First of all, let me state that I am a Board-certified psychiatrist with 22 years of postgraduate experience, working in a mainstream, medication-oriented practice for a hospital corporation—NOT some left-field wacko or pissed-off psychoanalyst. So I am a believer in psychiatry, at least in concept. But it’s high time for progressives, including those who may have seen benefits from psychiatric treatment for themselves or a loved one, and those compelled to defend us against the forces of neo-superstition, to face a harsh truth about contemporary psychiatry: the scientific underpinnings of biological psychiatry are for the most part bullshit, the product of bad science generated by the corrupted institutions of psychiatric research.
First of all, consider the brain. It’s far and away the most anatomically and physiologically complex organ of the human body. It’s completely encased in bone. The vast array of functions it performs originate at a microcellular level. And it is IMPOSSIBLE to perform anything but the most cursory physiological examination of these processes without doing irreversible damage to the organ. CAT scans, MRIs, PET scans, etc.—all of these high-tech studies give you only the most coarse picture of what’s happening physiologically. The minute amounts of neurochemicals involved in the processes cannot be measured in the peripheral blood. Animal studies, in vitro studies, and postmortem studies are all of little value, because they can’t demonstrate you how a human brain actually works.
But that’s just the brain—then there’s the mind. A good way to differentiate the two is to use the analogy of a computer, considering the brain as the hardware, and the mind as software. Now consider the fact that the brain has developmental plasticity, i.e. as it grows in the child it does so in a completely unique manner, in response to a myriad of physiological and environmental factors—so that no two brains in the world have exactly the same hardware system. Then note that the software system is even more plastic, processing all one’s life experiences, parental instruction and modeling, our pains and pleasures—with an even more highly individuated result. What we have in the world today is over 6 billion megacomputers, each with its own unique hardware and software installation. What little we know now about this hardware system dwarfs what we know physiologically about the software. The "coding" of the simplest memory—say, a mental image of a childhood dog—is utterly inscrutable to us, if for no other reason because of the dissimilarity of all these unique cognitive systems. I believe the operations of this brain/mind system to be the single greatest scientific mystery of all—and contemporary psychiatry has not even begun to solve it.
Nonetheless we are discharged with the duty to treat patients with identified mental disorders. Over the years we have stumbled upon medications that provide significant benefit to some, and therapeutic techniques that likewise help in some cases. But our real understanding of the underlying processes is next to nil. So how do we justify our treatments to a patient population that wants to know what a problem is, or how a treatment works?
Well, historically psychiatrists have typically filled in the gaps of their knowledge by just making shit up. The most visible example is the psychoanalysts, who made up drive theory, the id, the ego, the superego, anal fixation, penis envy, and a bunch of other stuff. And that’s but one set of the numerous inventions that psychiatrists have cooked up over the years to explain psychiatric phenomena. Sure, we’ve advanced from demons to defenses, from dementia praecox to major depression—but a great preponderance of what passes for scientific fact in psychiatry is still half-baked supposition, propped up by a steady stream of corrupted pseudoscience generated by a research community that is drunk on money from the pharmaceutical industry and other commercial interests. There are a good number of ways that this corruption of the scientific method manifests itself—the mythical "chemical imbalance", the systematic exaggeration of medication benefits, etc.—each worthy of its own diary. But my focus here today is on the issue of psychiatric diagnosis.
Most medical diagnoses start as a syndrome—that is, a collection of signs (observed abnormalities) and symptoms (complaints by the patient)—and are defined as a diagnosis once the etiology (cause) is established. When the American Psychiatric Association began compiling accepted diagnostic entities into the Diagnostics and Statistics Manual (or DSM) in order to promote uniformity of nomenclature, a lot of the defined disorders were based on controversial causes, often drawing from psychoanalytical theory. In its third edition (DSM-III) published in 1980, it was decided to remove all suggestion of etiology from the compendium, defining disorders strictly on the basis of the observed signs and reported symptoms. The result was considerable improvement of inter-rater reliability, but diminished clinical meaning for the diagnosis—since it was intentionally dumbed down by excluding the clinician’s interpretation of causation. For example, depression that appears out of the blue with no apparent stressor is not in any way distinguished diagnostically from depression that appears in response to overwhelming life stressors. By neglecting causation, it logically follows that the nominal identification of a disorder will has less predictive value in the selection of an effective treatment regimen—which casts doubt on the wisdom of using this approach. But in the topsy-turvy world of biological psychiatry, logic, wisdom, and doubt are nothing more than disposable nuisances.
Recently a diary appeared on the Recommended list citing an MSNBC article, which reported an apparent increase in the number of children with autism. As a psychiatrist with no particular expertise in autism, I feel unqualified to summarily dismiss the validity of this report, especially since the information available was quite sketchy. But I can with great certainty report that we ARE experiencing an epidemic of psychiatric diagnoses over the past couple of decades—and I highly suspect that this explains the article’s contention.
Autism is but one of a number of psychiatric diagnoses that have been dramatically expanded in scope over the past couple of decades. These diagnostic entities are referred to as spectrum disorders, which are characterized by traits that occur in varying degrees across the range of human behavior, defying any specific effort to differentiate between what is pathological and what is merely a normal variant. The most dramatically abused diagnosis of this type is bipolar disorder, which follows the typical pattern of expanding the boundaries of designated pathology:
- Take a diagnosis that has a history of being acceptance in the psychiatric community as valid. (In the case of bipolar disorder, that would be "classic" manic-depressive illness.)
