  Ultimately the outcome is impossible to predict with any kind of precision, and the best we can expect from genes vs. subsequent behavior studies are weak, tenuous correlations.

Cleft palate is another example of a pathology that is caused by a gene defect; actually a gene deletion.  This condition results in a characteristically strained and nasal speech quality which can be quite stigmatizing.  The nasal speech is a secondary effect of the gene deletion.

Children with this kind of speech are sometimes mocked and bullied by their peers.  The child might react to this kind of stigmatizing by speaking as little as possible, by withdrawing socially, or in various other ways.  These reactions would be considered tertiary effects of the defect.  And so on.  As with the PKD, each step in the chain takes us further from the genetic defect, and the statistical associations grow proportionally weaker, and it would be stretching the matter to say that the lack of speech was caused by the gene deletion.  Nor would one conclude that the child’s social withdrawal was a symptom of a genetic disease.  And this is true even though the link between the deletion  and the cleft palate is clear-cut and direct.

In the same way, it is simply not tenable to claim that “schizophrenic” behaviors (e.g. disorganized speech) are symptoms of a genetic disease.  This is particularly the case in that correlations between the “diagnosis” and genetic anomalies are typically very small.  The effects of any minor genetic anomalies that might exist have had ample opportunity to be shaped by social and environmental factors, and these are more credible causal constructs.

“Schizophrenia” is not a unified condition.  Rather, it is a loose collection of vaguely defined behaviors.  For this reason, any genetic research done on this condition will inevitably result in conflicting and confusing results.  It’s like looking for genetic similarities in all the people who play bridge, or read romance novels, visit libraries, play football, or whatever.  If the sample sizes are large enough, and in genetic research sample sizes are often enormous, one could probably find small effects in all or most of these areas, but no one would conclude from this that these are genetically determined activities, much less illnesses.

A person’s ability to learn depends on two general factors:  a) the structure of his brain, as determined by his DNA, and b) his experiences since birth.

One can’t learn to play the piano, for instance, unless one has appropriate neural apparatus, and fingers, both of which require appropriate DNA.  But even a person with good genetic endowment in these regards, will never learn to play unless he is exposed to certain environmental factors.  He must, at the very least, encounter a piano.  In the same way, a person whose genetic endowment might be relatively marginal might become an excellent pianist, if he were to receive persistent environmental encouragement and support.

Similar reasoning can be applied to the behavior of not-being-“schizophrenic.”  This behavior involves navigating the pitfalls of late adolescence/early adulthood, and establishing functional habits in interpersonal, occupational, and other important life areas.  Obviously it requires appropriate neural apparatus, hence the weak correlations with genetic material, but equally clearly it calls for a nurturing childhood environment, with opportunities for emotional growth and acquisition of social, occupational, and other skills.

Given all of this, it’s not surprising that researchers are finding correlations between DNA variations and a “diagnosis” of schizophrenia, but given the number of links in the causal chain and the multiplicity of possible pathways at each link, it is also not surprising that the correlations are always found to be weak, and of little or no practical consequence.

Nor is it surprising that the correlations between being labeled “schizophrenic” and various psychosocial factors are by contrast generally strong.  Having a schizophrenia label is correlated with childhood social adversity, childhood abuse and maltreatment, poverty, and a family history of migration.

. . . . . . . . . . . . . . . .

Generally similar considerations apply to Partners contentions with regards to “PTSD”, “autism”, suicide, and “OCD”, but space precludes a detailed discussion here.

. . . . . . . . . . . . . . . .

“Eric Kandel, MD, a Nobel Prize laureate and professor of brain science at Columbia University, says, ‘All mental processes are brain processes, and therefore all disorders of mental functioning are biological diseases…The brain is the organ of the mind. Where else could [mental illness] be if not in the brain?'”

