INTRODUCTION
On March 21, 2022, Daniel Morehead, MD, psychiatrist, published an essay on Psychiatric Times titled: The DSM: Diagnostic Manual or Diabolical Manipulation? Subtitle: “Nobody likes the DSM”. This is Episode 2 of his defense of psychiatry.
Here’s the first paragraph:
“It is hard to overstate the torrents of criticism that have rained down upon the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). This poor, beleaguered document has been repeatedly and energetically attacked from all sides on a routine basis. It is not only the usual critics of psychiatry who have excoriated its approach—patients and family members, journalists, members of the academy, sociologists, psychologists, psychiatrists, National Institute of Mental Health (NIMH) directors, and even DSM task force chairs themselves have come down heavily against it on both general and specific grounds.2“
And here’s the second paragraph:
“Every major periodical in this country has featured articles critical of the DSM, from The New York Times3 to Science.4 The flow of critical books and articles continues to this very day.5,6 And with the release of the DSM-5-TR, the floggings will doubtless continue.7 The DSM has been, and remains, the centerpiece of contemporary critiques of psychiatry.”
The final sentence above makes little sense. I think the good doctor means “central target” rather than “centerpiece”. But even then, the statement is not accurate. The central target is the bogus medicalization of matters that are not actually illnesses. The DSM is simply one facet of this hoax.
Dr. Morehead continues by outlining the criticisms to which the DSM has been subjected. These include: the lack of biological pathology in the various DSM items; the fact that the diagnostic criteria are simply made up by committees to enhance psychiatrists’ earnings and power; successive revisions of the DSM have widened the diagnostic net considerably, enabling psychiatrists to bill their patients and third-party payers for an increasingly wider range of “treatments”; the DSM approach is not medical but social; the diagnoses are based on consensus rather than lab measures; DSM’s diagnoses are arbitrary agreements among self-appointed experts and are not medical entities.
Some pretty significant criticisms there. Indeed, a naïve and fair-minded reader might hope that Dr. Morehead will take some of these criticisms on board in an unprejudicial and objective manner so that we all might benefit from his wisdom. But alas:
“I submit that all of these critics are wrong.”
Wow! We’re all wrong. Even Thomas Insel, former Director of the NIMH. Patients and their families, journalists from “every major periodical in the country”. Sociologists, psychologists, and even individuals who chaired DSM’s task forces. All wrong. Oh my!
DR. MOREHEAD’S ARGUMENT
So presumably Dr. Morehead is going to explain how he comes to such a profound and far-reaching conclusion:
“They are wrong because they are mistaken about both the practice of medicine and the nature of the mental illnesses the DSM attempts to classify. I submit that you, as a practicing psychiatrist or other mental health professional, intuitively know that you are practicing legitimate and scientifically based medicine as you make use of the DSM. Allow me to put this intuition into words.”
Note that in the second part of the above paragraph he is addressing psychiatrists “or other mental health professionals”, and he tells these individuals that they “intuitively know” that they are “practicing legitimate and scientifically based medicine” as they make use of the DSM. So, those of us who are members of the anti-psychiatry movement are wrong because – according to Dr. Morehead – psychiatrists and other mental health professionals intuitively know that they are practicing legitimate and science-based medicine when they use the DSM.
And then, arrogance heaped on arrogance, he – the great doctor – is going to put this intuitive knowledge of psychiatrists and other mental health professionals into words.
Effectively what Dr. Morehead is asserting here is that he has the ability to read other people’s minds. And not just the conventional look-into-my-eyes nonsense that was sometimes portrayed in old movies. No! Dr. Morehead is claiming the ability to read the minds of people he has never even met. And he’s also claiming the ability to clarify what these people are thinking, presumably on the grounds that they can’t do this for themselves.
Dr. Morehead is telling psychiatrists that they “intuitively know” that they are “practicing legitimate and scientifically based medicine” as they make use of the DSM. But intuition is a poor indicator of validity. In particular, intuition seldom alerts us to our own prejudices and distortions, which is why we have this very different thing called science. It’s a way of pursuing truth that specifically involves setting aside our intuitions – even those intuitions that are dear to us – and systematically following the facts wherever they may lead. Dr. Morehead, by contrast, appears to be relying entirely on his personal belief system and the intuition of his psychiatric colleagues, as clarified by himself, to sustain his “argument”.
