Tag Archives: myth of mental illness

ADHD: A Destructive Psychiatric Hoax

INTRODUCTION

Earlier this year, Alan Schwarz, an investigative reporter for the New York Times, published his latest book:  ADHD Nation.

The blurb on the jacket states:

“More than 1 in 7 American children get diagnosed with ADHD—three times what experts have said is appropriate—meaning that millions of kids are misdiagnosed and taking medications such as Adderall or Concerta for a psychiatric condition they probably do not have.  The numbers rise every year.  And still, many experts and drug companies deny any cause for concern.  In fact, they say that adults and the rest of the world should embrace ADHD and that its medications will transform their lives.

In ADHD Nation, Alan Schwarz examines the roots and the rise of this cultural and medical phenomenon: The father of ADHD, Dr. Keith Conners, spends fifty years advocating drugs like Ritalin before realizing his role in what he now calls ‘a national disaster of dangerous proportions’; a troubled young girl and a studious teenage boy get entangled in the growing ADHD machine and take medications that backfire horribly; and Big Pharma egregiously over-promotes the disorder and earns billions from the mishandling of children (and now adults).”

And who could argue with any of that?  But the blurb continues:

“While demonstrating that ADHD is real and can be medicated when appropriate, Schwarz sounds a long-overdue alarm and urges America to address this growing national health crisis.”

And there, of course, is where we must part company.

When I first read the jacket blurb, I was curious as to what kinds of arguments Alan Schwarz would marshal to support the contention that ADHD is “real”, and that it sometimes warrants “medication”.  And let us be clear as to the meaning of the word “real”.  Nobody is denying that inattention, hyperactivity, and impulsivity can be real problems.  The issue at stake , however, is whether it makes any sense to conceptualize this loose cluster of vaguely-defined problems as an illness.  Usually when people say or write that ADHD is “real”, they mean that this cluster of problems listed in the APA’s catalog (DSM) is a genuine, bona fide illness – just like diabetes; and that people who “have” this so-called illness must take their “medication” in the same way that diabetics must take insulin.  So, the promise on the jacket that Mr. Schwarz would demonstrate that ADHD is a real illness seemed significant, and as I said earlier, I was particularly interested in whether he had anything new to add to this debate.

Here’s the opening page of the Introduction.

“Attention deficit hyperactivity disorder is real.  Don’t let anyone tell you otherwise.

A boy who careens frenziedly around homes and busy streets can endanger himself and others.  A girl who cannot, even for two minutes, sit and listen to her teachers will not learn.  An adult who lacks the concentration to complete a health-insurance form accurately will fail the demands of modern life.  When a person of any age has a combination of these struggles—severely enough to impair his daily functioning—with no other plausible explanation for them, then he could very well have a serious, if still somewhat mysterious, condition that medicine has decided to call ADHD.

No one quite knows what causes it.  The most commonly cited theory is that the hypractivity, lack of focus, and impulsivity of classic ADHD result from some sort of dysfunction among chemicals and synapses in the brain.  A person’s environment clearly plays a role as well: a chaotic home, an inflexible classroom, or a distracting workplace all can induce or exacerbate symptoms.  Unfortunately, as with many psychiatric illnesses, such as depression or anxiety, there is no definitive way to diagnose ADHD, no blood test or CAT scan that lets a doctor declare, ‘Okay, there it is’—all one can do is thoughtfully assess whether the severity of the behavior warrants a diagnosis.  (After all, we all are distractible or impulsive to varying degrees.)  One thing is certain, though: There is no cure for ADHD.  Someone with the disorder might learn to adapt to it, perhaps with the help of medication, but patients young and old are generally told that they will deal with their abnormal brains for the rest of their lives.” (p 1)

And there is it.  Let’s take a closer look.

“Attention deficit hyperactivity disorder is real.  Don’t let anyone tell you otherwise.”

The reality or otherwise of “ADHD” is the fundamental issue of this entire debate, and it is clear from this opening statement that Mr. Schwarz has not approached this question with anything resembling the kind of open-mindedness that one expects from an investigative journalist.

But it gets worse.

“A boy who careens frenziedly around homes and busy streets can endanger himself and others.”

Mr. Schwarz is clearly trying to create the impression that this kind of behavior is fairly typical of children who “have ADHD”, and he is also pointing out that the behaviors are serious.  What he doesn’t mention, however, and perhaps isn’t even aware of, is that physically dangerous activity – including running “into street without looking” – was one of the specific criteria for ADHD in DSM-III-R, but was diluted to “runs about or climbs excessively” in DSM-IV.  And in DSM-5, the word “excessively” was dropped.  Here are the actual items from the three editions:

DSM-III-R (1987):
“(14) often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill-seeking), e.g., runs into street without looking” (p 53)

DSM-IV (1994)
Under the sub-heading Hyperactivity:
“(c) often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)” (p 84)

DSM-5 (2013)
Under the sub-heading Hyperactivity and impulsivity:
“c.  Often runs about or climbs in situations where it is inappropriate.  (Note: in adolescents or adults, may be limited to feeling restless.) (p 60)

So, a boy who careens frenziedly around homes and busy streets would probably meet the standard in all three editions, but – and this is the critical point – there is no requirement in the latter editions of such extreme behavior to score a “symptom” hit.  Contrary to Mr. Schwarz’s implied assertion, a child does not have to engage in such extreme or dangerous behavior to meet any of the APA’s criteria for this so-called illness. And it needs to be noted particularly that since 1994, the only requirement under this item for adults and adolescents is that they experience feelings of restlessness!

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

“A girl who cannot, even for two minutes, sit and listen to her teachers will not learn.”

How can Alan Schwarz – or anyone else, for that matter – deduce that a girl who doesn’t pay attention to her teachers, can’t pay attention.  This is an invalid inference, but is standard procedure in psychiatry.

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

“When a person of any age has a combination of these struggles—severely enough to impair his daily functioning—with no other plausible explanation for them, then he could very well have a serious, if still somewhat mysterious, condition that medicine has decided to call ADHD.”

This again is standard psychiatric patter:  the flaw is contained in the phrase “…with no other plausible explanation for them…”

Anyone who has had even the slightest experience working with children and families can attest to the fact that there are always alternative psychosocial explanations, if one is prepared to look for them.  The reality, however, is that within the practice of psychiatry, these alternate explanations are almost never sought.

And the reason they are not sought is because psychiatry has effectively closed the door on these kinds of deliberations.  Within the psychiatric framework, if a child (or adult) meets the arbitrary and inherently vague criteria listed in the DSM, then he has a brain illness called ADHD.  So the notion of even looking for psychosocial explanations not only doesn’t happen, but would be seen within psychiatry as ridiculous.

In real medicine, if a person has pneumonia, then that is the explanation of his persistent cough, nasty phlegm, weakness, etc..  The notion of a physician in such circumstances casting around for an alternative psychosocial explanation would be pointless.  Similarly, psychiatrists, firmly wedded as they are to their spurious illness perspective, don’t look for ordinary human explanations of the problems they encounter.  The difference, of course, between psychiatry and real medicine is that the latter’s diagnoses are indeed genuine explanations of the presenting problems.  In psychiatry, the “diagnoses” are merely labels that psychiatrists assign to the loose clusters of vague problems, and have no explanatory value whatsoever.

To demonstrate this, consider the two following hypothetical conversations.

Client’s parent:  Why is my son so distractible; why does he make so many mistakes in his schoolwork; why does he not listen to me when I speak to him; why is he so disorganized?
Psychiatrist:  Because he has an illness called attention-deficit/hyperactivity disorder.
Parent:  How do you know he has this illness?
Psychiatrist:  Because he is so distractible, makes so many mistakes in his schoolwork, doesn’t listen when you speak to him, and is so disorganized.

The critical point being that in psychiatry, the only evidence for the “illness” is the very behavior it purports to explain.  In other words:  your son is distracted because he is distracted.

Contrast this with a similar conversation in real medicine.

Patient:  Why am I so tired; why did my temperature spike; why am I spitting up such dreadful-looking phlegm?
Physician:  Because you have pneumonia.
Patient:  How do you know I have pneumonia?
Physician:  Because I can hear characteristic sounds through the stethoscope; your chest X-ray shows large quantities of fluid in both lungs; your sputum labs are positive for pneumococcus; and because everything you have told me is consistent with this diagnosis.  I can show you the X-rays if you like.

In this conversation, there is no circularity to the reasoning.  The pneumonia is the cause of the symptoms and constitutes a genuine and useful explanation.

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

“No one quite knows what causes it.”

Well actually, lots of people know what prompts children to “careen frenziedly around homes and busy streets”.  It is very simply that the discipline and self-control to refrain from this kind of activity has not been instilled at an appropriate age.  And it’s not “somewhat mysterious”.  It’s something that parents and grandparents have been dealing with probably since prehistoric times.  And the same goes for the other ADHD behaviors, misleadingly called “symptoms” in the DSM.

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

“The most commonly cited theory is that the hyperactivity, lack of focus, and impulsivity of classic ADHD result from some sort of dysfunction among chemicals and synapses in the brain.”

And just when we thought that the long-discredited chemical imbalance hoax was about to die!  Mr. Schwarz seems unaware that most leading psychiatrists are at the present time busy distancing themselves from this particular inanity, which was a mainstay of the psychiatric hoax for decades.  The very eminent and highly prestigious Tufts psychiatrist Ronald Pies, MD has even gone so far as to claim that psychiatry never promoted this hoax – an assertion that adds an entire new dimension to academia’s allegorical ivory tower.

Then Mr. Schwarz gets to the point:

“Unfortunately, as with many psychiatric illnesses, such as depression or anxiety, there is no definitive way to diagnose ADHD, no blood test or CAT scan that lets a doctor declare, ‘Okay, there it is’—all one can do is thoughtfully assess whether the severity of the behavior warrants a diagnosis.  (After all, we all are distractible or impulsive to varying degrees.)”

So despite the earlier vagueness, and despite Mr. Schwarz’s condemnation of what he describes as the over-diagnosis of ADHD, he is clearly a firm supporter of psychiatry’s contention that inattention, impulsivity, and general gadding about constitute an illness, if the behaviors cross some ill-defined threshold of severity.

This is another of psychiatry’s core fallacies, routinely promoted, not only in the successive editions of the DSM, but also in the defensive writings of psychiatry’s most prestigious promoters:  if a problem of thinking, feeling, or behaving crosses some arbitrary and vaguely defined thresholds, of severity, duration, or frequency, it becomes, through some alchemy known only to psychiatry, an illness.  The fact that no organic pathology has ever been identified is of no consequence.  If the problem is severe enough, then it’s an illness.

And the reason for this travesty is that within the looking-glass realm of psychiatric diagnosis, the cause of the problem is irrelevant.  This is the essential point of Robert Spitzer’s phenomenological approach as embodied in his DSM-III and in subsequent editions.  Why a person exhibits a problem is of no consequence.  If, in the case, say of “ADHD”, a child is inattentive, overly active and impulsive to the degree specified, albeit loosely, in the text, then he has the illness.  Whether he emits these behaviors because of lax parenting, inconsistent parenting, indulgent parenting, sibling rivalry, emotional abuse, or some other cause, makes no difference to the “diagnosis”.  In marked contrast to real medicine, where diagnosis and cause are virtually synonymous, in psychiatric diagnosis, the cause of the problem is immaterial.  If the child emits the behaviors in question, for any reason or cause, then he “has the illness”.  The “illness” in fact is nothing more than the presence of the vaguely-defined problem behaviors.  There is no requirement of neurological pathology, nor any evidence that the behaviors in question entail a neurological pathology.  DSM-III describes this approach as “…atheoretical with regard to etiology or pathophysiologic process except with regard to disorders for which this is well established and therefore included in the definition of the disorder.” (p xxiii), which is not the case with ADHD.

Far from acknowledging the obvious dishonesty of this “atheoretical” approach, DSM-III-R actually makes of it a virtue:

“The major justification for the generally atheoretical approach taken in DSM-III and DSM-III-R with regard to etiology is that the inclusion of etiologic theories would be an obstacle to use of the manual by clinicians of varying theoretical orientation since it would not be possible to present all reasonable etiologic theories for each disorder.” (p xxiii)

In reality, however, by ignoring etiological questions, the APA created the context in which “mental disorders” could be created at will on the basis of any human problem, and these “disorders” could be, and indeed are, morphed readily into “mental illnesses”, and, of course, as we see in Mr. Schwarz’s text, neuro-chemical imbalances.  Psychiatry has conveniently abandoned the notion that new diagnoses must be grounded on proven organic pathology.  Real doctors discover new illnesses through painstaking research and study – often taking years or even decades.  Psychiatry just makes them up and confirms their ontological validity by a committee vote.

For decades, psychiatry, confident in the knowledge that few people read the DSM,  simply lied with regards to the absence of organic pathology.  They told their clients, the public, and the media the blatant lie that the “chemical imbalances” existed and were the cause of the problems.  And – the biggest whopper of all – that the drugs corrected these non-existent imbalances.  They also routinely asserted that their “patients” would in many (or perhaps most) cases have to take the drugs for life.  And here again, Mr. Schwarz follows his psychiatric mentors, lock step.

“One thing is certain, though: There is no cure for ADHD.”

Again note the dogmatic arrogance.  Children who are inattentive, unruly, disobedient, and disruptive to the inherently vague degree specified in the DSM are incapable of acquiring an age-appropriate level of discipline!  How in the world could Mr. Schwarz know this?  As early as 1973, Huessy, Marshall and Gendron (Five hundred children followed from grade 2 to grade 5 for the prevalence of behavior disorder, Acta Paedopsychiatrica, 39(11), 301-309), showed that hyperactivity is not a stable pattern across time.  There is also an abundance of research going back to the 60’s that demonstrates clearly that children who are habitually inattentive, impulsive, and hyperactive  even to an extreme degree, can be trained readily to behave in a more productive and less disruptive fashion.  In fact, prior to the mid-60’s, no such research was needed, because parents and teachers routinely and successfully trained children to control their movements, and to pay attention to their studies and to their chores.  Indeed, parents and teachers accepted that this was an intrinsic part of their responsibilities.  But in 1968, with the publication of DSM-II, psychiatry’s “top experts” decreed that these problem behaviors constituted an illness that required specialist attention.  This “illness” was labeled hyperkinetic reaction of childhood.  The description ran to four lines:

“308.0  Hyperkinetic reaction of childhood (or adolescence)*
This disorder is characterized by overactivity, restlessness, distractibility,
and short attention span, especially in young children; the
behavior usually diminishes in adolescence.” (p 50)

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

“…patients young and old are generally told that they will deal with their abnormal brains for the rest of their lives.”

Despite decades of lavishly funded and highly motivated research, and despite the numerous enthusiastic, and subsequently discredited, claims to the contrary, there is not one shred of evidence that people who have been given the ADHD label have any brain pathology whatsoever.  In fact, no edition of DSM, including the present DSM-5, has ever included any kind of brain pathology as a criterion item for this so-called illness.  DSM-5 does include ADHD in the Neurodevelopmental Disorders section, but all that this entails is that the onset of the problem was in the developmental period.  There is no requirement of neurological pathology.  “The neurodevelopmental disorders are a group of conditions with onset in the developmental period.  The disorders typically manifest early in development, often before the child enters grade school, and are characterized by developmental deficits that produce impairments of personal, social, academic, or occupational functioning.” (p 31)  Describing “ADHD” as a neurodevelopmental disorder strikes me as extraordinarily deceptive, in that most people would interpret the term “neurodevelopmental disorder” to entail some kind of neurological pathology.  What the APA has done here is convey the impression that there is a neurological pathology involved in “ADHD”, without having to produce evidence that this is the case.

THE “OVER-DIAGNOSIS” OF ADHD

Then Mr. Schwarz gets to the main theme of his book:  that ADHD is being grossly over-diagnosed, a theme incidentally that many psychiatrists have adopted in recent years in an attempt to rescue their crumbling profession from the criticisms of anti-psychiatry.  Watch how Mr. Schwarz does this:

“The American Psychiatric Association’s official description of ADHD, codified by the field’s top experts and used to guide doctors nationwide, says that the condition affects about 5 percent of children, primarily boys.  Most experts consider this a sensible benchmark.

But what’s happening in real-life America?

Fifteen percent of youngsters in the United States—three times the consensus estimate—are getting diagnosed with ADHD.  That’s millions of extra kids being told they have something wrong with their brains, with most of them then placed on serious medications.  The rate among boys nationwide is a stunning 20 percent.  In southern states such as Mississippi, South Carolina, and Arkansas, it’s 30 percent of all boys, almost one in three.  (Boys tend to be more hyperactive and impulsive than girls, whose ADHD can manifest itself more as an inability to concentrate.)  Some Louisiana counties are approaching half—half—of boys in third through fifth grades taking ADHD medications.