- Expand the applicable signs and symptoms far beyond the traditional boundaries of pathology in order to define a new "spectrum" of psychiatric disorders. (Manic-depressive illness became "Bipolar I Disorder", while the broader spectrum of mood instability was defined as "Bipolar II Disorder".)
- Market and prescribe medications to treat these newly defined disorders. (In the case of Bipolar II Disorders, a generation of anticonvulsant medications, became FDA-approved for treatment.)
The same process of expanding "pathological" criteria has since been applied to Attention Deficit Disorder and Autism. It has been ushered in by the dominant contemporary paradigm of biological psychiatry, which has apparently never met a statistical outlier that it couldn’t pathologize. It sells a "Brave New World"-style dream of cosmetic psychopharmacology, a world in which bothersome personality quirks or weaknesses will eventually become treatable psychiatric illnesses.
It would be easy to attack the ethical and spiritual deficits that haunt this vision, but that would be out of my area of expertise as a psychiatrist. So instead I’ll hit it right in the metaphorical breadbasket—it’s based on bullshit science that refuses to exercise appropriate rigor to the interpretation of its data, due to a vested interest in the outcome. This corruption is driven not only by money—lots of it—but by a fundamental insecurity that psychiatry has carried throughout its sordid history. Other doctors have always disliked psychiatrists, in part because they don’t dealing with psychiatric patients, but also because they have doubted their validity as physicians. Biological psychiatry has given psychiatrists not only money, but credibility as a medical specialty—now we’re "one of the guys", practicing medicine instead of voodoo.
However, in order to gain this status, we’ve once again fallen back on making up shit to fill in the blanks. We’ve discovered three neurochemicals that indeed appear to be involved in the mediation of mood—-norepinephrine, serotonin, and dopamine—and now we’re acting like we have it ALL sussed out. We have a long list of defined disorders that are spreading like an epidemiological wildfire throughout the population, but each of them is stupid at the core—because our diagnostic classification willfully neglects the issue of causation, and relies on superficial diagnostic criteria just so we psychiatrists can agree on them. THEN we conveniently forget that fundamental flaw, and pretend that they’re real diseases.
The point is clearly illustrated in the previously referenced diary, which cited another article reporting the research finding that 1% of all cases of autism are associated with a specific genetic abnormality. This finding calls into question our entire system of classifying psychiatric disorders—because if 1% of patients with a clinical syndrome have an identified cause, then that would in other specialties call for the definition of a unique disease state with a genetic etiology. But in doing so now, it would violate the arbitrary rule of neglecting causation in defining psychiatric disorders. It also raises the question: If this 1% is caused by a known genetic defect, then what the hell is causing the disorder in all the other cases that are lumped into this diagnostic classification?
Just a hunch here, but I’m willing to bet that most of the cases with this genetic abnormality would have fallen into the stricter historical definition of autism—a clinical presentation that emerged on its own as a diagnostic entity—rather than the vast number of "afflicted" persons that have been uncovered after systematic nitpicking of the general population. It’s just part of an Orwellian grand design: a narrow view of "health" applied to the diversity of human endowment, a reductionist vision that values half-assed biological evidence over contemplation of the human spirit. Oh, and the marketing of quick fixes for fashionable diagnoses.
Progressives as a rule reflexively jump to the defense of psychiatry against its critics—either because they generalize from their own limited experience, or because we share common enemies. But those who feel like doing so here and now should instead reflect on just who I am. I’m not a victim of psychiatry, I’m a beneficiary. I’m not an outsider, but an insider. I’m writing this diary for no other fact that SCIENCE IS BEING ABUSED—and as a believer in science, I cannot stand by and let others be deceived. Progressives who likewise believe in science need to examine their own understanding of its basic principles, and apply rigorous skepticism to anything that is touted as scientific fact—because rigorous skepticism is in fact the life’s blood of science.
I will continue to diary on related topics over the coming year. I invite you to visit my website, and those of other psychiatric skeptics, with an open mind—because in fact there is something rotten in psychiatry, and many of us know it.
ADDENDUM: Many valid concerns were raised in the Comments about my observations regarding autism in the diary above. I must admit that autism is not my area of expertise, and that I used that subject as a springboard to address larger concerns that I had about psychiatric diagnosis. I in no way meant to discredit the initial diary post by mem from somerville, which advocates for support of the Human Genome Project, which is indeed a worthy cause.
I also have to acknowledge that the broader definition and recognition of autism apparently helps individuals, who have in the past suffered because their differences, to obtain services to help them cope and function at their optimum level. Unlike the other spectrum diagnoses I referred to, autism is NOT associated with established pharmaceutical treatments, so the kind of systemic corruption I noted is not directly applicable. In truth, autism is the least pertinent spectrum diagnosis to allude to her, so I should have probably exoluded it from my larger argument.
Because of these concerns, I have retitled the diary. I will continue to address the core issues raised, but will exercise more caution to avoid stepping out of my area of expertise. I apologize for these lapses, and thank you for your constructive feedback.