But let’s soldier on.
“The DSM-5 includes a lengthy definition of mental illness, but the first 6 words will suffice for our purposes: ‘A mental disorder is a syndrome….’12 What is a syndrome? As we know from medical school, a syndrome is simply a collection of medical signs and symptoms. Is a syndrome a disease? No—but diseases manifest as syndromes. Diseases stand behind syndromes, and many different diseases can stand behind the same syndrome.”
This is true. The successive revisions of the DSM do include statements to this effect. But the point is irrelevant because the title of the book is “Diagnostic and Statistical Manual of Mental Disorders”. The word “disorder” is essentially synonymous with illness, disease, or ailment (see New World Dictionary of American English 3rd Edition: “disorder…an upset of normal function; ailment”). But even that is irrelevant because the items listed in the various editions of the DSM are almost invariably described by psychiatrists themselves as “mental illnesses“.
So trotting out the old “syndrome, not an illness” cuts no ice. We routinely hear from psychiatric “experts” that mental illnesses are real illnesses just like diabetes, but I’ve never heard of any psychiatrists claiming that the targets of their diagnoses and treatments are real syndromes.
Dr. Morehead continues:
“Take depression, for instance. Many underlying diseases can produce depression (and the same applies for all other DSM disorders). Hypothyroidism can manifest as depression, as can obstructive sleep apnea and vitamin D deficiency. Yet we usually do not know the specific disease behind an episode of depression. In psychiatry, we typically rule out commonly known diseases that produce depression while managing depression with general and nonspecific treatments such as psychotherapy and antidepressant medications.”
Here again, Dr. Morehead provides us more irrelevancy and nonsense. “Many underlying diseases”, he tells us, “can produce depression”. He cites hypothyroidism, obstructive sleep apnea, and vitamin D deficiency as examples. But he’s confusing depression caused by a general medical condition with depression the so-called mental illness. DSM-III-R, DSM-IV, and DSM-5 all cite an organic cause as an excluding factor in both “major depressive disorder” and “dysthymia”. In DSM-III-R, the wording is:
“It cannot be established that an organic factor initiated and maintained the disturbance” (p 223 and 232)
In DSM-IV the wording is:
“The symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g. hypothyroidism)” (p 327 and 349)
In DSM-5 the wording is:
“The episode [of major depressive disorder] is not attributable to the physiological effects of a substance or to another medical condition” (p 161)
and
“The symptoms [of dysthymia] are not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition (e.g. hypothyroidism)” (p 168)
In addition, DSM-IV and DSM-5 include the diagnoses of substance -induced depression and depression due to a general medical condition as diagnoses and illnesses in their own right.
Here’s the wording used in DSM-IV:
“Mood Disorder Due to a General Medical Condition” (p 366)
and
“Substance-Induced Mood Disorder” (p 370)
And here’s the wording used in DSM-5:
“Mood Disorder Due to Another Medical Condition” (p 180)
and
“Substance/Medication-Induced Depressive Disorder” (p 175)
Note that in DSM-5, the phrase “Another Medical Condition” has been substituted for “General Medical Condition”. This is because after six decades of referring to real illnesses as General Medical Conditions, the APA finally realized that they were actually implying that psychiatric “illnesses” weren’t real illnesses. (Horrors!) By using the phrase Another Medical Condition, they strive to maintain the fiction that their “illnesses” are real – just like diabetes. But it takes more than a change in phraseology to turn consensus agreements by self-styled experts into real illnesses.