ADHD has become, by far, the most misdiagnosed condition in American medicine.

Yet, distressingly, few people in the thriving ADHD industrial complex acknowledge this reality.  Many are well-meaning—they see foundering children, either in their living rooms, classrooms, or waiting rooms, and believe the diagnosis and medication can improve their lives.  Others have motives more mixed:  Sometimes teachers prefer fewer troublesome students, parents want less clamorous homes, and doctors like the steady stream of easy business.  In the most nefarious corner stand the high-profile doctors and researchers bought off by pharmaceutical companies that have reaped billions of dollars from the unchecked and heedless march of ADHD.” (p 2-3)

But what Mr. Schwarz doesn’t mention, and perhaps isn’t even aware of, is that 69% of those “top experts” in psychiatry who “codified” the criteria for ADHD for DSM-5, and whose prevalence estimates Mr. Schwarz accepts implicitly, were also in the pay of pharma.

Nor does Mr. Schwarz seem to be aware that these same “top experts” who codified the criteria for ADHD have progressively liberalized the criteria for this so-called illness.  I have listed the DSM-IV (1994) relaxations in an earlier post.  The relaxations for DSM-5 (2013) were:

– the number of inattention “symptoms” required for adolescents and adults reduced from six to five (p 59)

–  the number of hyperactivity/impulsivity “symptoms” for adolescents and adults also reduced from six to five (p 60)

–  DSM-IV specified that some symptoms of ADHD had to have been present prior to age 7 (p 84).  DSM-5 relaxed this age-of-onset criterion to 12 (p 60).

It needs to be stressed that none of these relaxations were, or indeed could have been, based on empirical evidence or science.  There is no definition of ADHD other than that set down in successive revisions of the DSM.  The notion that the pharma-paid “top experts” compared ADHD-as-it-really-is with the description in the DSM, and found discrepancies, is simply not possible.  There is no ADHD-as-it-really-is.  There is no definition other than the one that the APA made up, and they can, and do, change it at will.  And, so far, the vast majority of the changes have been in the relaxation direction.

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

And this is the central point.  To bemoan the over-diagnosis of ADHD is an empty, futile exercise.  Given the facts that:

– the criteria are impossibly vague and subjective, and
– pharma makes more money the wider the net is cast, and
– psychiatry shares in these profits through a variety of avenues, and
– the drugs are addictive, and
– schools receive additional funding for every ADHD child on their rolls,

“diagnosis” creep is inevitable.  “Diagnosis” creep is not some accident or some pharma-produced sabotage that has befallen psychiatry despite its best efforts to remain pure and undefiled.  “Diagnosis” creep is an integral component of the monster that psychiatry has consciously and deliberately created.  “Diagnosis” creep is an integral part of psychiatry’s expansionist agenda, and was facilitated enormously by Robert Spitzer’s atheoretical, phenomenological approach in DSM-III (1980).  Though, incidentally, in the case of “ADHD” it was occurring prior to 1980.  Here’s a quote from Ullmann and Krasner’s A psychological Approach to Abnormal Behavior,  Second Edition, (1975):

“The treatment of children who have received the label of ‘hyperactive’ has been a source of further controversy in both psychology and pediatrics…Drug therapy, particularly stimulants such as amphetamines, have become the popular form of treatment including up to 10% of all students in some school districts…” (p 496)

And even then, forty-one years ago, there were clear dissenting voices:

“The label plus the drug treatment brings the child into the mentally ill or sick category and the social and self-labeling that follow…The use of drugs enhances the belief in the efficacy of outside agents rather than attribution of change to one’s own efforts (an important element in the development of self control in children and responsibility in teachers).” (Op. Cit. p 497)

If should also be noted that the relaxation of criteria is not confined to “ADHD”.  DSM-5 also relaxed the APA’s definition of a mental disorder, effectively expanding the net for all their so-called diagnoses.

The definition of a mental disorder in DSM-IV (1994) was:

“… a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability or an important loss of freedom.  In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one.  Whatever its original cause, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual.  Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflict is a symptom of a dysfunction in the individual, as descried above.” (p xxi-xxii)

This definition can, I think, be accurately paraphrased as:  any significant problem of thinking, feeling, and/or behaving.  And indeed, it is extremely difficult to think of a significant problem of thinking, feeling, and/or behaving that is not listed within DSM.

The definition of a mental disorder in DSM-5 (2013) is similar to that quoted above, but contains additional verbiage, and one enormous relaxation of the definition.  To enable readers to judge this for themselves, here’s the DSM-5 definition:

“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.  Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.  An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.  Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflicts results from a dysfunction in the individual, as described above.” (p 20) [Emphasis added]

The word usually on the fourth line expands the potential range of psychiatric “diagnosis” enormously.  One might even say that it becomes so wide as to embrace the entire population.  The point being that in DSM-IV, the problems had to reach a certain level of significance or severity.  But in DSM-5, that requirement was effectively dropped.  Admittedly, both phrases are vague, but DSM-IV’s requirement that distress or disability be present, is obviously a more stringent standard than DSM-5’s assertion that distress or disability is usually present.  In effect, the severity threshold has been abandoned, and there is a clear invitation to practitioners to assign “diagnoses” to individuals with increasingly milder presentations.  And it needs to be stressed that this change was not based on any kind of scientific information or discovery.  This change was simply a decision by the APA to expand the prevalence of their so-called illnesses to virtually everyone on the planet.  It also needs to be stressed that this is not an empty issue, but has already been implemented in the case of “ADHD”.  Compare the severity criterion for ADHD in DSM-IV with that in DSM-5:

DSM-IV:
“D.  There must be clear evidence of clinically significant impairment in social, academic or occupational functioning.” (p 84) [Emphasis added]

DSM-5:
“D.  There is clear evidence that the symptoms interfere with , or reduce the quality of, social, academic, or occupational functioning.” (p 60)

Here again, both statements are vague, but significant impairment in… is obviously a tighter standard than interfering with, or reducing the quality of….

Given all of these considerations, it’s extremely difficult to avoid the conclusion that the APA not only supports the wide expansion of this so-called diagnosis, but has actively pursued and facilitated this expansion for decades.

. . . . . . . . . . . . . . . . 

CONCLUSION

 Mr. Schwarz has done a good job of exposing pharma’s tactics and strategies.  Although much of this story is well-known and has been told before, he does present the scam in a detailed and readable form.  He also addresses the problem of parents pushing to get their children “diagnosed” and on drugs, and the undeniable fact that people do become addicted to these products.  He also exposes the link between CHADD and pharma.

Perhaps now he can take a look at the even bigger scam:  psychiatry’s spurious and destructive medicalization of literally every problem of thinking, feeling, and/or behaving, including childhood inattention, impulsivity, and general lack of discipline.

Pharma does indeed push their products using very questionable methods.  But they couldn’t sell a single prescription for methylphenidate or for any other psychiatric drug without psychiatry’s bogus and self-serving “diagnoses”.  And they couldn’t have increased their sales to the extent that they did, without the commensurate relaxation of the “diagnostic” criteria, that psychiatry knowingly and willingly provided.  Bemoaning the use of hurriedly-completed facile checklists is empty talk, unless one is also willing to turn one’s criticism against the DSM’s equally facile “symptom lists”, of which the checklists are simply mirrors.

Psychiatry is nothing more than legalized drug-pushing.  There is not one shred of intellectual or scientific validity to their so-called taxonomy.  They invent these so-called illnesses to expand their turf, and then liberalize the criteria to expand it further.

Under the guise of medical care, they routinely rob people of their sense of competence, their dignity, and in many cases, their lives.  They have radically undermined the concept of success-through-disciplined-effort, and have ensnared millions of people worldwide in their ever-expanding web of drug-induced dependency and self-doubt.  They are not the thoughtful and expert codifiers of genuine illnesses, as Mr. Schwarz contends.  Rather, they are drug-pushing charlatans and hoaxsters who have systematically and deliberately deceived their clients and the general public to enhance their own prestige and their incomes.

If there was ever a subject that called for thorough investigative journalism, psychiatry is it.

Allen Frances Saving Psychiatry From Itself?

On October 12, 2014, the eminent psychiatrist Allen Frances, MD, participated in a panel discussion at the Mad In America film festival in Gothenburg, Sweden.  After the festival, he wrote an article – Finding a Middle Ground Between Psychiatry and Anti-Psychiatry – for the Huffington Post Blog, summarizing the positions he had discussed at the festival. The article was re-published on MIA on October 26, 2014.

The article is ostensibly an attempt to find common ground between psychiatry and its critics, but the piece contains numerous distortions and omissions which I think need to be identified and discussed.

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

“There will never be any compromise acceptable to the die-hard defenders of psychiatry or to its most fanatic critics.

Some inflexible psychiatrists are blind biological reductionists who assume that genes are destiny and that there is a pill for every problem.

Some inflexible anti-psychiatrists are blind ideologues who see only the limits and harms of mental-health treatment, not its necessity or any of its benefits.

I have spent a good deal of frustrating time trying to open the minds of extremists at both ends — rarely making much headway.”

This is Dr. Frances’s opening passage.  Essentially what he’s saying here is that there are “extremists” on both sides of this issue.  Although he doesn’t say that these individuals are minorities, I think that this is implied.  Certainly those of us in the anti-psychiatry camp are a minority, but the implication that psychiatrists who are  “blind biological reductionists” represent a minority is, I suggest, simply false.  I have been retired now for 13 years, but in the previous twenty-five years, I doubt if I encountered more than three or four psychiatrists who were not “blind biological reductionists”.  The phrases “chemical imbalance” and “illness just like diabetes” were standard fare in psychiatry’s narrative, and the 15-minute “med check” was the standard “treatment” for all problems.

With regards to “inflexible anti-psychiatrists” being “blind ideologues”, I think I can speak from personal experience.  I am indeed inflexibly anti-psychiatry.  My position in this regard is based entirely on the fact that the various problems listed in the DSM (apart from those indicated as due to a general medical condition) are not illnesses, and that conceptualizing these problems as illnesses has done, and continues to do, vastly more harm than good.  I am – to use Dr. Frances’s term – inflexible on this matter in the same way that I am inflexible on the matter that the Earth is round rather than flat.

But, on the other hand, as I’ve stated many times on my website, if psychiatry will adduce convincing evidence that the various items catalogued in their manual really are illnesses, (i.e., stem from an identified biological pathology), then I will accept this evidence, apologize for my errors, and close the website. At the risk of understatement, this evidence is not to hand, and at present, psychiatry’s contentions, explicit and implicit, that the various problems that they “treat” are illnesses are nothing more than destructive, disempowering, self-serving, unsubstantiated assertions.

And lest there be any perception that psychiatry’s love-affair with biological reductionism is a thing of the past, here’s a quote from Jeffrey Lieberman’s June 19, 2012 video Causes of Depression.  Dr. Lieberman is Psychiatrist-in-Chief at New York Presbyterian/Columbia University Medical Center, and at the time of the video was President-elect of the APA.  The video was made by The University Hospital of Columbia and Cornell.

“…the way nerves talk to each other, and communicate, is through the secretion of a chemical called a neurotransmitter, which stimulates the circuit to be activated.  And when this regulation of chemical neurotransmission is disturbed, you have the alterations in the functions that those brain areas are supposed to, to mediate.  So in a condition like depression, or mania, which occurs in bipolar disorder, you have a disturbance in the neurochemistry in the part of the brain that regulates emotion.”

And lest there be any perception that Dr. Frances did not contribute to psychiatry’s ardent embrace of biological reductionism, here’s a quote from the Introduction to DSM-IV, of which Dr. Frances was the Task Force chairman:

“The terms mental disorder  and general medical condition are used throughout this manual.  The term mental disorder is explained above.  The term general medical condition is used merely as a convenient shorthand to refer to conditions and disorders that are listed outside the ‘Mental and Behavioral Disorders’ chapter of ICD.  It should be recognized that these are merely terms of convenience and should not be taken to imply that there is any fundamental distinction between mental disorders and general medical conditions… (p xxv) [Boldface added]

. . . . . . . . . . . . . . . . 

“Fortunately, though, there are many reasonable people in both camps who may differ markedly in their overall assessment of psychiatry but still can agree that it is certainly not all good or all bad. With open-mindedness as a starting point, common ground can usually be found;”

At the risk of appearing cynical, I see this as a rather facile attempt at divide-and-conquer.  Psychiatry is the Goliath here, and the anti-psychiatry movement is a very weak and poorly-provisioned David.  What Dr. Frances is doing is marginalizing the more extreme members of the anti-psychiatry camp, and attempting to gather the more moderate members into psychiatry’s fold, under the pretense that most psychiatrists are reasonable people who will welcome their input with “open-mindedness”.  In reality, apart from a truly tiny number of psychiatrists, there is no receptivity within psychiatry to the anti-psychiatry concerns.  In fact, the dominant feature of the present debate is psychiatry’s increased insistence that the problems they “treat” are indeed real illnesses, and that their “treatments” are safe and effective.

In a recent radio interview with Michael Enright on Canadian Broadcasting Corporation’s The Sunday Edition, Jeffrey Lieberman, MD, one of the most eminent and prestigious psychiatrists in the world, characterized Robert Whitaker as “a menace to society” for daring to suggest otherwise!  And there was scarcely a ripple of protest from psychiatry.

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

“And finding common ground has never been more important. We simply can’t afford a civil war among the various advocates of the mentally ill at a time when strong and united advocacy is so desperately needed.”

Note the term “civil war” with its connotations of brother against brother, families torn apart, etc…  The message here is:  that those of us who are “open-minded” basically want the same thing, so why are we engaged in this struggle?  But note also the phrase “the mentally ill”.  The essential core of the anti-psychiatry movement is that the various problems embraced by psychiatry’s catalog are not illnesses.  But Dr. Frances dismisses this entire issue in the guise of being open-minded and conciliatory.

In addition, the phrase “the mentally ill”, with its connotations of amorphousness, homogeneity, and anonymity, is extraordinarily stigmatizing.  I would concede that person-first language is sometimes promoted to an excessive degree, but the phrase “the mentally ill” is not at all helpful.

Ironically, Dr. Frances uses this phrase in the context of advocacy!  “…various advocates of the mentally ill…”  I respectfully suggest that a good first advocacy step for Dr. Frances would be to stop calling the individuals concerned “the mentally ill”.

Incidentally, the phrase “the mentally ill” occurs in Dr. Frances’s paper three times; the phrase “the severely ill” occurs once.

And why is this “strong and united advocacy…so desperately needed”.  Because:

“Mental-health services in the U.S. are a failed mess: underfunded, disorganized, inaccessible, misallocated, dispirited, and driven by commercial interest. The current nonsystem is a shameful disgrace that won’t change unless the various voices who care about the mentally ill can achieve greater harmony.”

But, and Dr. Frances fails to mention this, it is psychiatry itself that has been running this “shameful disgrace” for the past 150 years or so.  And psychiatry was, and still is, a very willing and devoted partner to pharma, the major commercial interest.

Also note the guilt-trip:  if you’re not joining the great Allen-Frances coordinated unification drive, then you just don’t care about “the mentally ill”, (that phrase again).

 

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

“…those who don’t need psychiatric medicine get far too much: We spend $50 billion a year on often-unnecessary and potentially dangerous pills peddled by Big Pharma drug pushers, prescribed by careless doctors, and sought by patients brainwashed by advertising. There are now more deaths in the U.S. from drug overdoses than from car accidents, and most of these come from prescription pills, not street drugs.”

But Dr. Frances neglects to mention that his own DSM-IV had a clearly expansionist agenda, details of which I’ve discussed in an earlier post.  It is the proliferation of “diagnoses” and the progressive relaxing of the criteria that enables the increases in prescribing.  And Dr. Frances has been a major player in this area.

He also neglects to mention his own interest-conflicted collaborative relationship with Janssen Pharmaceutica in the mid-1990’s in the promotion of Janssen’s drug Risperdal (risperidone).  In that regard, Dr. Frances was quoted in a witness report as stating:

“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.” [Boldface added]

. . . . . . . . . . . . . . . . 

“The mess is deeply entrenched because 1) there are few and fairly powerless advocates for the most disadvantaged; 2) the commercial interests are rich and powerful, control the airwaves and the politicians, and profit from the status quo; and 3) the mental-health community is riven by a longstanding civil war that distracts from a unified advocacy for the severely ill.

The first two factors won’t change easily. Leverage in this David-vs.-Goliath struggle is possible only if we can find a middle ground for unified advocacy.