Dr. Kandel (now 87 years old) is an eminent neuroscience researcher at Columbia University.  There’s an extensive biography in Wikipedia.  His early research focused on the neurophysiology of memory.  He has received numerous awards, including the Nobel Prize in Physiology/Medicine (2000), and is widely published.  His record of research achievements is enormous, and his knowledge and expertise are vast, but in the statement quoted by Partners, and, incidentally, by other psychiatry adherents, he is simply wrong.

Let’s take a closer look.  Logically, the Kandel quote can be stated symbolically as:  A is identical to B; therefore malfunctions or aberrations in A are malfunctions or aberrations in B.

On the face of it, this seems sound, and indeed, it is a valid inference in some situations.  For instance, the furnace in a person’s home is the primary heating appliance; therefore, malfunctions in the furnace are malfunctions in the primary heating appliance.  Indeed, in a simple example of this sort, the statement is tautological.  We are simply substituting the synonyms furnace and primary heating appliance, and the inference contains no new information or insights.  But the inference is fallacious in more complex matters.

Let’s concede, for the sake of discussion, that the premise of the Kandel quote is true, i.e., that all mental processes are brain processes.  The term mental processes embraces a wide range of activities, including sensations, perceptions, thoughts, choices, positive feelings, negative feelings, hopes, beliefs, speaking, singing, general behavior, etc.

The term “disorders of mental functioning” is harder to define, but, again for the purposes of discussion, let’s accept the APA’s catalog as definitive in this regard.  Let’s accept that anything listed in the DSM is a “disorder of mental functioning”.

It’s immediately obvious that some of the DSM entries are indeed the result of brain malfunctioning.  In the text these are referred to as disorders due to a general medical condition or to the effects of a substance.  But in the great majority of DSM labels, no such biological cause is identified, and so the conclusion in the Kandel quote would appear to call for some kind of evidence or proof.  However, in the Kandel quote, the conclusion is not presented as something that has been, or even needs to be, proven.  Rather, it is presented as a logical conclusion inherent in, and stemming directly from, the premise.  And it is from this perspective that the Kandel quote needs to be evaluated.

To pursue this, let’s consider the example of “oppositional defiant disorder”.  This is a disorder of mental functioning as defined above, because it is listed in the DSM.  And according to Dr. Kandel’s “logic”, it is also therefore a “biological disease”.  The “symptoms” of oppositional defiant disorder as listed in DSM-5 are:

  1. Often loses temper.
  2. Is often touchy or easily annoyed.
  3. Is often angry and resentful.
  4. Often argues with authority figures or, for children and adolescents, with adults.
  5. Often actively defies or refuses to comply with requests from authority figures or with rules.
  6. Often deliberately annoys others.
  7. Often blames others for his or her mistakes or misbehavior.
  8. Has been spiteful or vindictive at least twice within the past 6 months. (p 462)

Obviously for any of these behaviors to occur, there has to be corresponding neural activity. But there is no necessity that the neural activity is diseased or malfunctioning in any way.  A child learning from his environment, developing his behavioral repertoire in accordance with the ordinary principles or learning, could acquire any or all of these behavioral habits without any malfunctioning in his neural apparatus.  We acquire counterproductive habits as readily, and by essentially the same processes, as we acquire productive ones.  In general, if a child discovers that he can acquire power and control in his environment by throwing temper tantrums, he will, other things being equal, acquire the habit of throwing temper tantrums.  Similarly, if arguing with parents and other authority figures yields positive results, there is a good chance that this also will become habitual.  And this is not because there is anything wrong with the child’s brain.  Rather, it’s because his brain is functioning correctly.  He is internalizing as habits those decisions and actions that pay off.  It is often observed in child-raising practice that if you’re not training your children, they’re training you.

Similar observations can be made about the other seven “symptoms” of oppositional defiant disorder, and indeed all the DSM labels.  A person with a perfectly normal-functioning brain can acquire the habits in question if the circumstances are conducive to this learning.