THE FLAW IN DR. MOREHEAD’S ARGUMENT
I realize that this has all become very complicated. But here’s the gist of the matter. Dr. Morehead has presented himself in this paper as the champion of psychiatry. He’s going to prove that all of us anti-psychiatry people are just plain wrong. But in this particular paragraph, he seems to be unaware of the distinction that is actually central to the psychiatric hoax, that there exists a number of “independent depressive disorders” (DSM-5 p 175; item C) (e.g. major depressive disorder; dysthymia) for which there is, within the rules and traditions of psychiatry itself, no need to identify a specific biological cause. It is normal practice in psychiatry to simply confirm that the individual has checked five of the nine boxes on the intake sheet and is experiencing significant distress or impairment, and voila – we have a “diagnosis of major depression” – a DSM-approved, genuine, billable diagnosis without any need to show a biological cause. In fact, in those rare cases where a psychiatrist is able to ascertain a biological cause, he/she is not permitted (by psychiatry’s own rules) to diagnose “major depression” or “dysthymia”.
So, from all of this inanity, Dr. Morehead extracts these gems of insight:
“Yet we usually do not know the specific disease behind an episode of depression. In psychiatry, we typically rule out commonly known diseases that produce depression while managing depression with general and nonspecific treatments such as psychotherapy and antidepressant medications.”
The implication here is that they would like to be able to show a biological cause, but in reality have long since written out that requirement. And the likely reason for that write-out is that if they begin to go down that road, they would have to refer the individuals so diagnosed to other specialties (e.g. endocrinologists, neurologists, etc.). Eventually there would be nothing left for psychiatrists. And that’s a sobering thought.
Dr. Morehead is trying to prove that all depression stems from a biological illness. But, he tells us, psychiatrists in most situations do not know the specific disease that is causing the episode of depression. So they just manage the depression with general and non-specific treatments, such as psychotherapy and antidepressants. But he betrays no awareness that such proof is not only unknown (usually), but even if it were known would prohibit a diagnosis of “major depressive disorder” or “dysthymia” by psychiatry’s own rules. Psychiatry is crystal clear on this facet of the hoax: if it is known that the cause of the depression is a general medical condition, then diagnoses of “major depressive disorder” and “dysthymia” are expressly prohibited.
I realize that this entire discussion seems too incredible for words. But there it is – the Great Psychiatric Hoax. And in this particular case, the current defender of psychiatry has himself apparently been taken in by the hoax!
Note also the phrase: “… managing depression with general and nonspecific treatments such as psychotherapy and antidepressant medications.” How many psychiatrists at this time are providing psychotherapy?
Back to Dr. Morehead:
“Is this approach to clinical diagnosis out of step with the rest of medicine? Hardly—in primary care settings, syndromes represent the most common means of diagnosing problems and prescribing treatments.13,14 Think about such common syndromes as upper-respiratory infection (URI), gastroenteritis, and arthritis: All of these syndromes can be expressions of many different diseases. In the case of a URI, for instance, the primary care physician (PCP) evaluates the signs and symptoms, diagnoses the syndrome, and then prescribes empiric antibiotic treatment or other nonspecific interventions such as nonsteroidal anti-inflammatory drugs (NSAIDs)—all without knowing which specific disease is behind the URI symptoms.”
MORE FALSEHOODS: GENERAL MEDICINE IS JUST AS UNSCIENTIFIC AS PSYCHIATRY
The gist of this paragraph is another of psychiatry’s old chestnuts – that general medicine is just as unscientific as psychiatry. General medicine, Dr. Morehead argues, treats upper respiratory infections (URI’s), gastroenteritis, and arthritis by treating the syndromes without knowing the nature or name of the precise illness. And there is a measure of truth in this. URI is an imprecise term for any infection involving the nasal cavities, the bronchi, and areas in between. The cause is usually bacterial, viral, or (in rare cases) fungal. But – and this is the critical point – there has to be an infection, and this infection is the root cause of the problem. And all physicians are trained in how to recognize an infection, often from cursory inspection. It is true that they can’t identify the precise nature of the infection in this way. They can’t usually identify the bacterium, virus, or fungus involved. But one doesn’t need a sledgehammer to crack a walnut, and for most purposes, a preliminary diagnosis of this sort is all that is needed. In other words, the illness is diagnosed with as much precision as is needed.