I think reasonable people can readily agree on four fairly obvious common goals:

1.  We need to work for the freedom of those who have been inappropriately imprisoned.

2.  We need to provide adequate housing to reduce the risks and indignities of homelessness.

3.  We need to provide medication for those who really need it and avoid medicating those who don’t.

4.  We need to provide adequate and easily accessible psychosocial support and treatment in the community.”

There is indeed a David and Goliath aspect to this issue.  Pharma-psychiatry is Goliath; and the struggling anti-psychiatry movement is David.  But note how Dr. Frances has reconfigured this. Goliath is now “the commercial interests” (presumably pharma), and David is psychiatry (without, of course, the few “blind biological reductionists”) plus those “reasonable” members of the anti-psychiatry movement who genuinely care for “the mentally ill”.  Casting pharma and psychiatry as being on opposite sides of this issue, and portraying psychiatry as the powerless, innocent victim, are extraordinary feats of mental gymnastics.

. . . . . . . . . . . . . . . . 

“Eighty percent of all psychiatric medicine is prescribed by primary-care doctors after very brief visits that are primed for overprescribing by misleading drug-company advertising.”

But not a single one of those prescriptions could have been written if psychiatrists had not invented, and avidly promoted, the “illnesses” for which they are prescribed.

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

 “Many psychiatrists also tend to err by being too quick to write prescriptions.”

But isn’t this an integral part of the medical model:  diagnose the illness, prescribe the treatment; follow-up.  This isn’t some kind of unforeseeable aberration.  Rather, this is psychiatry as psychiatrists – leaders as well as rank and file – have consciously and deliberately sculpted it over the past 50 years.  This spurious and destructive travesty is the inevitable culmination of psychiatry’s efforts to establish itself as a bona fide medical specialty.  The fact that it is such a colossal failure is not a reflection on the efforts of the participants, or the pharma money that fuelled those efforts.  Rather, it reflects the obvious fact that the medical model is not a useful way to conceptualize or approach non-medical problems of thinking, feeling, and/or behaving.   

. . . . . . . . . . . . . . . . 

“I think reasonable people can agree that we need to reeducate doctors and the public that medications have harms, not just benefits…”

Doctors need to be re-educated to the fact that medications have harms, not just benefits!  Don’t they read the PDR?   And note the use of the generic term “doctors” rather than psychiatrists, even though it was psychiatrists who routinely proclaimed the safety and efficacy of the drugs they pushed, and downplayed adverse reactions, when they mentioned them at all.  And it was the pharma-funded psychiatric research mill that churned out, and continues to churn out, the spurious studies that “established” the safety and efficacy of these products.

. . . . . . . . . . . . . . . . . 

“…it is equally ludicrous that anyone should be sent to jail for symptoms that would have responded to medication if the waiting time for an appointment had been one day, not two months.”

First, note the implication that the criminal behavior is a “symptom” that “would have responded to medication.”  But what of the increasing number of very serious criminal acts committed by people who are actually taking psychiatric drugs, particularly SSRI’s?

. . . . . . . . . . . . . . . . 

“When, more than 50 years ago, Tom Szasz began to fight for patient empowerment, freedom, and dignity, the main threat to these was a snake-pit state hospital system that warehoused more than 600,000 patients, usually involuntarily and often inappropriately. That system no longer exists. There are now only about 65,000 psychiatric beds in the entire country, and the problem is finding a way into the hospital, not finding a way out.”

This is not entirely accurate.  The late Thomas Szasz, MD, was indeed concerned about coercive psychiatry, but he was even more concerned about psychiatry’s spurious medicalization of non-medical problems: what Dr. Szasz called the myth of mental illness.  And this latter concern is one that Dr. Frances consistently fails to address, or even acknowledge.  To abuse the late Dr. Szasz’s legacy in this way strikes me as dishonorable.  And to suggest that the concerns so forcefully expressed by Dr. Szasz are now a thing of the past is simply false.

. . . . . . . . . . . . . . . . 

“Anti-psychiatrists are fighting the last war. Psychiatric coercion has become largely a paper tiger: rare, short-term, and usually a well-meaning attempt to help the person avoid the real modern-day coercive threat of imprisonment.”

So psychiatric coercion is rare, short-lived, and is essentially an act of kindness to keep people out of prison.  But on August 28, 2014, Dr. Frances wrote an article on the Huffington Post Blog in which he lionizes D.J. Jaffe, whom he describes as “one of a small group of stalwart defenders of the 5 percent” (people with “severe mental illness”).  Dr. Frances provides an extensive quote from D J. Jaffe in which Mr. Jaffe clearly supports the infamous Tim Murphy bill, which, if implemented, would increase vastly the amount of coerced psychiatric “treatment” in the US.

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

Depression is not an illness.  Childhood inattention is not an illness.  Painful and distressing memories are not illnesses.  Habitual criminality is not an illness.  Psychiatry’s routine medicalization of these and other non-medical problems is a disaster of monumental proportions, and Dr. Frances has been a major contributor to this process.

At the present time, psychiatry is being exposed as the self-serving, disempowering, and destructive charlatanism that it is.  The anti-psychiatry movement, though still the David, is gaining ground and adherents daily.  Psychiatry has no defense, and can see the edifice, so carefully and deceptively constructed over decades, crumbling by the day.

What Dr. Frances is trying to do is co-opt the anti-psychiatry movement, by marginalizing its more extreme members, while gathering the rest under a dubious banner of reasonableness and compromise.  But beneath the thin veneer of amenability, there are still the spurious, self-serving concepts and the destructive, disempowering practices of a system that is intellectually and morally bankrupt, and has no legitimate claim to being a medical specialty.

Allen Frances and the Spurious Medicalization of Everyday Problems

On April 5, Allen Frances MD, published an article on the Huffington Post blog.  The title is Can We Replace Misleading Terms Like ‘Mental Illness,’ ‘Patient,’ and ‘Schizophrenia’  It’s an interesting piece, and it raises some fundamental issues.

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

“Those of us who worked on DSM IV learned first-hand and painfully the limitations of the written word and how it can be tortured and twisted in damaging daily usage, especially when there is a profit to be had.”

The fact that words can acquire multiple, and even contradictory, meanings is well known to most high school graduates.  People of all walks of life are generally sensitive to this reality, and take steps to clarify their meanings, especially with regards to words that are known to be ambiguous.

In the above quote, Dr. Frances is, I believe, implying that he and the other members of the DSM-IV work group chose their words carefully, but that their meanings were corrupted in “damaging daily use”.  Additionally, he appears to ascribe blame for this process to the drive for profits, presumably on the part of pharma.

But this is not consistent with the fact that ambiguity and a general lack of verbal precision are primary characteristics of successive revisions of the DSM, including DSM-IV.  In DSM-IV’s criteria for attention deficit hyperactivity disorder, for instance, the term “often” occurs in every criterion item, even though its lack of clarity, and its potential for abuse, are obvious.

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

“This did not stop the widespread misuse of the terms Attention Deficit Disorder, Asperger’s Disorder, Bipolar Disorder, PTSD, Paraphilia and others. The lesson: If some wording in DSM can possibly be misused for any purpose, it almost certainly will be.”  [Emphasis added]

Here again, the impression being given is that Dr. Frances and his team defined these various terms judiciously and with precision, but that others came along afterwards and “misused” these carefully crafted definitions for their unstated, but presumably venal, purposes, while the injured innocents of the DSM-IV work groups could only watch in dismay from the sidelines.

The reality, of course, is quite different.  All of the definitions, in every edition of the DSM, are notoriously vague, and are subject to diverse interpretation.  This vagueness has consistently served the interests of psychiatry in expanding its scope and influence.  DSM-IV was simply one of the steps in this process, and the notion that Dr. Frances and/or other members of the work group were naïve to this dynamic is simply not credible.

. . . . . . . . . . . . . . . . 

“‘Mental illness’ is terribly misleading because the ‘mental disorders’ we diagnose are no more than descriptions of what clinicians observe people do or say, not at all well established diseases. For example, the term ‘schizophrenia’ just describes a heterogeneous set of experiences and behaviors; it doesn’t at all explain them and eventually there will be hundreds of different causes and dozens of different treatments. ‘Schizophrenia’ is certainly is not one illness.”

This is in marked contrast to what Dr. Frances and his task force wrote in the DSM-IV section on schizophrenia:

 “The essential features of Schizophrenia are a mixture of characteristic signs and symptoms (both positive and negative) that have been present for a significant portion of time during a 1-month period (or for a shorter time if successfully treated), with some signs of the disorder persisting for at least 6 months (Criteria A and C).” (p 274)

The clear implication here is that “Schizophrenia” (with a capital S!) is a single unified entity that can be recognized by its characteristic signs and symptoms.

In addition there are numerous phrases and sentences that imply clearly that, as far as the authors were concerned, schizophrenia is a unified condition.  These include “The individual with Schizophrenia…”; “Individuals with Schizophrenia…”; “The onset of Schizophrenia…”; “…the symptoms of Schizophrenia…”; ”…prevalence of Schizophrenia…”; “…age of onset for the first psychotic episode in Schizophrenia…”; “…course and outcome in Schizophrenia…”; etc…  In no part of the DSM-IV entry is there the slightest intimation that “schizophrenia” is anything other than a single unified “disorder”.

So again, it seems reasonable to ask:  what has changed?  Is there some new science that has debunked the old unified illness notion?  Or is it simply the case, as many of us on this side of the issue have maintained for years, that the unified illness notion was never more than a convenient psychiatric fiction, devoid of any scientific underpinning, which Dr. Frances is now disavowing.

Note particularly in the above quote from Dr. Frances’ current paper, the phrase:  “…it [schizophrenia] doesn’t at all explain them [the problematic experiences and behaviors]…”

Here again, this represents a marked departure from DSM-IV, where schizophrenia (the unified disorder) is clearly presented as the cause of the so-called symptoms.  In the section on schizophrenia (p 277) it states:

“Although quite ubiquitous in Schizophrenia, negative symptoms are difficult to evaluate because they occur on a continuum with normality, are nonspecific, and may be due to a variety of other factors (e.g., as a consequence of positive symptoms, medication side effects, a Mood Disorder, environmental understimulation, or demoralization).”

The statement that negative symptoms may be due to “other factors” clearly implies that in other cases, they are due to (i.e. caused by) schizophrenia.  Note, incidentally, that one of the other factors that is given as causative of negative symptoms is “a Mood Disorder”, again clearly implying that those “disorders” also are being conceptualized and presented as the causes of the “negative symptoms”.

. . . . . . . . . . . . . . . . 

“The ‘mental illness’ term also lends itself to a simple-minded biological reductionism that pays insufficient attention to the psychological and social factors that are crucial in understanding anyone’s problems. Everyone complains about ‘mental illness,’ but nobody has come up with a better substitute.”

The DSM-IV entry on Schizophrenia runs to 16 pages – p 274-290.  In all of that text, there is only one reference to environmental factors:

“Although much evidence suggests the importance of genetic factors in the etiology of Schizophrenia, the existence of a substantial discordance rate in monozygotic twins also indicates the importance of environmental factors.” (p 283)

and there is no specific reference to “…psychological and social factors that are crucial in understanding anyone’s problems.”  Additionally, on page 275, DSM-IV states:

“…positive symptoms may comprise two distinct dimensions, which may in turn be related to different underlying neural mechanisms…”

which at the very least suggests a “simple-minded biological reductionism”.  So, again, what we have is Dr. Frances lamenting a situation of which he and his colleagues were some of the primary architects.

And the old chestnut —we all hate the term “mental illness, but alas, nobody has come up with a better substitute.”  This, I suggest, is less than candid.  There are lots of better (i.e. more accurate) terms, e.g., problems of thinking, feeling, and/or behaving.  It is difficult to avoid the conclusion that psychiatrists cling to the term “mental illness”, not because they can’t come up with anything better, but rather because it serves as an integral part of the spurious medicalization of these problems.  If the concept of “mental illness” were to be eliminated, as it should be, then psychiatry’s justification for its role in this area would also go.  The notion that the APA, with all its talent and its prestigious PR company, couldn’t come up with a better term if they wanted to, is simply not remotely credible.

Note also that Dr. Frances’ concern about the term “mental illness” is because “…it lends itself to a simple-minded biological reductionism that pays insufficient attention to the psychological and social factors…”.  And this, of course, is a valid concern.  But it is not the core concern.  The core concern with the term “mental illness” is that the problems it purports to delineate are not illnesses at all.  The spurious medicalization of these problems is the fundamental error from which all of psychiatry’s excesses and venality flow.  It is also the issue that they simply refuse to address.

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

Dr. Frances expresses some reservations about the use of the term “patient”, because it implies  “…participation in a hierarchical relationship that brings with it little responsibility for shared decision making.”  Then he continues:

“But I have also never been comfortable with cold, market-sounding terms like ‘client,’ ‘consumer,’ ‘customer’ or ‘service user.’ These are business terms and lack the connotation of caring and responsibility associated with helping a ‘patient.’…Unless someone comes up with a better term, I think it would be better to rehabilitate the connotation of ‘patient’ rather than replace it, making clear that it implies full partnership in a therapeutic relationship.”

Here again, I suggest that Dr. Frances is being less than candid.  Social workers refer to the people they serve as “clients”, and the word has never suggested connotations of coldness or market place values in that context.  In fact, in my experience, social workers, other than those who have been co-opted by psychiatry, are arguably the most compassionate and client-centered professional group in this field.  And there are lots of other words, e.g. – and this is pretty radical –”person”.  And in fact, Dr. Frances’ own DSM-IV routinely uses the word “individual”.

If, as appears to be the case, Dr. Frances is arguing that psychiatrists cling to the term “patient” because it reflects their values of caring and warmth, all I can say is that I find this difficult to reconcile with the fact that the 15-minute med check has become psychiatry’s standard practice, and that the psychiatric falsehood – “a chemical imbalance just like diabetes” has been, and continues to be told to countless millions of psychiatric “patients”.

Dr. Frances expresses the belief that the word “patient” should be rehabilitated to make it clear that the term implies “full partnership in a therapeutic relationship”.  But he’s neglecting the fact that the term “patient” already has a perfectly valid and generally accepted meaning:  a person who is sick and who goes to a physician for assessment and/or healing.  And this, I suggest, is precisely why psychiatrists, including Dr. Frances, cling to the term – because when used in the psychiatric context, it embodies within its meaning the fiction that the problems “treated” by psychiatrists are illnesses requiring medical intervention.

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

 Dr. Frances then quotes from a debate that he had with Anne Cooke PhD, editor of the BPS report Understanding Psychosis.  He notes that they are in agreement on some issues.

“We certainly join forces in worrying that loose usage and commercial gain have extended the terminology of mental ‘illness’ to many expectable problems of everyday living that are much better explained by psychological factors and social context and better described using everyday language.”

But:

“…we part company when you suggest that all diagnostic labels can be easily and safely. Your suggestion would have disastrous consequences for those who have severe psychiatric problems.”

There’s an obvious typo here, but it seems clear that Dr. Frances is stating that there would be disastrous consequences if diagnostic labels were dispensed with in the case of people with “severe psychiatric problems”.

There are two noteworthy points here.  Firstly, Dr. Frances has started referring to the DSM “diagnoses” as “diagnostic labels“, which is interesting.  Secondly, his use of the term “severe psychiatric problems” implies the existence of a discreet, identifiable set of problems, in the same way as the phrases “severe cardiac problems” or “severe kidney problems”.  In fact, this is not the case.  The DSM-IV definition of a mental disorder embraces all significant problems of thinking, feeling, and/or behaving, including expectable problems of everyday living.  If an expectable problem of everyday living, e.g., bereavement, crosses a  vaguely defined threshold of significance, then it is, by Dr. Frances’ own DSM-IV definition, a psychiatric problem.  And if it crosses an equally vaguely defined threshold of severity, then it becomes a severe psychiatric problem.

But even if we set that issue aside, the question still remains as to why dispensing with psychiatric “diagnoses” would result in disastrous consequences.  Dr, Frances tells us why.

“Here’s why: An adequate differential diagnosis of delusions and hallucinations requires full consideration of whether the problems are best described as: ‘Substance Induced Psychotic Disorder’, ‘Psychotic Disorder Due To A General Medical Condition’, “Delirium’, ‘Dementia’, ‘Schizophrenia’, Brief Psychosis’, Delusional Disorder’, ‘Bipolar Disorder’, ‘Major Depressive Disorder’, ‘Catatonia’, Obsessive Compulsive Disorder’, or ‘Sleep Disorder’. Each of this has different implications and calls for different actions. Only when all have been ruled out, can one conclude before that the experiences have no clinical significance and can be described adequately with everyday language.”