So to return to the question in the Kandel quote:  “Where else could [mental illness] be if not in the brain?”, the answer is clear:  In the self-serving and unwarranted perception of psychiatrists.  Mental illness is the distorting lens through which psychiatrists view all problems of thinking, feeling, and behaving.  It is the device they use to legitimize their drug-pushing and to maintain the fiction that they are practicing medicine.

. . . . . . . . . . . . . . . .

“You’re right that mental illness is also affected by social and environmental conditions–by a person’s disposition, or upbringing, or current environment. It’s also true that mental illness is affected by drug use (both prescribed and not prescribed). So are other medical conditions, such as heart disease and cancer.”

I’m not sure where Partners are coming from here, because I never made any such statement.  In my view, which I have stated clearly on numerous occasions, “mental illness” is a psychiatric invention, self-servingly created to promote the spurious notion that all problematic thoughts, feelings, and/or behaviors are illnesses.  And not just illnesses in some vague allegorical sense, but real illnesses “just like diabetes”, which need to be treated by medically trained psychiatrists with mood-altering drugs and high voltage electric shocks to the brain.

Partners’ vague concessions concerning environment, child-rearing, and drug effects is a fairly standard psychiatric sop, but doesn’t mitigate their earlier contentions on the “long history of biological evidence” and their uncritical endorsement of the logically spurious Kandel quote.

. . . . . . . . . . . . . . . .

“And it’s true that mental illness is often difficult to diagnose because of
1) the current limitations of the field of research. Thomas R. Insel, MD, director of the National Institute of Mental Health, for example, talks about how the diagnosis and treatment of mental illness today is where cardiology was 100 years ago, concluding that we need to continue scientific research of mental illnesses.  (There’s a longer quote on this below.)”

And (from later in the comment)

“Longer aforementioned quote:
Take cardiology, Insel says. A century ago, doctors had little knowledge of the biological basis of heart disease. They could merely observe a patient’s physical presentation and listen to the patient’s subjective complaints. Today they can measure cholesterol levels, examine the heart’s electrical impulses with EKG, and take detailed CT images of blood vessels and arteries to deliver a precise diagnosis. As a result, Insel says, mortality from heart attacks has dropped dramatically in recent decades. ‘In most areas of medicine, we now have a whole toolkit to help us know what’s going on, from the behavioral level to the molecular level. That has really led to enormous changes in most areas of medicine,’ he says.

Insel believes the diagnosis and treatment of mental illness is today where cardiology was 100 years ago. And like cardiology of yesteryear, the field is poised for dramatic transformation, he says. ‘We are really at the cusp of a revolution in the way we think about the brain and behavior, partly because of technological breakthroughs. We’re finally able to answer some of the fundamental questions.'”

It is at least forty years since I started hearing about psychiatry’s great biological breakthroughs that were just around the proverbial corner, and the promise, if my readers will pardon the pun, is getting a little old.

What’s noteworthy, however, is that in other disciplines, where there is hope or expectation of breakthroughs, the proponents of these endeavors generally wait until the evidence is in, before implementing practices based on these hopes.  In fact, to the best of my knowledge, psychiatry is the only profession whose entire work, indeed, whose entire conceptual framework, is based on “evidence” and “breakthroughs” that are not yet to hand.

Note also the truly exquisite contrast between Partners’ earlier and confident contention that “mental illnesses have a long history of biological evidence” with the assertion here that the “diagnosis” and “treatment” of “mental illness” today is where cardiology was 100 year ago.

Incidentally, Dr. Insel, former Director of the NIMH, also said:

“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.” (Transforming Diagnosis, 2013)

And let us be quite clear.  “Lack of validity” in this context means that the “diagnoses” don’t actually correspond to any disease entities in the real world.  Note also that Dr. Insel didn’t say poor validity, or low validity.  He said lack of validity – meaning none.

. . . . . . . . . . . . . . . .

Back to the Carolina Partners comment:

“2) mental illness symptoms often overlap with symptoms caused by other illnesses, for example, someone with cancer may also become depressed after diagnosis. Or someone’s fatigue may be caused by a vitamin deficiency, rather than by depression.