But – and this is also a critical point – an infection is a medical pathology: something has gone wrong in the structure or function of the tissues concerned, and a scientifically validated generic solution to the problem is available. So the physicians administer the general antibiotic, but also arrange for cultures to be taken and studied so that if the generic solution is unsuccessful, they will have a more precise follow-up remedy ready to go. All of which is very medical and very scientific.
In contrast to which the APA’s five out of nine checklist for “major depressive disorder” plus the presence of significant distress or impairment is a farce. Firstly, the checklist items themselves can and do occur regularly in people who are not depressed. Secondly, a person could be markedly depressed while displaying none of the checklist items. Thirdly, the DSM-5 field trials, designed to assess the reliability of a diagnosis of major depressive disorder, yielded a Cohen’s d of only 0.28, indicating minimal interrater agreement. Fourthly, there is no evidence, prima facie or otherwise, that the items are inter-related in a way that would suggest convergence around a common underlying biological pathology. And of course, fifthly, any item that does clearly stem from a genuine medical condition is expressly excluded from consideration.
“Major depressive disorder” is nothing more than a loose collection of vaguely defined thoughts, feelings, and behaviors. And antidepressants are nothing more than numbing pills. There are no valid reasons to consider depression an illness, and lots of valid reasons for conceptualizing it otherwise. In reality, depression is an adaptive device whose function is to alert us to the need to effect some changes in our lives and to encourage us to follow through on these changes. It is our way of responding to adverse events or abiding adverse circumstances. It is not an illness except in those rare cases where the depression is actually caused by a biological problem, though even in those cases it would be better conceptualized as a symptom rather than an illness. So, for instance, depression might be a symptom of hypothyroidism. In cases where the individual can’t, or chooses not to, respond appropriately to the depression, the thoughts, feelings, and behaviors can become habitual.
SOME PSYCHIATRIC DISORDERS ARE GENUINE ILLNESSES
Back to Dr. Morehead:
“Because DSM syndromes such as depression do not often match up with any single and well-defined disease, critics say that they are not based on anything. They regularly assert that we do not know the central etiology or pathophysiology of even a single major mental illness (with the possible exception of Alzheimer dementia). Therefore, the entities in DSM are simply guesses based on convention, as are the collections of symptoms that define them.”
Note the glaring falsehood “They regularly assert that we do not know the central etiology or pathophysiology of even a single major mental illness (with the possible exception of Alzheimer dementia).” In fact, most people on this side of the debate recognize that a great many of psychiatry’s diagnoses are valid illnesses of known pathology. Here’s a short list:
- Delirium due to a general medical condition
- Substance-induced delirium
- Alzheimer’s dementia
- Vascular dementia (formerly multi-infarct dementia)
- Dementia due to HIV
- Dementia due to head trauma
- Dementia due to Parkinson’s disease
- Various other specific dementias
- Substance-induced persisting dementia
- Substance intoxication
- Substance withdrawal
- Opioid intoxication
- Sedative/hypnotic withdrawal
- Neuroleptic-induced acute akathisia
- Neuroleptic-induced tardive dyskinesia
But the follow-up assertion:
“Therefore, the entities in DSM are simply guesses based on convention, as are the collections of symptoms that define them.”
is accurate and well put for the majority of psychiatry’s “diagnoses”. Though I would make one small addition to the assertion. I would add that the guesses are based on convention and on psychiatry’s never-satiated need to expand its scope and business. Witness the fact that the bereavement exclusion, long considered an inviolable facet of depression phenomenology, has, since DSM-5 (2013) been effectively eliminated. Numerous other instances of diagnostic creep can be found by examining successive editions of the DSM. For instance, in DSM-III-R the diagnostic criteria for ADHD contained the item “onset before the age of seven” (p 53). In DSM-5 this item reads” “several symptoms were present before age 12” (p 60). Also a large number of new entries have appeared, e.g. attenuated psychosis syndrome in DSM-5 (p 122); binge eating disorder, DSM-5 (p 350); disruptive mood dysregulation disorder, DSM-5 (p 156).