So in plain “everyday language”, what Dr. Frances is saying is this:  If a person is expressing delusional beliefs and hallucinating, we need to explore the nature and causes of the delusions and hallucinations if we want to adequately define and identify the problem.  So we have to compare the precise details of the individual’s presentation with the various DSM entities mentioned in order to get the correct “diagnosis”.  But he’s already told us that one of the “diagnoses” (schizophrenia) is merely a heterogeneous set of experiences and behaviors.  So it’s difficult to imagine what benefits would accrue from this kind of “differential diagnosis”, over and above a description of the problem in plain language.  Is Dr. Frances suggesting that the statement:  John is hallucinating and paranoid because he has been using PCP, is less informative than the statement:  John has Substance-Induced Psychotic Disorder?  It’s also difficult to imagine what “disastrous consequences” might result from the observation that Mary is expressing delusional beliefs because of a brain tumor, that would be averted by the formula Mary has Psychotic Disorder due to a general medical condition.

In fact, it is a general contention on this side of the issue that psychiatric “diagnoses” militate against the exploration of the nature and causes of the presenting problems, in that psychiatrists routinely terminate this kind of enquiry once they have determined the “diagnosis”.  And these are the very “diagnoses” that Dr. Frances earlier conceded are purely descriptive with no explanatory significance.

. . . . . . . . . . . . . . . . 

“Labels can help a great deal. They can hurt a great deal. They can provide clarity, but they can also badly mislead. The words we use in mental health all carry the heavy baggage of misleading and potentially stigmatizing connotation. They are vastly overused to describe mild problems of everyday life better described with everyday language. But we need diagnostic labels for the ‘severely ill’ and all suggested replacements are much more harmful than helpful.”

So Dr. Frances concedes that the words used in mental health are vastly over-used to describe “mild problems of everyday life”, but once again, he doesn’t seem to be acknowledging that his own DSM-IV was one of the great contributors to this process.  Psychiatric proliferation and expansion were both well under way by the time he convened his work force, but his final product endorsed every single aspect of DSM-III that had enabled and facilitated the expansion, e.g.:

  • the adoption, with only minor, inconsequential changes, of DSM-III’s all-embracing definition of a mental disorder;
  • the use of inherently vague language in the criteria sets;
  • the use of polythetic (two out of five, six out of nine, etc.) criteria sets;
  • the decision not to revert to DSM-I’s widespread use of the term “reaction”, which recognized that the problems being addressed were reactions of the individual to psychological, social, and biological factors;
  • the insistence, in the definition of a mental disorder, that the problems reside “in an individual”, as opposed to the person’s circumstances or environment;
  • the extensive use of the “not otherwise specified” (NOS) category, which essentially enabled psychiatrists to expand the so-called nosology more or less as they wished.

In addition to this, DSM-IV introduced specific innovations that also facilitated expansion of psychiatric turf into “the problems of everyday life.”

Firstly, it was DSM-IV that made it possible for an individual to be labeled “bipolar” without ever having displayed a manic episode.

Secondly, there occurred in DSM-IV a general liberalizing of the criteria for many of the so-called diagnoses.  “ADHD” is a good example.  DSM-III listed 14 criteria items for this label; DSM-IV listed 18.  One DSM-III item was dropped.  The additional five items in DSM-IV are:

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

This is almost a defining feature of early childhood.

    “1 (e)  often has difficulty organizing tasks and activities”

Again, a fairly common attribute of young children.

    “1 (f)  often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such  as schoolwork or homework)”

Note the use of the word “or”.  So if the child avoids, dislikes or is reluctant to do his/her homework, this criterion is endorsed.  I suggest that very few children actually like doing homework!

    “1 (i)  is often forgetful in daily activities” (p 84)

Again, the pathologizing of the normal.

         “2 (c)  is often ‘on the go’ or often acts as if driven ‘by a motor'”

The use of colloquialisms here is especially interesting, in that expressions like “always on the go” and “like he’s driven by a motor” are things that parents often say about their young children without any pathologizing connotations or intent.  By including these expressions in this list of “symptoms”, Dr. Frances and his team have effectively pathologized these descriptors, and brought psychiatric scrutiny to bear on children so characterized.

In addition, the following fairly extreme item in DSM-III

    “(14)  often engages in physically dangerous activities without considering possible consequences (not for the purpose of thrill-seeking), e.g., runs into street without looking” (p 53) [Emphasis added]

was liberalized in DSM-IV to the much more banal

     “2 (c)  often runs about or climbs excessively in situations in which it is inappropriate (in adolescents or adults, may be limited to subjective feelings of restlessness)” (p 84)

In DSM-III, the “age of onset” had to be before the age of seven.  In DSM-IV, this requirement has been eased to “Some hyperactive-impulsive or inattentive symptoms that caused impairment were present before age 7 years.” [Emphasis added] (p 84)

And, perhaps most significantly of all, in DSM-III the label ADHD is clearly conceptualized as pertaining to childhood.  DSM-IV, however, states:

“In most individuals, symptoms attenuate during late adolescence and adulthood, although a minority experience the full complement of symptoms of Attention-Deficit/Hyperactivity Disorder into mid-adulthood.  Other adults may retain only some of the symptoms, in which case the diagnosis of Attention-Deficit/Hyperactivity Disorder, In Partial Remission, should be used.  This diagnosis applies to individuals who no longer have the full disorder but still retain some symptoms that cause functional impairment.” (p 82)

In the light of all this, it is difficult to accept Dr. Frances’ contention that the proliferation and expansion of psychiatric “diagnoses” was not an integral part of his, and psychiatry’s overall plan.

And incidentally, psychiatry’s usual response to this particular criticism is that they must update the criteria, as more knowledge is gained about the “illnesses”. But this is untenable.  The only definition of the “illness” is the one given in the DSM.  There is no deeper entity to which the criteria refer.  What psychiatrists call ADHD is nothing more than a loose clustering of vaguely described habitual behaviors and omissions.  Psychiatry can add to, or modify, the list at will.  In stark contrast to real medicine, there is no reality to which these additions or modifications must conform.  If the APA decides that  “…is often forgetful in daily activities” is a “symptom” of the “illness” known as ADHD, then that decision makes it so.  And if the decision represents a liberalization of the criteria, then, literally overnight, more people will now “have” the “illness”.  And given that this process has been going on for the past fifty years, it is difficult to avoid the conclusion that it is intentional.

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

Dr. Frances’ position in this and other recent papers appears to be that in general, psychiatric “diagnoses” and “treatment” are OK, but that they are being overused by unscrupulous practitioners with the encouragement of pharma, and perhaps other monied interests.

And of course the expansion of psychiatric “treatment” is indeed a huge problem.  But it is a problem of Dr. Frances’ own making – a fact which, to the best of my knowledge, he has never conceded.

But, even more importantly, the expansion is not the critical issue.  The central issue is the spurious medicalization of non-medical problems in the first place.  There are no more grounds for considering severe depression an illness than there are for mild depression.  Severe and persistent inattentiveness is no more an illness than mild or transient inattentiveness.

It is from this spurious medicalization that all of psychiatry’s excesses flow.  Once psychiatry recognized that they could create illnesses by fiat, then the door was opened, and remains open, for unlimited expansion and pathologizing.  And Dr. Frances’ DSM-IV was a major – and perhaps the major – step in this process.

The Dehumanizing Aspect of DSM

In January 2014, the journal Research on Social Work Practice published a special issue: A Critical Appraisal of the DSM-5: Social Work Perspectives.  There were many excellent articles in this volume, some of which I have highlighted in earlier posts.

One of the very outstanding articles is The Diagnostic and Statistical Manual of Mental Disorders as a Major Form of Dehumanization in the Modern World, by Eileen Gambrill, PhD, a graduate school Professor at the School of Social Welfare, University of California, Berkeley.

Here’s the abstract:

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is one of the most successful technologies in modern times. In spite of well-argued critiques, the DSM and the idea of ‘mental illness’ on which it is based flourish, with ever more (mis)behaviors labeled as brain diseases. Problems in living and related distress are converted into  medical problems, obscuring the role of environmental factors such as poverty and related political, social, moral, and economic factors such as the interest of the state in controlling deviant behavior and maintaining the status quo. This view shrinks rather than expands opportunities for freedom, growth, and dignity. It ignores the vast literature showing that unusual environments create unusual behaviors and that by arranging learning opportunities we can change behavior. Reasons for this marketing success are discussed and alternatives suggested including consensual counseling regarding problems in living and drawing on a science of behavior attending to environmental learning opportunities.”

This article presents a fundamental and thorough challenge to the idea of mental illness, with its dehumanizing consequences, and its decontextualized approach to human problems.

The article is lengthy – 19 pages plus references – and it is impossible for me to convey the depth and impact of the piece in a short post of this kind.  Here are some quotes:

“Psychiatric labels have been applied to an ever-increasing variety of behaviors viewed as mental disorders.”

“Biomedical psychiatry and pharmaceutical companies, with the help of the state, have been very successful in forwarding medical views of problems-in-living including transforming everyday behaviors, thoughts, and feelings into mental illnesses requiring medical solutions (medication), as illustrated by the ever-lengthening list of behaviors viewed as signs of mental illness and promotion of medical remedies (prescribed medication).”

“Acceptance of the statistically normal condition as equivalent to the psychologically healthy one results in pathologizing people who vary from the statistical norm and even imposing intervention on such individuals.”

“A DSM label gives an illusion of understanding, encouraging detachment from lived experiences.”

“Central to the understanding of words and their effects is reification: the assumption that use of a word means that the reality to which the word allegedly refers actually exists.”

“The promotion of the belief that deviant or troubling behaviors are caused by an illness (a brain disease) has spawned scores of industries and thousands of  agencies, hundreds of research centers, and thousands of advocacy groups that forward this view, none more successful than the industry of the Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association.”

“Being labeled may result in attention only to characteristics that complement the label – a confirmation bias.”

“An individual functional analysis will typically reveal that behaviors, even those that appear bizarre and irrational ‘make sense.’   That is, there is a payoff for the client but at a high cost.”

“Stripping life’s trials and tribulations from their context is dehumanizing in understanding related experiences and potential remedies.”

“With the publication of the DSM 5, there is yet another opportunity for social work to think carefully about its role in promoting and being a handmaiden to a medicalized view of troubling, troubled, and very dependent behaviors. Social work has an inspiring history of attention to avoidable suffering and injustice—not just talking about it, but actively trying to reduce it.”

“The DSM shrinks rather than expands opportunities for freedom, growth, and dignity by obscuring the vast literature, which shows that behavior is influenced by the environment. If we accept the grand narrative of disease to understand behavior, we become architects of clients’ dehumanization as well as our own. By recognizing environmental circumstances, we can understand that behavior always makes sense.”

“A number of trends encourage use of a contextualized approach to understanding human behavior and avoidable suffering. One is the sheer excess of medicalization including deception and fraud on the part of the pharmaceutical companies and physicians and scientists…”

“It is time to wake up from our slumber in the arms of a medicalized psychiatry to recognize missed opportunities to help clients.”

Dr. Gambrill’s article embraces almost every facet of the current psychiatry debate.  Her arguments are cogent and clear, and her references are comprehensive.  The article is scholarly without being tedious.

Dr. Gambrill’s call to Social Workers, both in academia and in the field, to emancipate themselves from psychiatric dominance, and to focus more on alleviating distress by mitigating its true causes, will hopefully resonate widely.

I strongly encourage my readers to read this article and pass it on.

More Psychiatric ‘Myth’ Debunking

On July 15, I wrote a post called Psychiatry Debunks the ‘Myths.’  In that article I focused on the myth-debunking of Cognitive Psychiatry of Chapel Hill, but in researching the topic for that post, I came across a psychiatry resident named Shan (no last name) who blogs on a website called Exploratory Encephalotomy.

With regards to the name of the website, Dr. Shan explains on his About the blog page:

“…’exploratory encephalotomy’ implies opening up somebody’s brain in order to search for something.  To the best of my knowledge, it’s not a real medical procedure yet…”

On February 13, 2013, Dr. Shan posted an article titled 6 common misconceptions about psychiatryHere are four of his six myth debunkings interspersed with my comments.

“Myth: Psychiatrists treat and counsel people regarding their emotional problems

Psychiatrists are medical doctors who diagnose and treat medical illnesses that affect the brain and the mind.  These illnesses can often cause emotional problems (just like any other medical illness can cause emotional problems), but the psychiatrist’s role is to treat the illness, not to tell the patient how to deal with life concerns.  In fact, most psychiatrists try to avoid providing counseling, except as it relates to a patient’s medical therapy.

Psychologists and counselors, by contrast, may counsel people regarding emotional problems.  These professionals, however, are not medically trained, so they do not treat medical illnesses.”

Not much ambiguity there.  Standard bio-bio-bio-psychiatry.

“Myth: Psychiatrists talk to a patient about their deeper conflicts while they lie on a couch and face the other direction 

This process, known as psychodynamic psychotherapy, was invented by Sigmund Freud in the 1800′s.  Freud is famous because he was the first psychiatrist; however, his methods have very little evidence-based support.  In the modern age of evidence-based medicine, this approach has fallen out of favor.  In the middle of the 20th century, a group of scientists at Washington University in St. Louis started a charge towards an increase in evidence-based practice in psychiatry.  Since then, the psychiatry world has developed objective diagnostic systems and advanced treatment methods that involve pharmacological therapy as well as surgical/procedural therapy.”

The inaccuracies about Dr. Freud we can let go.  But in other regards, Dr. Shan is telling it like he’s been told:  “objective” diagnostic systems; “advanced” treatment methods including drugs, surgery (lobotomies?) and procedures (electric shocks?).

Myth: Psychiatric illnesses are caused by emotional conflicts

There was a time when it was widely believed that psychiatric illnesses are emotional in nature.  Modern advances in genetics have helped to disprove this notion.  We now know that a predisposition towards mental illness is largely influenced by your genetic makeup.  This can be exacerbated by mental stress, much like in most medical illnesses – for instance, if you have a strong family history of diabetes, you can prevent/delay the onset of the disease by eating well and exercising a lot, but that doesn’t change the fact that it’s a biological disease with biological consequences.”

There it is – “psychiatric illnesses” are real illnesses – just like diabetes: biological diseases with biological consequences.

Myth: Psychiatrists only treat crazy people 

This is false in the same way that the statement ‘cardiologists only treat failing hearts’ is false.  Most psychiatric patients have a genuine illness that is caused by a defective balance between different compounds in their brains (much like diabetes with insulin and sugar).  When that balance is corrected, they are no longer ill.  The illness may manifest as depression, anxiety, or a variety of other features that can make a person feel “sick,” but wont’ make them act ‘crazy.’

Other illnesses, such as mania and schizophrenia, may affect a person’s ability to function within societal norms, but we can usually treat them and allow the person to go back to their previous level of functioning.  This is a big change from the days of big “mental asylums” and the like – instead of hiding people who are just ‘crazy,’ we can now treat people who are ‘sick’ and allow them to go back to real life.  As a result of that, words like ‘crazy’ have become antiquated.”

Here we see clearly articulated the chemical imbalance theory, which the eminent psychiatrist Ronald Pies, MD, assures us that no well-informed psychiatrists ever promoted.  And we even have the assurance that when the balance is “corrected” – “they are no longer ill.”  (Corrected, presumably, by the drugs, the surgeries, and the other unspecified procedures.)

Obviously Dr. Shan has completely accepted, presumably from his med school teachers, the medical model of human distress.

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

To me, and I imagine to most of us on this side of the debate, the logical and evidentiary shortcomings of psychiatry are glaringly obvious.  I have often wondered how it is that people with sufficient intelligence to complete a medical degree not only don’t see through the fraud and the travesty, but actually embrace it with apparent fervor and dedication.

I realize, of course, that once a psychiatrist has been practicing for a number of years, the need to make a living can effectively eclipse any reservations he or she may have on the subject.  But it’s harder to understand why people, nearing the end of their medical training, who presumably have a wide range of choices, would set their sights on the only medical specialty that invents, rather than discovers, the “illnesses” that it treats.

Dr. Shan’s website provides, I think, some insights into this matter.  Here are some quotes.  The first is from the About page linked above.

“Soon after I started medical school, I found myself stuffing my mind into the proverbial box that I so detested in the past.  I surprised even myself at how quickly I’d acquiesced to the stringent rules of the medical field as they attempted to execute a subtle Machiavellian attack on my hopes to continue my young writing career.  Before long, I started to notice the gradual corrosion of the unique outlook that I’ve developed thanks to my scientific training combined with my interest in the social sciences and the amalgam of cultural settings around which I was reared.  This outlook was slowly being replaced by the guidelines of your favorite local medical board; in an attempt to ensure quality healthcare, those guidelines find a way to become ingrained into the medical student’s mind while extinguishing any iota of creativity and independent thought.”

