I was recently pointed to this article by Johann Hari in The Guardian that takes a critical look at depression and the treatment for depression. Unfortunately, it turned out to be nothing more than the usual mental-illness denial talking points, misdirection, and obfuscation.

As you will see if you follow the link above, this is a well-worn topic here. The basics are this – there are those, for various reasons, who are engaged in what I think qualifies as mental-illness denial. They include scientologists, because they push their cult/religion as an alternative to psychiatry. There are also those who follow Szasz who saw psychiatry as a mechanism for political oppression. I also find denial at times among rival professions who want to take psychiatry down a peg or two (often they just confuse their experimental expertise for clinical expertise – always a problem).

They all tend to have in common the core claim that “mental illness” is a fiction. How can thoughts be diseased? This is ultimately a straw man that confuses different types of illness. Some illness is based in biological pathology – cells are damaged, deteriorating, poisoned, genetically flawed, or essentially not functioning within healthy parameters for some reason. You can often see the pathology in a biopsy or measure it with some physiological parameter.

But not all illness is pathological disease. There are also disorders in which some biological function is outside of healthy parameters without clear pathology. The brain in particular is prone to this type of illness, and that is because brain function depends on much more than just the health of its cells (neurons and glia). Even healthy brain cells can be organized in such a way that their neurological function is compromised.

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I recently came across a critique of a prior post of mine on the DSM-V – Mental Illness vs Normal Behavior. The critique is by Philip Hickey, a retired PhD psychologist, on his blog Behaviorism and Mental Health – An alternative perspective on mental disorders.

Hickey disagrees with my defense of psychiatry, which he seems to equate with an extreme “medicalization” approach to life problems. In his response, however, he does not actually address my position, as I very carefully laid it out. Instead he attacks a series of straw men – characters in a narrative that he apparently already has well established in his mind. This narrative creates a very thick filter distorting his view of my position.

Hickey summarizes his position early on:

Now, for me, this is fairly obviously true and is borne out by the facts.  Psychiatrists who talk in terms of “diagnoses” and “chemical imbalances” etc., do in fact ignore causal factors such as abuse, poverty, and social deprivation.  They call their clients “patients” and they routinely tell these “patients” that they have “an illness just like diabetes” and that the pills will fix their brain chemistry.

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I have dedicated this week to discussing the complex topic of mental illness, specifically responding to those, like Dr. Fred Baughman, who deny that it is legitimate. In my final installment I will deal specifically with the issue of drug therapy, covering some general principles, as it applies to mental illness in general, and to ADHD in particular.

Rational pharmacotherapy is a critical and effective part of modern medicine. The bottom line is that drugs save lives, extend our lives, and improve our quality of life. Like any technology, they are a tool. Because they are a potent tool, however, they also have the ability to harm.

This duality is reflected in public opinion, that both desires the benefits of modern pharmacology, but also harbors a deep fear and mistrust of drugs and chemicals – words that are often used as pejoratives. This distrust extends to the pharmaceutical industry, which is also the target of much conspiracy and anti-corporate ideology. I am not going to discuss the vices and virtues of big pharma today – that’s for another time – but rather try to close the gap between how physicians think of and use drugs and the public perception of them.

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In my previous posts on this topic I have argued that mental illnesses are as real and scientific as any medical entities, they often have a biological basis in brain function and we now have the tools to see aspects of this dysfunction, there is no clean distinction between mental and other medical symptoms as even classical pathology can cause psychiatric symptoms, the clinical basis of their diagnosis is legitimate medicine, and objections to the very existence of mental illness are not valid. But even many who accept all this still may have a problem with the current practice of mental health, especially the tendency to overdiagnose and prescribe drugs to treat mental symptoms. Today I will address these concerns.

First it is important to recognize that these questions are distinct from the underlying question of whether or not mental illness diagnoses are legitimate and represent real biological entities. Dr. Baughman and other mental illness deniers often make, in my opinion, the argument from final consequences logical fallacy – the implementation of mental health is flawed, therefore the underlying theories must also be flawed.

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I have been writing this week about mental illness denial, as a follow up to my debate with neurologist Fred Baughman on The Debate Hour. In my previous entries I pointed out that mental phenomena are manifestations of biological brain function, that sometimes classical diseases (like tumors and infection) of the brain can cause psychiatric symptoms, and further that brain function also depends upon more subtle biology – specifically the pattern of neuronal connections and the robustness of neurotransmitter activity, and that problems there can also result in mental disorders. Today I will discuss in more detail the evidence for a biological correlate to mental illness.

Dr. Baughman insisted numerous times during the debate that there is no evidence for a biological cause of any mental illness. This statement is demonstrably false – so let me demonstrate.

Of course, as mentioned above, there are numerous cases where classical pathology, the kind that Dr. Baughman admits into his privileged list of acceptable biological causes of disease, cause mental symptoms – such as depression, apathy, sedation, mania, and psychosis. Here there is no controversy – treat the underlying identifiable cause (if possible) and the mental symptoms should resolve, or at least improve or stabilize.

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Yesterday I wrote about my debate with Dr. Fred Baughman, who denies the existence of mental illness and the scientific legitimacy of the field of psychiatry. I laid out the basic foundation of modern neuroscience and how this leads to the conclusion that there must be mental illness, for the brain causes the mind and the brain is a biological organ like any other. Today I will discuss some of the specific arguing tactics that Baughman and others use to avoid this seemingly unavoidable conclusion.