Dr. Morehead continues:
“Yet this criticism, too, is factually wrong and based on a false dichotomy. Either we know the specific cause and pathophysiology of a mental illness (they say), or we are making up a mental illness without justification. In fact, we can know that an illness is medically and biologically real without knowing the specific cause or pathophysiology of that illness.”
And there is a measure of truth in this. When AIDS first came to international attention in 1981, its specific cause or pathophysiology was unknown. But nobody doubted that it was (and still is) an illness. This was primarily because it was obvious to doctors and other healthcare people that it was killing people. By 2010, it had become one of the most common causes of death worldwide. And also by 2010, the pathophysiology was well understood; diagnosis by antibody presence was well developed; prevention strategies were being promulgated; and treatments were becoming increasingly available.
In short, there are various prima facie factors that indicate that a particular phenomenon is a bona fide illness. These include:
- some tangible indication of tissue damage (e.g. blisters, rash, sores, etc. on the skin or mucous membranes)
- routine association with physical pain or other adverse physiological consequences
- uncontrollable shakes or tremors
- difficulty breathing in the absence of obstruction
- frequent bone fractures
- swelling of joints
- blood-tinged cough
- nausea and vomiting
- blurry vision
- sudden, non-typical headache or vision loss
- ear pain or exudations
- stroke symptoms
- loss of consciousness
- severe cough
- irregular heartbeat
- discovery of the biological pathology within a reasonable timeframe
- etc.
Dr. Morehead then rolls out the Migraine argument:
“Migraine headaches are medically real with demonstrable pathological findings, and yet neurologists know neither their specific cause nor their central pathophysiology.”
And this is true, but not particularly relevant. Dr. Morehead’s main contention in this regard is that anti-psychiatry writers say that:
“Either we know the specific cause and pathophysiology of a mental illness (they say), or we are making up a mental illness without justification.”
But actually, it’s considerably more complicated than that. Most of the anti-psychiatry writing with which I am familiar says that only those DSM items that are due to a general medical condition are valid illnesses, though I think most of us would also allow the possibility of validity for those items that had a good probability of entering that category within a reasonable time frame, using prima facie indicators similar to the ones set out above.
Within the framework of general medicine, there will always be a few conditions whose precise pathophysiology has not yet been determined. But, and this is crucial, within the framework of psychiatry, virtually no progress has been made in this area in the last 70 years or so. I cannot think of a single psychiatric “functional diagnosis” that has been proven to have genuine medical validity in this time frame, despite the expenditure of vast sums of money and other resources on this endeavor.
THE BROKEN BRAIN
In 1984, Nancy Andreasen, professor of psychiatry at Iowa College of Medicine, wrote a book called The Broken Brain, subtitle “The Biological Revolution in Psychiatry”.
Here’s a quote:
“Although none of the mental illnesses is as yet as fully understood as Parkinson’s disease, biologically oriented psychiatrists hope that during the next ten to twenty years a similar logical progression from understanding structure to understanding cause to developing treatment will unfold for major mental illnesses such as depression or schizophrenia. ” (p 29) [Emphasis added]
Note the word “hope”. Science is not a question of finding what one hopes to find. It’s about finding the truth.
Here’s another quote:
“The remainder of this book explains in more detail the recent discoveries and contribution of biological psychiatry, which will revolutionize the treatment of mental illness during the 1980s and 1990s.” (p 32)
That was 38 years ago, and the promise of the great biological revolution in psychiatry is still unfulfilled.
Nevertheless, psychiatry touts each minor finding in this area as a hopeful sign, and the research departments issue press releases that continue to claim that the biological revolution – the Holy Grail of psychiatry – is just around the corner, routinely ignoring or downplaying the reality that the correlations found are always partial and that there are always individual research subjects who have the biological anomaly in question but who don’t meet the DSM criteria and vice versa.
The fact is that psychiatry in the 50’s, 60’s and 70’s was truly a laughing stock within the medical community. Desperate for legitimacy and for a share of the generous third-party payments that real doctors were receiving, they set upon the goal of producing billable diagnoses, gambling everything on the notion that the discovery of validating pathophysiologies was “just around the corner”. Well, as we all now know, these pathophysiologies were never found, despite the widespread chemical imbalance claims to the contrary. And psychiatry today is as invalid and deceptive as it has ever been.