And from a post Re-introduction, dated August 2012:

“I was soon to find out that medicine is not just a subject to study or a set of ideas to learn.  It is an entire frame of mind to which a student must adhere.”

“At first, I felt like a robot, relying entirely on the memory centers in my brain while completely disregarding any remaining smidgen of independent thought.  As optimistic as I may have been about the ultimate destination, it seemed like the journey asked for my humanity as a toll.  I began to come to terms with the idea that in order to be a Doctor, I must first cease to be a human.  I had to think in flowcharts, not ideas.”

“After a few years in medical training, I’ve finally started to understand where that outlook comes from: in the process of learning medicine, it is strikingly difficult not to let one’s mind turn into a hard drive.  It happened to me after a while too.”

In other words, if I’m reading Dr. Shan correctly, in order to become a physician, one has to switch off one’s own critical thinking ability, and accept the tablets of stone as handed down by the lecturers and professors.  This model may have some merit in the teaching of anatomy, physiology, etc., and even in the specialties like nephrology, cardiology, etc…  After all, there is a great deal of factual material to be learned, and a pedagogical approach is probably economical and effective.

But it is disastrous as a method of preparing people for a career in the alleviation of distress, despondency, painful memories, feelings of inadequacy, etc…

Whatever initial thoughts or orientations trainees might have, in order to become qualified in, and practice, psychiatry, they must internalize the illness mantra, the spuriousness of which is evident to anyone with an ounce of critical thinking.  They must dish out the pills.  And they must never question or challenge the orthodoxy.  They must never say that the Emperor has no clothes, because once that admission is made, the whole charade comes tumbling down.

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

Psychiatry doesn’t just damage its victims.  It takes its toll on the practitioners also.  A human being cannot internalize this nonsense and inflict it on his/her fellow travelers day in and day out for years on end, without doing profound violence to his/her own humanity.

Psychiatry Debunks the ‘Myths’

Psychiatry has always had its share of critics, but in the past two decades these criticisms have increased in frequency and intensity.  Psychiatry’s underlying concepts are being denounced as spurious to the point of inanity, and its practices are being accurately and forcefully exposed as destructive, disempowering, and stigmatizing.

Psychiatry has no rational or logical response to these criticisms.  Its leadership and its rank and file remain stubbornly blind to the arbitrariness and invalidity of its so-called diagnoses, the unquestioning adoption of which distorts their perceptions of people and their problems.

Psychiatrists no longer perceive childhood misbehavior as a problem that needs to be corrected through normal parental discipline and correction – but rather as a manifestation of a pediatric illness:  conduct disorder, or oppositional defiant disorder, or attention deficit/hyperactivity disorder, or disruptive mood dysregulation disorder.

They no longer perceive human despondency as the normal response to oppression, misery, poverty, discrimination, victimization, overwork, or an empty, purposeless lifestyle, – but rather as major depressive illness.  They have convinced themselves that they can treat, and even cure, depression by tinkering irresponsibly with people’s internal chemistry, while blithely ignoring the circumstances and context that created and maintain the negative feelings.

Painful memories, with which the human species has dealt successfully since we were hunter gatherers on the plains of Africa, are now also illnesses which can, by some amazing coincidence, also be cured by tinkering with people’s internal chemistry.

Psychiatrists betray no trace of insight into the fact that they “see” these illnesses because of their dogmatic conviction that they exist, in the same way that the early microscopists “saw,” and even drew pictures of, homunculi in human sperm.

Psychiatrists, enthralled as they are in their own self-congratulatory rhetoric, are blinded to the obvious reality that giving people the false message that they are damaged, and need to be “treated,” by psychiatrists for problems that previous generations took in their stride, is inherently crushing and disempowering.  Falsely telling people that they are broken, breaks them.

Humanity is so much more than the crippled caricature of helplessness and dependency that psychiatry has self-servingly invented, and which, with pharma promotion, is tragically becoming the norm for countless millions of people worldwide.

And psychiatry has no defense.  They hitched their wagon to pharma decades ago.  They willingly and knowingly became drug pushers, no different in essence from those that work the street corners, and they developed an elaborate web of rationalizing deceptions from which there is no way out.  All they can do now is find new ways to promote their spurious doctrines and, of course, to regurgitate their criticisms of those of us who dare to speak out against their sacred scriptures and their shameless “treatments.”

A standard part of the latter endeavor is the contention that all criticisms of psychiatry are myths, and, on a fairly regular basis, one of their number undertakes to “debunk” these “misguided” notions.

On June 19, 2014, Cognitive Psychiatry of Chapel Hill (CPCH) published 10 Common Myths About Psychiatry.  From their website, it would appear that CPCH consists of two psychiatrists:  Jennie Byrne, MD, PhD, and Nicola Gray, MD.  Both Drs. Byrne and Gray are published and widely experienced, and I think by any conventional standards would be considered well-informed and knowledgeable psychiatrists.

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

Here are some of the myths that they “debunk,” interspersed with my comments.

“Mental Illness Diagnoses Are Labels For Normal Behavior
We have been asked quite often over the years, where Psychiatrists draw the line between normal behavior and mental illness. Where someone who is a little shy, becomes a case of anxiety, or where someone who gets sad, has depression. Much like a benign tumor, vs. cancer, we determine a diagnosis when the behavior becomes debilitating and the patient can no longer go about their daily lives as they have in the past.”

This particular “debunking” is standard DSM fare.  A problem becomes a mental illness when it causes either:

a) significant distress

or

b) significant disability in social, occupational, or other important activities.

There are two problems with this definition of a mental illness.  Firstly, there is no reliable way to assess the term “significant.”  A “diagnosis” of “mental illness” always and inevitably hinges on the subjective judgment of a psychiatrist, who, incidentally, always has a vested interest in the outcome.  Secondly, a problem that is not an illness doesn’t become an illness simply by becoming more severe.  The only human problems that are illnesses are those that entail biological pathology.  This is what the word “illness” means!  Apart, obviously, from those conditions labeled “due to a general medical condition,” no psychiatric diagnosis has been definitively linked to a biological pathology.  In the words of Thomas Insel, MD, Director of NIMH, DSM is “…a dictionary, creating a set of labels and defining each.”  It is emphatically not a list of illnesses.

. . . . . . . . . . . . . . . . . 

Psychiatrists Will Force Medication On You
Every patient is different, as are his or her needs. A good Psychiatrist will never force medications on their patient. Patients should have a treatment that is completely unique to them, and a practiced Psychiatrist will work with them to find that exact treatment they need.”

This is not only false, but is also, I suggest, offensive to the millions of people worldwide who have been committed to mental hospitals and forcibly drugged.  Unless, of course, Drs. Byrne and Gray are saying that only bad psychiatrists engage in that sort of practice?  “Psychiatrists will force medication on you” is certainly not a myth.  Note the spelling of psychiatrist with a capital P!

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

Psychiatry Only Involves ‘Crazy’ People
Actually, the majority of patients we see have an actual illness or imbalance (much like diabetes), that with the proper treatment, the imbalance is corrected and they are no longer ill…”

This is the old, never-confirmed-and-in-fact-much-refuted-chemical-imbalance-theory that, according to the confident assertions of the eminent psychiatrist Ronald Pies, MD, was never subscribed to or promoted by any well-informed or knowledgeable psychiatrists.

Well, the spurious, simplistic theory is still very much alive, at least in Chapel Hill, NC.  Note even the “much like diabetes” deception, and the sheer intellectual effrontery:  “…with the proper treatment, the imbalance is corrected and they are no longer ill.”

This is particularly troubling in that there are no psychiatry-pharma products that correct any neural imbalance of any kind.  All psychiatric drugs are neurotoxins that produce their effects by creating a pathological state within the brain.  The quote is even more troubling, in that it is clearly aimed at potential clients, and as such constitutes recklessly false advertizing.

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

And in case there is any doubt as to CPCH’s intended meaning:

The Mentally Ill Will Never Recover
As we discussed in our 3rd myth, many patients that see a Psychiatrist actually have an illness or imbalance that is causing a mental discrepancy. Once this imbalance is corrected, they are, in fact, cured of their mental illness. However, there are still some cases that involve life-long treatment and monitoring.”

So, the “mental discrepancy” is caused by an imbalance, which can be “corrected” by psychiatrists, which effects a “cure.”  Perhaps Dr. Pies needs to pay a visit to Chapel Hill.

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

Mental Illness is Uncommon
This is one myth we wish were true. However, one in every five Americans will be diagnosed or touched by a mental illness in their lifetimes, according to the National Institute of Mental Health.”

Again, this is standard psychiatric fare, though they’ve got the numbers wrong – it’s fully 50% of us poor, broken, disempowered Americans who will be “diagnosed with mental illness” in our lifetimes.  The one in five figure is the official prevalence at any given point in time!

Of course, the reason these prevalence figures are so high is because for the past sixty years, psychiatry has steadily expanded its “diagnostic” net by two simple expedients: increasing the number of “mental illnesses”; and lowering the thresholds for each.  Unlike real medicine, psychiatrists don’t discover their illnesses, they just decide, usually by a vote, that a problem that hitherto had been one of the ordinary challenges of life is now, by psychiatric fiat, an illness.  This is disease-mongering without even a pretense of legitimacy.

. . . . . . . . . . . . . . . . 

Psychiatric Drugs Will Change Your Personality
Any medication out there can cause negative effects for a patient if taken too long or given the wrong dosage. The way we see it, is this; if someone with depression overcomes it through their medication, their personality will be changed, yes – they will be free from negative thoughts, anti-social behavior, and feelings of defeat, which is a definite change in personality – a positive change. The same can be said for an illness like Schizophrenia, with the right treatment plan, their minds will become less consumed by hallucinations, delusions, and irrational anxieties – another healthy and positive personality change.”

Note the implication, which is, incidentally, false, that negative effects only occur if the drug is taken for “…too long or at the wrong dosage.”  And then the spin:  antidepressants liberate the user from negative thoughts, anti-social behavior (Department of Corrections take note), and feelings of defeat.  And the glorious prospect for people suffering from the “illness” called schizophrenia, if they follow the “right treatment plan” (and I wonder what that would be): their craziness will fade like a morning mist under a summer sun – “another healthy and positive personality change.”  What planet do these psychiatrists live on?  Have they ever even seen a person ravaged by tardive dyskinesia or akathisia?

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

But it gets worse.  On June 27, Psychiatric Times linked on their Facebook site to the 10 Common Myths article by CPCH.  Here’s what Psychiatric Times said:

“There are many stigmas out there regarding Psychiatry, both good and bad.  Today, Cognitive Psychiatry will debunk 10 myths revolving around their practice.”

I can’t even imagine what’s meant by “…stigmas…both good and bad…”.  But setting that aside, it is clear that Psychiatric Times is endorsing CPCH’s efforts at myth debunking, and is also, presumably, endorsing the contents of the article – chemical imbalances (just like diabetes), and all.

And who, or what, one might ask, is Psychiatric Times?

Here’s what Wikipedia says:

“Psychiatric Times is a medical trade publication written for an audience involved in the profession of psychiatry.”

“Psychiatric Times was first published in January 1985 as a 16-page bimonthly publication. It was founded by psychiatrist John L. Schwartz and originally edited by Ronald Pies.” [Emphasis added]

On Psychiatric Times’ home page there’s a link called “Editorial Board.”  It you open this you’ll see that the second name on the list is none other than the very eminent psychiatrist Ronald Pies, MD.  He is also listed as one of the three editors-in-chief emeriti.

And this is the same Dr. Pies who described the chemical imbalance theory as “…a kind of urban legend – never a theory seriously propounded by well-informed psychiatrists.”

Well, as an “urban legend,” it’s proving remarkably resilient.  And it’s proving resilient because it has indeed been promoted by psychiatrists.  And it is still being promoted by psychiatrists, including, at least in this instance, the Psychiatric Times editors.

On one matter, however, I am in complete agreement with Dr. Pies.  The psychiatrists concerned are definitely not well-informed.

‘ADHD’ and Dangerous Driving

In 2006, Laurence Jerome, a Canadian psychiatrist, and two colleagues wrote a paper titled What We Know About ADHD and Driving Risk: A Literature Review, Meta-Analysis and Critique.  It was published in the Journal of the Canadian Academy of Child and Adolescent Psychiatry in August, 2006. The primary result of the meta-analysis was:

“Current data support the utility of stimulant medication in improving driving performance in younger ADHD drivers.”

The study is lengthy and well-referenced, but in keeping with standard psychiatric practice, it conceptualizes and presents ADHD as a “…common psychiatric disorder…” with symptoms of “…inattention, impulsiveness and hyperactivity…”  In other words, they present ADHD as something that a person has rather than as something that a person does. The problem with this approach is that it creates the impression that meaningful or significant correlations/effects have been found, where in fact all that has happened is an elucidation of the terms used.

For instance, the authors refer to a study by Fried et al. (2006) and state:

“Fried et al. (2006) evaluated driving behavior using the DBQ [Driving Behavior Questionnaire] and found that the ADHD group had significantly more lapses, errors and violations than controls.”

On the face of it, this looks like an interesting finding.  It purports to be an important fact that has been discovered about people who have this condition.  But in reality, lapses, errors, and violations are an integral part of the definition of ADHD.  The DSM criteria includes:  careless mistakes; difficulty remaining focused; mind seems elsewhere; easily distracted; forgetful; etc…  One doesn’t get into this group in the first place without a history of habitual lapses, errors, and violations.  The fact that these habitual lapses and errors carry over into a person’s driving behavior isn’t particularly surprising.

There are several other examples of this in Jerome et al., e.g.:

“A number of studies examined cognitive abilities associated with safe driving performance. Measures of both inattention and impulsivity were found to be higher in the ADHD groups as compared to controls.”

Here again, inattention and impulsivity are defining features of the condition labeled ADHD.  All that has actually been found here is that people who are inattentive and impulsive are inattentive and impulsive! The study reports that people who carry a “diagnosis” of ADHD are involved in more collisions, and receive more traffic citations than controls.  This is interesting, but again, hardly surprising for the reasons discussed above.  One could look at all this simply as benign, meaningless verbiage, but in reality, the constant repetition of these factoids reinforces the notion that the label ADHD refers to a real illness, and that this “illness” has real sequelae, in the same way that kidney failure, for instance, usually entails edema and anemia.

EFFECTS OF PSYCHOTROPIC DRUGS

The authors discuss several studies on the effects that stimulant and non-stimulant drugs that are used to “treat” ADHD have on driving behavior.  The results were mixed.  The authors draw attention to some methodological problems in this area and also concede that “…all currently available studies are industry sponsored.”

NEUROLOGY

Dr. Jerome et al. posit a neurological deficit as the source of the impulsivity and inattention.

“Core functional impairments in executive function related to response inhibition, working memory and flexible strategic response help explain both general ADHD pathology and its specific manifestations in problem driving in this group.”

This paper, as noted earlier, was written in 2006.  Note the cautious language in the quote above:  “…help explain…”  Today, eight years later, there’s still no definitive neural pathology known to be causally associated with these problem behaviors, and the “illness” is still being “diagnosed” by subjectively assessing, and counting, the individual’s actions.  In fact, and this is particularly compelling, the American Academy of Child and Adolescent Psychiatry in its current practice parameters for ADHD state unambiguously that unless there is a clear history of severe head injury, or other neural pathology

“…neurological studies…are not indicated for the evaluation of ADHD.” [Emphasis added]

At this point Dr. Jerome et al. make the great leap of faith:

“…it was not the knowledge base of driving skills that differentiated the driving problems in ADHD youth so much as their inability to apply these rules at the appropriate time and under the appropriate circumstances. In other words the problem is an output problem; they can ‘talk the talk but they can’t walk the walk’.” [Emphases added]

Note the words “inability” and “can’t.”  This is one of the fundamental problems in the “diagnosis” of ADHD and other psychiatric “illnesses” – the logically flawed leap from “doesn’t” to “can’t.”  And this unwarranted leap is the basis for the conclusion that the individuals in question have an illness, and, in extreme cases qualify for disability.  A person with kidney failure doesn’t and can’t produce urine.  But a person “with” ADHD can, with proper training, learn to behave in a more attentive and less impulsive manner.