All behavior is normal

Dr. Baughman’s points are more semantic arguments and misdirection than valid logic. He argues, for example, that the entire range of human behavior should be considered normal. All traits vary, he argues, and it is not valid to simply label the extreme ends of this variation as abnormal. To reiterate what I wrote yesterday, he returns to his position that only classic pathology can be considered a disease, he excludes all other criteria a-priori, and only disease can be considered a medical condition.

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On Friday I appeared on The Debate Hour hosted by the Infidel Guy, the topic of discussion being “Is psychiatry a legitimate science?” I was defending psychiatry as legitimate while Dr. Fred Baughman, also a neurologist, defended his long time position that psychiatry is (to quote his website) “100% fraud.” I thought I would use my next few entries to delve into some of the issues raised more deeply.

Now, there is much to criticize about the mental health professions. It is a very diverse collection of beliefs and methods, and it is not possible to paint this diversity with a single brush. It ranges from rigorous science to pure pseudoscience. It is also an extremely challenging field, dealing with the complexity of human thought and behavior and confronting difficult ethical issues such as autonomy and legal responsibility.

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The headline on this dubious health website reads: “ADHD is a FAKE Disease Invented by Big Pharma to Drug Children for Profit.” Every bit of that headline is made up, ironically – it’s fake. I have written about ADHD previously, and also about mental illness denial itself. This is a common theme among proponents of alternative medicine or snake oil treatments, because it is a rhetorically convenient way to attack mainstream medicine and bolster medical conspiracy theories.

Let me dispense with the easy parts first – the diagnosis of attention deficit hyperactivity disorder (ADHD) was not “invented by Big Pharma.” Unsurprisingly, the article provides exactly zero evidence to support this conspiracy claim. Right there the author of this article, and the hosting site, have lost all credibility. This is a specific and dramatic factual claim. Any responsible journalist, or author on a site that takes it upon itself to dispense medical advice, would have invested the five minutes it would take to discover that it is not true.

It literally took me 30 seconds to find this reference, a published article detailing the history of the ADHD diagnosis (so someone less Google savvy might take 5-10 minutes, but I just searched on “history of ADHD diagnosis”). The medical profession does have a tendency to write things down and publish their observations and musings about medicine. This leaves a nice paper trail for any medical historian to follow. The first descriptions of something similar to ADHD go back to the 18th century. Sir Alexander Crichton published an entire book “On Attention and its Diseases” in 1798.

It is also interesting to note that, right from the beginning, it was recognized that disorders of attention are multifactorial:

“A distraction of attention does not necessarily have to be pathological, e.g. mental stimuli, volition, or education can have a great impact on healthy attention.”

What a concept – a behavior as complex as attention is the result of a combination of inherent ability and environment. In the subsequent 200 plus years our concept and knowledge of ADHD evolved, documented in the DSM, the standard manual of mental disorders. There is also a vast published literature on ADHD. Searching PubMed on ADHD results in over 2000 references. The second of which is a helpful review of the genetics of ADHD, in which they estimate that the heritability of ADHD is 30-40%. Roughly that means that the disorder is 30-40% genetic and 60-70% developmental or environmental.

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Psychologist Jeremy Shapiro has an interesting article on RawStory in which he argues that one of the pillars of science denial is the false dichotomy. I agree, and this point is worth exploring further. He also points out that the same fallacy in thinking is common in several mental disorders he treats.

The latter point may be true, but I don’t see how that adds much to our understanding of science denial, and may be perceived as inflammatory. For example, he says that borderline personality disorder clients often split the people in their world into all bad or all good. If you do one thing wrong, then you are a bad person. Likewise, perfectionists often perceive that any outcome or performance that is less than perfect gets lumped into one category of unsatisfactory.

I do think these can be useful examples to show how dichotomous thinking can lead to or at least support a mental disorder. Part of the goal of therapy for people with these disorders is cognitive therapy, to help them break out of their pattern of approaching the world as a simple dichotomy. But we have to be careful not to imply that science denial itself is a mental illness or disorder.

Denialism and False Dichotomy

A false dichotomy is a common logical fallacy in which many possibilities, or a continuum of possibilities, is rhetorically collapsed into only two choices. People are either tall or short, there is no other option. There are just Democrats and Republicans.

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A recent article by Emily Korstanje details the story of Nadia, an 18 year old girl from Saudi Arabia who suffered from depression. Her religious parents took her to a faith healer who, through dubious methods involving choking her until she passed out, concluded that her symptoms were the result of demonic possession.

Fortunately Nadia was able to break away from that healer and defy her parents, but she still faces a more difficult challenge – her society.

“They need to separate religion from psychology, especially for us women, who suffer from depression because of our shitty circumstances, or we cannot—and will not—get help,” Nadia sad. “Society also needs to be rid of this of shame toward mental illness and stop saying that people are weak or not perfect believers, or possessed! Spirituality is important but it doesn’t mean that you deny what is really going on because it will only get worse.”

In the past, before science helped us understand things like psychology and neuroscience, it is understandable that prescientific cultures would reach for superstition to explain mental illness and neurological disorders. They had no way of understanding what a seizure was, let alone schizophrenia. So they used what explanations they had at hand and decided that such individuals were possessed by evil spirits, or cursed, or were being punished by god or the gods.

It amazes me, however, that in the 21st century this still occurs. Now, with all the knowledge of modern neuroscience, there is no excuse for confusing a brain disorder with spiritual possession. Further, we do not need to look to third world countries to find example – this is still happening in modern industrialized nations.

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