PSYCHIATRY VS. GENERAL MEDICINE
So psychiatry did in fact just invent their “diagnoses”. They collated bundles of “symptoms” on the basis of superficial similarities, gave them names, and then had the gall to promote them to the public and the third-party payers and the government as “real illnesses just like diabetes”. But the phrase “real illness just like diabetes” entails the notion that the specific bio-pathology is known, which in the case of psychiatry is nothing more than wishful thinking, or to use Nancy Andreasen’s word: psychiatry’s “hope”.
In addition to all of this, the great majority of medical interventions (by real doctors) involves ascertaining the biological cause and nature of a pathological condition and administering scientifically validated corrective procedures when such are known and available.
By contrast, the great majority of psychiatric interventions involve comparing clients’ or family members’ reports with simplistic unvalidated checklists and then administering pills or electric shocks on a more or less trial-and-error basis until the client or family member reports some amelioration of one or more of the checklist items.
Dr. Morehead continues:
“With depression, we can demonstrate pathological findings such as hippocampal and cellular atrophy, or a dysregulated HPA system, without knowing the central pathophysiology (or pathophysiologies) of major depression. Thus, we can know that depression reflects a biological illness even when we do not know the particular pathology behind it.”
However, here’s a statement from the ENIGMA MDD Working Group:
“The ENIGMA Major Depressive Disorder (MDD) Working Group is an international collaboration currently including 40 research samples from 14 different countries worldwide, including brain scans from around >5,000 MDD patients and >9,000 controls. The primary aim of our ENIGMA-MDD Working Group is to identify imaging markers that robustly discriminate MDD patients from healthy controls across many different samples using carefully a priori planned, standardized image processing and statistical analysis protocols.”
And here’s the conclusion from their tenth published paper:
“Over the past 7 years since its initiation, ENIGMA MDD has brought together research groups across the world with broad expertize to work together to gain a better understanding of brain abnormalities associated with MDD. By addressing issues of underpowered studies, our work has provided more reliable estimates of the extent of structural brain abnormalities in depression, showing that variability in structural brain alterations may only account for a small percentage of the depression phenotype.” (p 15) [Emphasis added]
And ENIGMA MDD is arguably the largest and most comprehensive attempt ever conducted to identify the neurobiology associated with major depressive disorder. I have discussed the ENIGMA MDD project in more detail in an earlier post.
Back to Dr. Morehead:
“Critics of the DSM are wrong. Psychiatry is not at odds with other medical specialties. Psychiatry differs from them only in the sense that more of the diseases behind psychiatric syndromes lack full explication. But this is not evidence of psychiatry’s inferiority. It is evidence that the complexity of the human brain far exceeds that of all other organs combined.”
But the pathophysiology of Alzheimer’s dementia is reasonably well understood. As are some of the other general medical conditions listed in the DSM. There is no reason to believe that the brains of the individuals who suffer from these conditions are somehow simpler than the brains of the great majority of psychiatry’s clients.
It really is past time for psychiatry to let this futile debate fade away. People become sad, because sad things happen to them. It’s not an illness. Sometimes it’s just bad luck; other times it’s deliberate exploitation by third party individuals or institutions. And it always has a biological underpinning, as does every thought, feeling, or action that we perform.
But the biological underpinning is not pathological in nature. It is not an instance of something going wrong in our brains, but rather an instance of something going right. It is the normal, proper, and adaptive response to adverse events or abiding adverse circumstances.
It is nature’s way of alerting us to the need to make changes in our lifestyles, habits, circumstances, etc., and for the most part it is a successful mechanism. In those situations where a person either can’t, or chooses not to, make appropriate changes, the depression will usually deepen, often resulting in a descent to deep despair.
CONCLUSION
Numbing depressive feelings with drugs or high-voltage electric shocks to the brain is not a medical treatment. Rather, it is a quick fix, not much different from what might be obtained from a street corner dealer. The veneer of psychiatric medicalization has never been confirmed and is no more convincing now than it was seventy years ago.