In former times, children who were routinely inattentive and impulsive were considered to be in need of training and discipline.  By and large, school teachers and parents provided this.  In fact, the training was usually provided before the matter even became an issue.  Today these children are spuriously and arbitrarily labeled as ill, and are given pills.  The pills suppress the problem behavior, but in many, perhaps most, cases the underlying problem of self-discipline is never addressed.  So these children grow up and, not surprisingly, they become inattentive and impulsive drivers, with a reportedly 50% increased risk of negative driving outcomes.  The “diagnosis” of “illness” contains within itself the disempowering, and incidentally false, message that the individual was incapable of acquiring the level of discipline, attention, and self-control needed for successful classroom participation.  Psychiatry has given these parents, and the children themselves, the false message that their brains are malfunctioning, that the pills will correct the problem, and that attempts to teach discipline and self-control in the normal manner are futile.  With pharma-psychiatry’s successful expansion of this “diagnosis” to the adult population, the disempowerment has become a more-or-less permanent “disability.”

The role that the initial “diagnosis” and subsequent drugging played in transforming what used to be an eminently remediable problem into a permanent disability is seldom addressed or even acknowledged.  The psychiatric fiction has to be maintained:  these individuals were “sick” as children and are still “sick” as adults.  Their inattention and impulsivity are still “symptoms” of the same debilitating “illness.”  Psychiatrists for the past sixty years have insisted that they are discovering real illnesses.  They remain self-servingly blind to the fact that, firstly, they invented these illnesses, and secondly, that their active promotion of these “illnesses” has created a culture in which personal effort and self-discipline are routinely marginalized in favor of the spurious and inherently disempowering notion of pharmaceutically correctable impairments.

Jerome et al. do pay passing acknowledgement to the need for “psychological strategies,” but it is clear that they conceptualize the matter as a medical problem with a pharmaceutical remedy:

“Experimental studies indicate that stimulants and to a lesser extent non-stimulant drugs used to treat ADHD improve areas of driving performance.”

These, incidentally, are the same industry-sponsored studies mentioned earlier.

and

“In particular the question of adherence to medication regimens over time to improve driving skills is likely to be a critical question based on our knowledge of poor long-term medication adherence for young adults with ADHD.”

and

“The individual attending physician has an opportunity to reduce morbidity and mortality for the individual ADHD patient as well as contribute to improved public health for the driving population at large by making the roads safer one driver at a time.”

and

“A number of jurisdictions including Canada and UK now require physicians to report ADHD drivers thought to be at risk of problem driving to the Ministry of Transportation.”

and

“The question of medico-legal liability is in its infancy with no established case law for physicians found negligent of failing to adequately treat ADHD patients with the appropriate medications to reduce driving risk. Whilst the available literature does not yet provide clear evidence that stimulant medication should be the standard of care for problem drivers long term, it is probably only a matter of time before this question will be debated in a legal arena.”

DISCUSSION

At the present time the pharma-psychiatric system is being widely exposed as the spurious, destructive, disempowering fraud that it is.  Organized psychiatry is responding to these criticisms not by cleaning up its act, but instead by increasing its lobbying activity in the political arena.

In particular, they are actively promoting the notion of involuntary community “treatment” with coerced “medication.”  Under this system, which is established by law in more than 40 US states, a judge can order an individual to attend the local mental health center and to abide by the center’s “treatment” plan.  The plan usually entails a requirement to take psychiatric drugs, sometimes the long-lasting injectable variety.  Here’s how Jeffrey Lieberman, MD, President of the APA, describes the program:

“There’s also other forms of psycho-social treatment that are very, very helpful. Sometimes people who have schizophrenia don’t want treatment, or don’t feel they need treatment, or just plain forget about treatment. In those cases, with what’s called assertive community treatment, a case manager or somebody that’s assigned to work with that person will go out to find them, will go to their home, you know, ‘You haven’t come to the clinic, you haven’t come to the office, you haven’t shown up, what’s going on here, you need to get your medication, you need to go through your rehabilitation,’ so they’ll get after them.”

This all sounds very cozy and friendly, and you know – come on down to the mental health center, you know, we care about you, etc., etc… But within the silk glove, there’s the mailed fist of confinement and coerced drugging.  Readers can check out the other side of the story at National Coalition for Mental Health Recovery, PsychRights page on OutPatient Commitment, and by searching for assertive outpatient commitment on Mad in America.  Dr. Lieberman is talking about people labeled with schizophrenia, but it doesn’t take too much imagination to see how the concept could be adapted to a wide range of other “diagnoses,” including ADHD.

As of yet, the ominous prediction in the final Jerome et al. quote above has not come to pass.  But is the day approaching when individuals “diagnosed” with ADHD during childhood will be subjected to special screening when they apply for a driving license?  Might their licenses be made contingent on their ingestion of psychoactive drugs?  After all, impulsive, inattentive drivers constitute a danger to themselves and others.  If, as psychiatry claims, their impulsivity and inattention are the result of a “mental illness,” then doesn’t it make sense that they be committed?  Isn’t it in their own interests and the interests of the public at large that they be coerced to take their “medications”? Such a move would be consistent with psychiatry’s long-standing expansionist agenda and with pharma’s objective to sell more drugs.

And lest my concerns be considered groundless speculation, here are some interesting quotes.

From Oren Mason, MD, a blogger physician, co-owner of Attention MD, and associate professor at Michigan State University.  He specializes in the “…diagnosis and management of attention deficit disorders and related conditions” (Ritalin Saves Truckers’ Lives. Soccer Moms’, Too, February 2014):

“There is a public health issue when inattentive or impulsive behaviors occur on busy, public streets and highways.”

and

“…we could potentially prevent 100,000 injuries and deaths every year with consistent use of ADHD medications.”

Incidentally, according to Dollars for Docs, Dr. Mason received $208,459 from Eli Lilly for speaking, consulting, travel, and meals between 2009 and 2012.

And from Brian Krans, an assistant editor at HealthLine News (Could Ritalin Be the Way to Keep Truckers Safe on the Road? January 2014):

“Another new study says that undiagnosed attention-deficit hyperactivity disorder (ADHD) may be the cause of many safety issues for drivers on the road.”

Note how ADHD has become the cause of the problem behaviors, rather than just another name for them.

and

“… research shows that medications like Ritalin and Adderall may be beneficial to help them increase reaction time [presumably should read decrease], reduce accidents, and ultimately save lives.

Interestingly, Healthline.com runs a good many ads for ADHD “medications.”  They are clearly marked Advertisement, but the font is very small.

and

“So, should truckers be screened for ADHD instead of self-medicating with harder drugs?”

There is an implication here that ADHD “meds” will reduce the incidence of truckers driving under the influence of speed.  In fact, Ritalin and most other ADHD “meds” are stimulants and are widely abused.  RitalinAbuseHelp.com states that

“Ritalin is taken by recreational drug users for its cocaine-like high.”

and

“Ritalin is taken by workers such as truck drivers to stay awake for long shifts.” [Emphasis added]

Here are some more interesting quotes:

From the American Academy of Pediatrics 2011 practice guidelines on ADHD:

“Given the inherent risks of driving by adolescents with ADHD, special concern should be taken to provide medication coverage for symptom control while driving.  Longer-acting or late-afternoon, short-acting medications might be helpful in this regard.”

And from the American Academy of Child and Adolescent Psychiatry: ADHD Practice Parameters:

“Single daily dosing is associated with greater compliance for all types of medication, and long-acting MPH [methylphenidate] may improve driving performance in adolescents relative to short-acting MPH…”

And from psychologist Russell A. Barkley, PhD, Clinical Professor of Psychiatry and Pediatrics at the Medical University of South Carolina in Charleston, and author of numerous books and studies on ADHD, quoted in this New York Times article from 2012:

“Medication [for drivers who have ADHD] should not really be optional…”

And Dr. Barkley is an eminent man.  I know this because on his website it says that he is “…an internationally recognized authority on attention deficit hyperactivity disorder (ADHD or ADD) in children and adults…”  I also know that he is conscientious and caring.  His website states that he “…has dedicated his career to widely disseminating science-based information about ADHD.”  If proof is needed of his dedication to disseminating information, one need only open the “books” tab on his website.  He has 16 different titles for sale at prices ranging from $14.41 for some paperback book versions to $131.75 for his rating scale books.  One can also subscribe to his newsletter ADHD Report for $105 per year.

Dr. Barkley is well regarded by the pharmaceutical industry.  Dollars for Docs reports that between 2009 and 2012, he received $120,283 from Eli Lilly alone, for consulting, speaking and traveling.  In February of this year he conducted a five-day, multi-city lecture tour of Japan sponsored by Eli Lilly.  And according to  his CV, in 2004-2005, he was awarded a grant of $99,750 from Eli Lilly to study the “Effects of atomoxetine on driving performance in adults with ADHD.”

Dr. Barkley has also reportedly served as a consultant/speaker to Shire, Medice, Novartis, Janssen-Ortho, and Janssen-Cilag.

Dr. Barkley played a significant role in the relaxing of the age-of-onset criterion from 7 to 12 in DSM-5.  As early as 1997, he and the equally eminent Joseph Biederman, MD co-authored Toward a Broader Definition of the Age-of-Onset Criterion for Attention-Deficit Hyperactivity Disorder (Journal of the American Academy of Child and Adolescent Psychiatry, September 1997).  In this article they state, apparently without the slightest hint of irony:

“We can see no positive benefits of the recommended AOC [age of onset criterion] except that it would certainly limit the number of children (and probably adults) with diagnosed ADHD.  Some special education districts or managed health care companies who might wish to restrict the access of those with ADHD to their services could conceivably see such a restriction as advantageous, but this is purely financial self-interest.”

So, all things considered, when Dr. Barkley tells a New York Times reporter that medication for drivers with ADHD “should not really be optional,” perhaps we should be concerned.

Over the past 60 years, pharma-psychiatry has demonstrated, time and again, that there is no human problem that they can’t exploit for their own benefit and, in the process, make ten times worse.  I will be watching this latest foray into road safety with trepidation.

Thomas Szasz Refuted: I Don’t Think So!

On February 28, Awais Aftab, MD, a psychiatrist working in Qatar, published an interesting article on Psychiatric Times.  The article, which is titled Mental Illness vs Brain Disorders: From Szasz to DSM-5, is an attempt to validate the concept of “mental illness” and, in particular, claims to refute the position of the late Thomas Szasz, MD, that mental illness is a spurious concept.

The validity or otherwise of the concept of mental illness is fundamental to psychiatry’s claim to legitimacy, and for this reason, Dr. Aftab’s article deserves close scrutiny.

AD HOMINEM

Dr. Aftab opens with a veiled ad hominem attack on Dr. Szasz:

“Thomas Szasz was a lifelong ferocious critic of the institution of psychiatry.”

 Dr. Szasz was indeed a critic of psychiatry, but the term “ferocious” conjures up images of irrationality and viciousness which were not characteristic of his presentation.  In addition, by counterposing the term “ferocious” with the term “institution of psychiatry,” Dr. Aftab has managed to create the impression of a mad dog snapping at the heels of a benign old gentleman.

This is hardly an auspicious start to what purports to be a discussion of fundamental principles.  But there’s more:

 “Although most psychiatrists remain unconvinced of his arguments, Szasz has been very influential by virtue of being psychiatry’s arch-adversary.”

 Here again, Dr. Aftab has sneaked in a significant falsehood and a subtle emotional distraction.  The fact is that Dr. Szasz was, and posthumously still is, very influential, because he presented sound, logical arguments in a convincing manner.  The impression that Dr. Aftab gives us, however, is that Dr. Szasz is influential just because he attacked psychiatry.  And doesn’t the term “arch-adversary” have subtle overtones of Professor Moriarity – the evil nemesis of the rational and infallible Sherlock Holmes?

MIND-BODY DUALISM

Dr. Aftab argues that Dr. Szasz’s rejection of the concept of mental illness is outdated, and therefore moot.

“Szasz’s argument goes awry when applied to our current understanding of mental disorders.  First, the concept of disease is not restricted to the presence of a physical lesion; second, the term ‘mental disorder’ is now conceptualized in a manner that transcends mind-body-dualism.”

So essentially, Dr. Aftab is saying that Dr. Szasz’s challenge may have had some validity in the old mind-body dualism days, but that those days are gone, and psychiatry today is on a much firmer and more valid footing.  This is because:

 1.  “the concept of disease is not restricted to the presence of a physical lesion”

 and

 2.  the current concept of mental disorder “transcends” mind-body dualism.

 This is uncomfortably vague, but Dr. Aftab elaborates:

 “For the most part, disease is understood largely in terms of suffering and functional impairment, which may or may not be associated with a structural lesion.  R. E. Kendell explains this view succinctly:…’For most of human history disease has been essentially an explanatory concept, invoked to account for suffering, incapacity, and premature death in the absence of obvious injury, and suffering and incapacity are still the must fundamental attributes of disease.’

Once we conceive of disease in terms of substantial or enduring states of suffering and incapacity, we are justified in applying it as a label to conditions in which disturbances in cognition, emotion, or behavior are associated with distress and impairment.”

This is the essential kernel of Dr. Aftab’s position.  So let’s take a closer look.

“For the most part, disease is understood largely in terms of suffering and functional impairment, which may or may not be associated with a structure lesion.”

The first question that arises is:  “understood” by whom?  I suggest that for most people, including physicians, the presence of an underlying causative pathology is an essential component of disease.  When physicians, other than psychiatrists, talk about disease, they are talking about underlying causative pathology.  Certainly they are concerned with “suffering and functional impairment,” but when, after exhaustive investigation, they are unable to establish the presence of any organic lesion or pathology, they will frequently assert that the individual isn’t really ill.  Usually in these cases, a referral is made to a psychiatrist, the clear implication being that psychiatrists treat people who aren’t really sick.

The notion that suffering and functional impairment, in and of themselves, constitute disease is the Ronald Pies argument, the details of which I’ve discussed and challenged elsewhere.

Interestingly, Dr. Aftab’s article, as mentioned earlier, is published in Psychiatric Times, which has until recently been edited by Dr. Pies.  Neither Dr. Pies or Dr. Aftab presents any argument in support of the notion – they simply assert it to be so.  Habitual thoughts, feelings, or behaviors that result in suffering and functional impairment are illnesses – because we say so.  To which I suppose there’s the implied rider:  And we’re psychiatrists, so it must be true.

Dr. Aftab seems to believe that the passage from the late Dr. Kendell clinches the matter.  So let’s take a look at the quote:  Disease, Dr. Kendell tells us, is an explanatory concept.  In other words, it provides us a way of understanding suffering, incapacity, and premature death in the absence of obvious injury.  None of this is contentious.  If a person is extremely tired and is coughing up dreadful-looking stuff, a physician might listen to his lungs, run some tests, perhaps take an X-ray, and diagnose pneumonia.  Pneumonia – an infection of the lung – explains the suffering and the incapacity.  Similarly, exhaustion, accompanied by edema and elevated creatinine and electrolytic levels, might be the result of kidney failure.  The point is that the pathology (i.e. the lung infection and the kidney failure) cause the symptoms.

This conceptual framework is the very paradigm of modern medicine.  Certainly there are cases in which the treating physicians are unable to ascertain a cause, but that in no way detracts from the general notion that the discovery and amelioration of underlying pathology is the defining feature of successful medicine.

But back to Dr. Kendell’s quote:  “…suffering and incapacity are still the most fundamental attributes of disease.”  He began by stating that disease (and presumably specific diseases) are explanatory concepts, i.e. they explain suffering and incapacity.  But, he continues, suffering and incapacity “are still the most fundamental attributes of disease.”  This is simply contradictory.  Take the pneumonia example.  The symptoms are caused by the pathology.  That’s what we mean when we say that the diagnosis has explanatory value.  By any ordinary use of the terms, the pathology is more fundamental than the symptoms.  The symptoms may be more obvious.  They may be the paramount consideration from the sick person’s perspective, but they are emphatically not “the most fundamental attributes” of a disease.  A cause is, by definition, more fundamental than its effect.

Nevertheless, Dr. Aftab concludes from this false and contradictory statement:

“Once we conceive of disease in terms of substantial or enduring states of suffering and incapacity, we are justified in applying it as a label to conditions in which disturbance in cognition, emotion, or behavior are associated with distress and impairment.”

In other words, we (psychiatrists) have decided that the essential meaning of the word disease is an habitual thought, feeling, or behavior that causes distress and impairment.  And because we say so – therefore it must be so.  And therefore, all the problems that we address are illnesses.

And that’s all there is to it.  All significant problems of thinking, feeling, and/or behaving are illnesses, because we say so.  Ultimately it always comes down to this.  Psychiatrists routinely dress this kind of spurious nonsense in confusing verbiage, but if you cut away the chaff, the kernel is always the same. 