While considering all these factors, it is still completely inaccurate to state that there is no biological foundation for mental illnesses. They are not ‘make-believe’ diseases, but rather are caused by a variety of factors, including biological ones. As we understand more about mental illness through research we will (as we have with cardiology, for example) gain more precise vehicles for measuring and understanding the biological implications of these disorders.”

This is a little rambling, but let’s see if we can unravel it.

“… someone with cancer may also become depressed after diagnosis.”

This is true.  In fact, I would say that most people who contract serious illness become somewhat sad and despondent.  But this in no way establishes the notion that the sadness should be considered an additional illness.

“…someone’s fatigue may be caused by a vitamin deficiency, rather than by depression.”

This quote contains one of psychiatry’s core fallacies:  that the various “mental illnesses” are the causes of their respective symptoms (as is the case in real illness).  To illustrate the fallacy, consider the hypothetical conversation:

Client’s wife:  Why is my husband so tired all the time?
Psychiatrist:  Because he has an illness called major depressive disorder.
Client’s wife:  How do you know he has this illness?
Psychiatrist:  Because he is tired all the time.

Psychiatry defines major depression (the so-called illness) by the presence of five “symptoms” from a list of nine, one of which is fatigue, and then routinely adduces the “illness” to explain the symptoms.  In reality, the “symptoms” are entailed in the definition of the “illness”, and the explanation is entirely spurious.  There are many valid reasons why a person might feel fatigued, but none of these is because he “has a mental illness”.  Mental illnesses are merely labels with no explanatory significance.  And because of the inherent vagueness in the criteria, they’re not even good labels.

“…it is still completely inaccurate to state that there is no biological foundation for mental illnesses.”

As stressed above, there is a biological foundation to everything we do – every thought, every feeling, every eye blink, every action.  But – and this is the point that seems to evade psychiatry – there is no good reason to believe that the various problems catalogued in the DSM are underlain by pathological biological processes.  And there are lots of very good reasons to believe that they are not.

“They are not ‘make-believe’ diseases, but rather are caused by a variety of factors, including biological ones.”

I don’t think I’ve ever used the term “make-believe” to describe psychiatric “illnesses”, though I do routinely describe psychiatric labels as invented.  The two terms are not synonymous.  What psychiatry calls mental illnesses are actually nothing more than loose collections of vaguely-defined problems of thinking, feeling, and/or behaving.  In most cases the “diagnosis” is polythetic (five out of nine, four out of six, etc.), so the labels aren’t coherent entities of any sort, let alone illnesses.

But the problems set out in the so-called symptom lists are real problems.  That’s not the issue.  I refer to these labels as inventions, because of psychiatry’s assertion that the loose clusters of problems are real diseases.  In reality, they are not genuine diseases; they are inventions.  They are not discovered in nature, but rather are voted into existence by APA committees.

“As we understand more about mental illness through research we will (as we have with cardiology, for example) gain more precise vehicles for measuring and understanding the biological implications of these disorders.”

But meanwhile psychiatry has made up its mind.  Within psychiatric dogma, all  significant human problems of thinking, feeling, and behaving are illnesses that need to be “treated” with drugs and electric shocks.

. . . . . . . . . . . . . . . . . 

FINALLY

All of this is interesting, and I suppose it’s important to refute the more or less steady stream of unsubstantiated assertions, fallacious reasoning, and spin that flows from the psychiatric strongholds.

But meanwhile the carnage continues.  There is abundant prima facie evidence that psychiatric drugs are causally implicated in the suicide/murders that have become almost daily occurrences here in the US.  My challenge to organized psychiatry is simple:  call publicly for an independent, definitive study to explore this relationship.  And my challenge to rank and file psychiatrists is equally simple:  pressure the APA to call for such a study.  If what you are doing is unqualifiedly wholesome, safe, and effective, then what do you have to fear?