Dr. Aftab seems to be under the impression that calling problems of thinking, feeling, and/or behaving illnesses has some explanatory value.  The “logic” presumably goes like this:  any kind of suffering and functional impairment, even in the absence of organic pathology, is an illness. So if a person so afflicted asks why he is suffering and functionally impaired, the correct answer (i.e. the explanation) is: because you have an illness.  But the only justification for conceptualizing the suffering as an illness is because psychiatrists, including Dr. Aftab, have arbitrarily and, I suggest, misleadingly chosen to call these problems illnesses.  The notion that one can explain human emotions and actions by assigning labels makes a mockery of genuine scientific enquiry. 

Imagine, by way of analogy, that a physicist, asked why it is that light can pass through glass, replied: because glass is transparent!  That is psychiatric logic. 

Having “established” that mental illnesses are real illnesses (because psychiatrists say so), Dr. Aftab continues his narrative:

“Although the terms ‘mental illness’ and ‘mental disorder’ are still used, the manner in which they are understood is very different from the old psychoanalytic view (and for that reason many psychiatrists argue that the terms should be abandoned).  The notion of mental illness as distinct and divorced from the notion of a biological disorder reflects a dualistic understanding of the mind-body relationship, a dualism that has become increasingly untenable given the advances of neuroscience.  While it may be true that in the 1950s, when Szasz came up with his critique, this particular dualistic understanding of mental illness was in fashion, psychiatrists have long abandoned such a view.  Szasz failed to appreciate that in his critique and held on to his original position until his death in 2012.”

Here again, there’s a lot of convoluted language which needs to be unraveled.  What Dr. Aftab is saying is that Dr. Szasz’s rejection of the term “mental illness” was based on a mind-body dualism philosophy that was current in the 50’s.  But, he tells us, psychiatry moved away from this antiquated thinking long ago, so Dr. Szasz’s criticisms no longer apply.  And poor, naïve Dr. Szasz flogged away at this dead horse for the remainder of his days.

But, as was the case in the earlier passage quoted, it is Dr. Aftab who is missing the point.

“Mind” is a spurious concept with no explanatory value.  It was adduced by the ancients to explain the phenomenon of thinking.  Their “logic” can be exemplified in the following hypothetical conversation:

Q:  Why is it that man can think?
A:  Because he has a mind.
Q:  How do you know he has a mind?
A:  Because he can think.

We use the term “mind” in common speech to refer to cognitive and emotional activities, but there have been very few serious thinkers in modern times who have attached any ontological or explanatory significance to the concept.

And this includes the psychoanalysts!  Freud believed that he was treating repressed emotions; Adler, feelings of inferiority; Harry Stack Sullivan, interpersonal relationships, Karen Horney, parental indifference; etc.  Even the first DSM (1952) betrays no adherence to a mind-body dualism.  For instance, under the heading “Definition of Terms” it states:

“…a psychotic reaction may be defined as one in which the personality, in its struggle for adjustment to internal and external stresses, utilizes severe affective disturbance, profound autism and withdrawal from reality, and/or formation of delusions or hallucinations.” (p 12)

There is no hint of mind-body dualism in this definition.  So the notion that Dr. Szasz was tilting at a long-dead ghost is simply not factually accurate.

Indeed, Dr. Aftab’s own words contradict this assertion:

“If the conditions we call mental illnesses are not diseases, then what are they?  Szasz argues that they are in fact problems in living, human conflicts, and unwanted behaviors.  ‘Psychiatrists are not concerned with mental illnesses and their treatments.  In actual practice they deal with personal, social, and ethical problems in living.'”

What could be clearer?  The quote from Dr. Szasz above refers to personal, social, and ethical problems in living.  Here again, there is no hint of anything mystical or nebulous – nothing that could be remotely construed as stemming from dualistic philosophy.  And yet, a few paragraphs later, Dr. Aftab writes:

“Szasz treats the concept of mental illness very literally as being purely a disease of the mind (and thereby an impossibility).”

This notion, that we mental illness deniers are arguing from a dualistic framework, is a common theme among psychiatric polemicists.  I have written on it here, here, and here.  But let me restate the matter yet again.

Psychiatry’s decision to call all significant problems of thinking, feeling, and/or behaving illnesses is arbitrary.  It is a labeling process with no ontological underpinning and no explanatory value.  It is also misleading, because the term “illness” already had a perfectly clear meaning before psychiatry commandeered it for its own purpose.  The reason for the commandeering was to convey the false impression that the subject matter of psychiatry is in fact real illness – “just like diabetes.”  The spurious medicalization of these problems is also used to justify the prescription of neurotoxic chemicals and neurotoxic electric shock treatment.

There is no suggestion of mind-body dualism in any of this.  On the contrary, it’s just Logic 101:  identification and criticism of spurious reasoning.  And the object of our criticism – the spurious medicalization of all significant problems of thinking, feeling, and/or behaving is, if anything, more pronounced and widespread today than it was during the 1950s.

Dr. Aftab continues by trotting out all the usual DSM pre-emptive disclaimers:  no definition of a mental disorder can be entirely satisfactory; the distinction between mental and physical is not tenable; there is much mental in physical and physical in mental; boundaries between specific diagnoses are difficult to specify, etc…

Then he throws out the gem:

“‘Mental disorder’ continues to be used because there is no appropriate substitute for it.”

This is almost a straight quote from DSM-IV, p xxi:

“…the term [mental disorder] persists in the title of DSM-IV because we have not found an appropriate substitute.”

And this is the great psychiatric falsehood.  There is a perfectly acceptable substitute.  Significant problems of thinking, feeling, and/or behaving could be called:  significant problems of thinking, feeling, and/or behaving.  If the APA, or Dr. Aftab, were sincerely looking for a label that accurately reflected the subject matter, that, or something similar, would work perfectly well.

The reason they don’t do that, however, is because they cling – like drowning men to life rings – to the spurious notion that these problems are illnesses – medical entities –because it is only through that absurdly transparent ruse that they can continue to claim competence in the field and go on justifying the destructive and ineffective treatments that they inflict on the people who come to them for help.  The only thing that psychiatrists know how to do is dish out drugs.  So they need a conceptual framework to justify this activity and to maintain the fiction that it is fundamentally different from ordinary street-corner drug-pushing.

Dr. Aftab draws his paper to a close by scrutinizing the DSM-5 definition of a mental disorder.  This definition, incidentally, is essentially the same as DSM-IV’s, with two important differences.  Firstly, the newer definition allows the possibility that the problem may have a biological underpinning (something that was not included in the DSM-IV definition).  And secondly, the definition is markedly broadened, in that, while the earlier one required either distress, disability, or risk of significant loss, the DSM-5 definition merely states that the problem is usually associated with these kinds of adversities.

Dr. Aftab now focuses this new definition of mental illness on the condition known as schizophrenia.  He contends that this condition is now known to have many neurobiological abnormalities.  He points out that Dr. Szasz had frequently made the obvious point that if a problem of living were found to be caused by neural pathology, then it would be a brain illness.  Dr. Aftab then poses the question:  now that we know that schizophrenia is caused by neurobiological abnormalities (a spurious contention, incidentally, but one which for our present purposes, we can let go), should it cease to be regarded as a mental illness and become, simply, a neurological illness.

And this is where we descend into tragi-comedy.  We can, Dr, Aftab assures us, confidently continue to conceptualize schizophrenia as a mental illness “…because the conception of mental disorder has expanded to include biological dysfunction within its scope.”  (This is a reference to the possibility of a biological underpinning in the DSM-5 definition mentioned above.)

But what Dr. Aftab doesn’t seem to appreciate, even slightly, is that the reason for this expansion of scope is that David Kupfer, MD, and his interest-vested DSM-5 cronies wrote it this way.  This is tablets-of-stone thinking stripped even of a semblance of disguise.  If Dr. Kupfer et al had written that the Earth was flat, would that have made it so?

The definition of a mental illness/disorder is not some kind of reality that the DSM-5 work group wrested from nature’s grudging bosom in the manner of real science, and which can now be used as a reliable yardstick by which these kinds of matters can be gauged.  Rather, it was a decision, made by Dr. Kupfer and his committees.  The only reality that they had to observe was that the definition would be acceptable to the APA membership.  The fact that Dr. Aftab would adduce this document as proof that schizophrenia, or indeed any of psychiatry’s so-called diagnoses, is an illness is beyond comprehension.

For at least the past sixty years psychiatry’s concepts and practices have been criticized as invalid and ineffective.  Until recently they have, with the help of pharma money, been able to deflect these criticisms, and they have created a drug-pushing empire that makes the cartels look like amateurs.  Then three things happened:  1.  the survivors started to speak out about the damage they had incurred at the hands of psychiatry; 2.  critics began to realize the potential of the Internet; and 3.  a mainstream journalist named Robert Whitaker saw through the travesty and threw the power of his pen and his personal energy into the debate.  On all fronts, psychiatry is being exposed as the intellectually and morally bankrupt institution that it has been for at least the last fifty years.  They continue to insist that they are real doctors, treating real illnesses. But the arguments that they address to support this contention always boil down to the same four words:  because we say so.

 

Understanding Human Behavior

A couple of months ago I wrote an article concerning ECT which generated some controversy.  One of the issues that came up was the relationship between biological explanations of human activity and more global explanations, which, for want of a better term, I’ll call person-centered explanations.

Any human activity can be viewed from different levels of abstraction.  Suppose, for instance, that I am sitting in my living room reading a book.  Then I put the book down, stand up, and go outside.  If the question were to be asked:  why did he put the book down and go outside? A wide range of perspectives and answers are possible.  One could, for instance, focus on the fact that I am a biological organism, and one could develop a detailed and comprehensive flow sheet of every muscle movement, every heartbeat, every sensory input, neural impulse etc., that had occurred from the moment that I put the book down until I was standing outside.  Such an account might be more or less detailed.  There would, of course, be physical limitations on the amount of information of this sort that is attainable, but from a theoretical point of view, one could compile a detailed, complete, and accurate biological account of the actions in question.  And such an account would be a valid response to the question:  why did he put the book down and go outside.

But there are other perspectives.  One could, for instance, ask me why I had behaved in this way.  This would be a person-centered approach.  And suppose I reply:  I had been sitting inside for too long; I wanted some fresh air.  Assuming that I’m truthfully describing my motives and feelings, this is also a valid and accurate explanation.

Of particular note is that although the two explanations appear very different, they are entirely compatible.  In fact, if the biological account is thorough and complete, one would be able to identify the neural activities that corresponded to my feelings of restlessness, my decision to move, my muscular movements, and my relief on getting outdoors.  Again, I stress that I doubt if that level of precision is, or ever will be, possible in practice, but the concept is valid.  Every element of the person-centered explanation will have a corresponding element in the biological flow-sheets.

For this reason it makes no sense to argue about which explanation is correct.  They are both correct.  I – the subject of the person-centered perspective – am also the subject of the biological perspective.

The act of stepping outside for fresh air is trivial and unremarkable, but the same plurality of perspectives can be applied to all our actions, including dysfunctional or counterproductive behavior.  The activity can be viewed as biological and can be probed and catalogued by neurologists, physiologists, etc…  Or it can be seen from a person-centered perspective and explored and formulated from that point of view.  There are also other perspectives, e.g. economic, political, social, familial, occupational, etc…  From the economic perspective, for instance, I would be considered a consumer, and my restlessness and my desire for fresh air might identify me as a marketing target for outdoor wear, wilderness vacations, bird-watching magazines, etc…  From a familial perspective, I am a husband, father, father-in-law, and brother within a fairly extended network of supportive relationships.  From a political perspective, I am a voter.  And so on.  I can be observed and studied from all of these perspectives, and although the observations will look very different, they are entirely compatible provided they are accurate.

For every thought, feeling, and behavior there is a corresponding neural event.  Some people contend that the thought/feeling causes the neural event; others say that the neural event causes the thought/feeling.  Still others contend that the cognitive/emotional activity and the neural activity are the same thing, but viewed form different perspectives.  The relative merits of these contentions have been debated by philosophers for hundreds of years, but for our present purposes, it doesn’t matter which is correct.  The point here is that there are neural events and there are thoughts/feelings/actions, and there is a correspondence between the two.  A super-neurologist with super-equipment could probe my brain and identify and catalog various patterns and clusters of neural and chemical activity.  But I experience these neural activities as thoughts and feelings.  Each perspective is valid, and each has its proper place.

A neurosurgeon, for instance, would be primarily concerned with the biological perspective, while most of our day-to-day interactions with other people are approached from a person-centered perspective.  A person asking me, for instance, why I had stepped outside is not enquiring about neural activity, inside my skull.  He’s asking about my thoughts/feelings/actions.

It is often tacitly assumed in psychiatric circles that because every thought, feeling, and/or behavior has a corresponding neural underpinning, therefore counterproductive thoughts, feelings, and/or behaviors must be the result of faulty or malfunctioning neural equipment.  But this is an unwarranted assumption.

Let’s take the example of childhood temper tantrums – and let’s look at these from a person-centered perspective.

If a child throws a tantrum in a grocery store, demanding candy or a toy or whatever, and if the parent gives in to his demands, then other things being equal, the probability of a tantrum in future store visits is increased.  This is one of the ways that we learn:  if an action brings about a favorable result, we try it again.  This is an adaptive mechanism.  It is not an instance of something going wrong in the child’s brain.  Rather it is an instance of something going right.  The child’s learning “machinery” has worked perfectly.  And from a person-centered perspective, it is an instance of the child learning to navigate his way in social relationships.

In the example above, I’ve described the scenario and outcome in very simplistic terms and have included the qualifier “other things being equal.”  But in practice other things are never equal, and the precise outcome on any given occasion is impossible to predict.  But whenever we interact with our children, we are teaching them something, and they are teaching us something.  In the above example, the child has learned:  if I want candy, I throw a tantrum.  The parent has learned:  if I want to stop his tantrum, I give him candy.  Unless something significant changes, it is likely that two things will happen.  The child will start to throw tantrums in other situations besides grocery stores, and any attempt on the part of the parent to regain control of the situation will be met initially with escalation of the tantrums.  This is not an instance of something going wrong within the child.  Instead, and apparently paradoxically, it is something going right.  The child is expanding his behavioral repertoire in accordance with the normal principles of behavior acquisition.  What has gone wrong is that the parent is teaching a response that ultimately will be problematic and counterproductive.

From a person-centered perspective, even frequent and severe temper tantrums can be understood as normal responses to suboptimal situations.  Obviously, in this context, I do not mean statistically normal.  Severe and frequent temper tantrums are not normal in the statistical sense of the term, but in the circumstances outlined above, they are normal in that they can be understood if viewed from a person-centered perspective.  There is no a priori need to invoke explanations based on neural malfunctions or pathology in the absence of compelling indications that such factors are present and causally significant.

Obviously each tantrum has a specific neural underpinning, but it is fallacious to assume neural  pathology based purely on the presence of negative or counterproductive behaviors.  Neuronal circuits and neurotransmitters that are functioning perfectly can underpin and drive destructive behavior as readily as constructive behavior.

The distinction between a person-centered perspective and a bio-neurological perspective applies to almost every facet of human existence.  We are biological organisms, but we are also thinking, feeling and self-directed persons.  For instance, I carry within me memories of the home in which I grew up and of my family of origin.  These memories are complex and intertwined, but I can bring them to the forefront of consciousness more or less at will.  Now let’s say that my super-neurologist with his super-equipment can probe around inside my skull and locate the neurons in which all these memoires are stored.  And let’s make him (or her) even more super, and imagine that he can “read” these various neuronal engrams.  There is still a fundamental qualitative difference between his readings and my memories of my childhood.  A good analogy would be that he can read the book, but I’m living the part.  Another analogy:  a person could, in theory at least, analyze a movie on a DVD and identify every pixel and sound unit.  But this is not the same as watching the movie.  A chemist can analyze every molecule of paint and canvas in the Mona Lisa, and still know absolutely nothing about the picture as a work of art or the motivation of the artist.

Our super-neurologist could analyze and catalog perfectly every sensory input and neuronal impulse in the actions of a tennis player making a spectacular backhand return.  But this is not the same kind of experience as that of the tennis player or even of the exulting fans.  And so on.

It’s tempting in this context to say that psychiatry has lost sight of the forest for the trees.  But it’s worse than that.  They’ve lost sight of the tree for the minute fibers and biological processes that sustain the tree’s growth.

There’s a quality to human experience that transcends neurons.  One can know everything that there is to be known about neurons and neurochemicals and know nothing of human life.  People are living, sentient, motivated beings, and we each have our own perspective and point of view.  We can be studied at various levels of abstraction:  atomic, molecular, bio-molecular, physiological, neuromuscular, skeletal, psychological, social, economic, political, occupational, etc… But we can also be approached and understood simply as individual people, with our individual histories, contexts, hang-ups, and aspirations.  No one perspective has any legitimate claim to being the preferred point of view.  One’s perspective has to be chosen in the light of the context.  If a person is sick (with a real sickness), then a biological perspective is probably preferable.  If he is sad or anxious, then a person-centered perspective seems the most apt.  If he is lonely and isolated, a social perspective might be most fruitful.  And so on.

In my experience virtually all the problems listed in the various editions of the DSM can be best approached, understood, and ameliorated from a person-centered perspective.  If you want to know why someone is depressed, take the time to get to know him, and then ask him.  Most people can tell you why they’re depressed or worried or nervous or scared or whatever.  But if it’s clear that your only interest is a 15-minute med check, they will tell you nothing.

If there is neural pathology then this, of course, should be addressed and alleviated to the extent possible.  But tampering crudely with the brain in the absence of confirmed pathology is dangerous and destructive.  Drugs do create altered states of consciousness, but the notion that we can provide effective help to people with problems of thinking, feeling, and/or behaving by tweaking their neurons betrays a fundamentally flawed and condescending view of humanity.

 

 

 

Psychiatry Is Not Based On Valid Science

BACKGROUND

On December 23, I wrote a post called DSM-5 – Dimensional Diagnoses – More Conflicts of Interest?  In the article I sketched out the role of David Kupfer, MD, in promoting the concept of dimensional assessment in DSM-5, and I speculated that at least part of his motivation in this regard might have stemmed from the fact that he is a major shareholder in a company that is developing a computerized assessment instrument.  I ended the piece with a general criticism of psychiatry:

“There is only one agenda item in modern American psychiatry:  the relentless expansion of psychiatric turf and drug sales.  They’ve promoted categorical diagnoses and chemical imbalances strenuously for the past five decades.  Now that these spurious notions are on the point of expiration, psychiatry is developing dimensional diagnoses and neurocircuitry malfunctions as the rallying points of the ‘new and improved’ psychiatry.

But the bottom line is always the same:  turf and money.  Something is truly rotten in the state of psychiatry.”

The article precipitated a fairly lengthy debate in the comments section.  The discussion was wide ranging, and some of the issues addressed were fundamental to the entire psychiatric debate, in particular:  whether or not psychiatry is based on valid science.

My own position is that the foundations of psychiatry are spurious, and the purpose of this post is to set out my position on this matter.

PSYCHIATRY’S USE OF THE TERM “ILLNESS”

Psychiatry’s most fundamental tenet is that virtually all significant problems of thinking, feeling, and/or behaving are illnesses that need to be studied and treated from a medical perspective.  What’s not usually acknowledged, however, is that this is an arbitrary assumption.

In common speech and within the medical profession, the word “illness” indicates the presence of organic pathology: i.e. damage or malfunction in an organ.  Historically, mental illnesses came into being, not because some scientist or group of scientists had recognized and established that problems of thinking, feeling, and/or behaving are caused by an organic malfunction, but rather because the APA had simply decided to extend the concept of illness to embrace these kinds of problems.  For the record, some problems of thinking, feeling, and/or behaving are known to be caused by organic pathology, and I exclude those from the present discussion.

It is not superficially obvious that other problems of thinking, feeling, and/or behaving are actually illnesses, and there is a strong burden of proof on those who adopt this position.  Psychiatry, however, has never proved this assertion, but nevertheless continues to expand its diagnostic net in the same way that it started – by fiat.  A particular pattern of thinking, feeling and/or behaving becomes a mental illness/disorder because the APA says so!

Obviously I can’t dictate to psychiatrists how they should and should not use words.  If they choose to call problems of this sort illnesses, then that’s their business.  But they should also acknowledge that they are using the word illness in a distorted and misleading sense of the term.

They are also deviating from the ordinary standards and procedures of medical science.  In the 1930’s, a German pathologist named Friederich Wegener discovered a “new” disease, which is now called Wegener’s Granulomatosis.  He discovered this disease the old-fashioned way – by years of diligent post-mortem examinations and hundreds (thousands?) of microscope hours.  The history of medical progress is the history of these kinds of discoveries.

By contrast, psychiatry produces their “diagnoses,” (e.g. ADHD, disruptive mood dysregulation disorder, conduct disorder, etc., etc.), simply by voting.  They cling to the unacknowledged extended use of the term illness in these kinds of deliberations and decisions, whilst maintaining the pretense in their practices and promotional literature that the word is being used in its classical sense of organic pathology.

The reason that several psychoactive drugs have become blockbusters in recent years is that psychiatry has the advantage, unique in the medical field, that it can invent illnesses, and relax the criteria for these illnesses, more or less at will.  Psychiatry, unlike other medical specialties, has no natural limits to its growth potential.  They can continue to expand the diagnostic net until everybody in the world has a diagnosis.  But it doesn’t even have to stop there.  They can go for everybody having two, three, four, etc., diagnoses.  If organized psychiatry votes an illness into being, there is no reality that can act as a brake or a check on this activity.

PSYCHIATRY AND SCIENCE

Despite this confusion in terminology, psychiatry routinely contends that its diagnoses are based on science.  In the Introduction to DSM-IV, the APA wrote:

“More than any other nomenclature of mental disorders, DSM-IV is grounded in empirical evidence.” (p xvi)

And, of course, an enormous number of studies had been done.  But, to the best of my knowledge, there wasn’t a single study on any “diagnosis” that addressed the fundamental question:  is there any logical reason why this particular problem of thinking, feeling, and/or behaving should be conceptualized as an illness?  This, in every case, was simply assumed, despite the fact that there are better, more productive, more parsimonious, and more logically sound ways to conceptualize these problems.

As a companion to DSM-IV, the APA published a five-volume sourcebook of references.  There were prevalence studies, correlation studies, data re-analyses, field trials, etc… All of which was wonderful.  But on the fundamental question:  is there any rational reason for conceptualizing these conditions as illnesses? –  there was nothing.  Which was not surprising, because there had been nothing along those lines in the earlier manuals.

THE CHANGE FROM DSM-I TO DSM-II

And speaking of the earlier manuals, it needs to be noted that a major shift in underlying theory occurred between DSM-I and DSM-II.  In DSM-I, most of the diagnostic terms contained the word “reaction” (e.g. schizophrenic reaction), the implication being that the problem in question was to be conceptualized as a reaction to something.  In DSM-II, the word reaction was dropped.  In the Foreword to DSM-II the drafting committee stated that the purpose of this change was to avoid terms that implied any particular causal theory.  This notion was repeated in the Introduction to DSM-III-R:

“The use of the term reaction throughout the classification [in DSM-I] reflected the influence of Adolf Meyer’s psychobiologic view that mental disorders represented reactions of the personality to psychological, social, and biological factors.”  (Adolf Meyer was an eminent Swiss-American psychiatrist, 1866-1950)

And

“The DSM-II classification did not use the term reaction, and except for the use of the term neuroses, used the diagnostic terms that, by and large, did not imply a particular theoretical framework for understanding the nonorganic mental disorders.” (p xviii)

All of this sounds fairly reasonable, but ignores the fact that the omission of the term “reaction” inevitably conveys the impression that the categories listed are to be conceptualized as primary illness entities.  Despite their proffered justification for the claim, it is more plausible that the term was dropped in a deliberate attempt to oust Adolf Meyer’s notion of mental disorders as reactions to biopsychosocial stressors, especially his reformulation of schizophrenia as a cluster of maladaptive habits acquired in response to such stressors.  It is also plausible that it was an attempt to return psychiatry to a Kraepelinian nosology of biologically-specifiable illnesses.  In any event, that is exactly what has happened.

PSYCHIATRY’S “NOSOLOGY”

Many eminent psychiatrists today refer to the DSM as a psychiatric nosology.  These include:

The word nosology (from the Greek word nosos, meaning disease) means classification of illnesses, and by using this term in this context, psychiatrists are implying, without valid reason, that all significant problems of thinking, feeling, and/or behaving are illnesses, even though there is no evidence that this is a valid or helpful stance.  In fact, as we’ve seen above, an alternative perspective (Adolf Meyer’s “reactions”) actually constituted psychiatric orthodoxy from 1952 to 1968.  What is also clear and noteworthy in this matter is that Adolf Meyer’s theoretical/explanatory concepts were not abandoned on the grounds that they had been scientifically discredited or disproven.  They were abandoned as part of an arbitrary decision by the DSM-II committee  to medicalize problems of thinking, feeling, and/or behaving.

DSM-II’s decision to drop the word “reaction” was not, as claimed, a move to an atheoretical classification.  Rather, it replaced a genuinely biopsychosocial causal framework with one that was purely biological:  i.e. that all problems of thinking, feeling, and/or behaving are by definition primary disease entities.  Under the present DSM system, psychiatry doesn’t have to prove that a problem is an illness, because that assertion is built into their definitions.  If the DSM is a nosology, then every item listed must be an illness.  This is not science.  It is intellectual chicanery.

Having demonstrated that they could do this without much opposition in DSM-II, the APA solidified the arrangement in DSM-III, and expanded it to the point of travesty in DSM-IV and 5.  In fact, in DSM-5, the disease notion is injected even more explicitly and more clearly than in the earlier manuals.  In the Introduction chapter, following a discussion on the value of dimensional assessment, the APA states:

“These findings mean that DSM, like other medical disease-classifications, should accommodate ways to introduce dimensional approaches…” (p 5) [emphasis added]

EXPLANATORY VALUE OF PSYCHIATRIC DIAGNOSES

The notion that all problems of thinking, feeling, and/or behaving are illnesses has no explanatory value.  Consider the following conversation.

Client’s daughter:  “Why is my mother so depressed?”
Psychiatrist:  “Because she has an illness called major depression.”
Client’s daughter:  “How do you know she has this illness?
Psychiatrist:  “Because she is so depressed.”

The only evidence for the illness is the very behavior it purports to explain.  Unlike diagnoses in real medicine, there is no actual illness behind the DSM symptom lists to provide genuine explanatory value.  Those of us on this side of the debate have been pointing out this kind of circular reasoning for decades, but I have never seen or heard a convincing response from psychiatry.  Instead, they continue to promote their “diagnoses” to their clients, the media, and the general public as if they had explanatory value – when in fact they have none.

Psychiatry sometimes counters this particular criticism by denying that they ever promoted mental illnesses as causes or explanations of the symptoms.  But in fact, causative language permeates DSM-III, IV, and 5.  In almost every section of DSM-5, one can find exclusion clauses like:  “The disturbance is not better explained by another mental disorder,” the clear implication being that mental disorders are being presented as explanations of the problems listed in the criteria sets.  Additionally, the notion of a disorder/illness as the cause of its symptoms is standard in general medicine.  For instance, the illness pneumonia causes the symptoms of coughing, weakness, etc.,.  By using this kind of language in DSM, the APA is promoting the notion that their putative illnesses are indeed the causes of the symptoms.  For instance, the behavior of running around the classroom and failing to pay attention to the teacher is routinely presented by psychiatry as being caused by the “illness” ADHD, and this is precisely how the notion of “mental illness” is perceived by clients, the media, and the general public.  If it is not psychiatry’s intention to create this impression, then they need to make a concerted effort to correct the misunderstanding.  I am not aware of any moves in this direction by the APA or by psychiatric opinion leaders.

THE IMPORTANCE OF VALID THEORIES

Organized psychiatry tends to dismiss this entire issue of the ontological status of the “mental illnesses” as academic or philosophical, and as having no real bearing on practice.  But imagine how different psychiatry would be today if it had retained Adolf Meyer’s formulations.  Research would probably not have been hijacked by pharma, and would be focused on social and environmental factors rather than on drug responses.  Psychiatrists would take detailed histories in an attempt to understand their clients, rather than gathering just enough information to clinch the “diagnosis.”  There would be no fifteen-minute med checks, and social skills training would be the dominant treatment modality.

Causal theories are not ivory tower abstractions.  In any systematic human activity, they are the pillars that support and drive practice.  And when they are spurious, as in the case of psychiatry, practices and procedures inevitably drift into error.  The legitimacy of a profession depends on the validity and adequacy of its underlying causal theories.  Indeed, the theories are the formal expression of the knowledge accumulated by the science at a given point in time.  This applies particularly to those concepts that are very basic and fundamental. A shipping industry, for instance, that was working on the assumption that the Earth is flat, other things being equal, would probably not be noted for excellence of service.  Similarly, a geo-centered astronomy would be a shaky foundation for the development of space travel.  Human endeavors that are based on valid theories are more likely to yield success than those based on invalid theories.

To guard against misunderstanding, I’m not saying that good theories are sufficient.  One also needs techniques, tools, skills, etc…  But working without valid theories, or worse, working with invalid theories, inevitably leads practitioners astray.  Which is exactly what has happened in the case of psychiatry.  By assuming that all significant problems of thinking, feeling, and/or behaving are illnesses, they have, very naturally, been drawn into seeing these problems as entities that they (the physicians) have to fix by means of medical-type techniques, and seeing the owners of the problems as “patients” – i.e. people who have to be fixed.  The illness theory also, because it conveys the false impression that the matter has been explained, has a dampening effect on practitioners’ curiosity as to genuine explanations.

Modern psychiatry has been plugging away at its so-called nosology for more than a hundred years, and the APA, in their successive revisions of the DSM, assure us that the classifications are scientific.  Thought leaders and individual psychiatrists, with few exceptions, assure us that the “illnesses” listed in the manuals are scientifically established, ontologically valid entities that provide the framework for understanding and ameliorating problems of thinking, feeling, and/or behaving.  But seldom is it acknowledged that this stance is nothing more than an assumption, the purpose of which was to establish psychiatric turf in a non-medical field.

“PSYCHIATRY IS VALID BECAUSE ITS TREATMENTS WORK”

It is sometimes argued that psychiatry derives validity and legitimacy from the fact that its treatments (i.e. drugs) work.  In rebuttal, many writers on this side of the debate have pointed out that small quantities of alcohol help a person overcome shyness, but that nobody would conclude from this either that shyness is an illness, or that alcohol is a medicine.  Drugs, whether they’re of the street, liquor store, or pharmaceutical variety, alter people’s thoughts, feelings, and/or behaviors.  In some cases, the users of these products and their families express themselves pleased with the alteration.

I have known a good many marijuana users who maintained, with, I think, good credibility, that pot helped them control their anger – made them mellow.  Over the years I have worked with several women who always kept a twelve-pack of beer in the refrigerator in case their husbands became angry or upset.  In these cases, the pot and the alcohol “worked” in the sense that they forestalled the anger and rage.  And psychopharmaceutical products sometimes “work” in this same pragmatic use of the term.  But there is no evidence that any psychopharmaceutical product fixes or alleviates any pathological process.  Indeed, what seems to be the case is that these drugs “work” by producing abnormal neurological states.  From a pragmatic point of view the abnormal state may seem better to the client, and/or his family, and/or the authorities.  But this does not establish that the original condition was an illness or that the drug is a medicine.  

CLARIFICATION

Obviously the problems listed in the DSM are real.  That’s not the issue.  What’s being challenged here is the contention that the clusters of problems set out in the manual can be validly conceptualized as symptoms of medical disease entities.  It is my position that such a conceptualization does violence to the subject matter, and has led psychiatry seriously astray.

For instance, at the present time there is a great deal of concern in professional and official circles about the rapidly increasing use of neuroleptic drugs to “treat” childhood temper tantrums and aggression.  What’s not usually acknowledged, however, is that these practices are a direct consequence of the spurious notion that all problems of thinking, feeling, and/or behaving are illnesses that warrant medical intervention.  In the “old days” parents who brought a child to a physician for temper tantrums or aggression would have been told that this, in the absence of some very obvious and compelling indications to the contrary, was not a medical problem.  Today it is a medical problem, not because there has been some breakthrough medical discovery, but simply because the APA says so, and because psychiatrists prescribe neurotoxic drugs that act as chemical strait-jackets and dampen the problem behavior.  Contrary to the congratulatory self-talk of Dr. Lieberman and his like-minded “opinion leaders,” this is not medical progress.

A SECOND CLARIFICATION

Again, to guard against misunderstanding, let me state very clearly that if psychiatry could produce convincing evidence that the myriad problems of thinking, feeling, and/or behaving listed in the DSM are in fact caused by specific illnesses/diseases of the brain or other organs, then my objections are moot.  And if that day comes, as I’ve said many times, I will fold my tent, apologize to all concerned, and end my days writing poetry, growing vegetables, and playing with my grandchildren.  In the meantime, I will continue to state as vigorously and as frequently as I can, that psychiatry’s most fundamental tenet is nothing more than a self-serving assumption which despite decades of highly motivated research, numerous premature, yet confidently asserted, eurekas, and virtually endless promises that the definitive evidence is just around the proverbial corner, remains nothing more than a false and destructive assumption.