Feb 04 2013

DSM-V – Mental Illness vs Normal Behavior

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36 Responses to “DSM-V – Mental Illness vs Normal Behavior”

  1. arnieon 04 Feb 2013 at 9:27 am

    Steve
    Thank you for your exceptionally balanced and thoughtful comments. Forty five years of psychiatric practice weighted toward psychotherapy and cross-cultural work leads me with very little to add except that, in psychiatry, I do still find a tendency to excessive effort expended on trying to categorize into discrete “entities” and not enough recognition and acceptance of the fact that most, if not all, of the clusters of mood, thought and behavioral symptoms and signs in reality represent spectra rather than discrete entities and that diagnostic “categories” and labels are at least partly arbitrary as each blends, and overlaps with, others. The almost infinite complexity of this topic (and of each person to which it relates) is best responded to with a huge dose of humble realization that any discussion of it is inevitably fraught with conceptual and liguistic over-simplification. Your summary, however, was about as good as it gets.

  2. ccbowerson 04 Feb 2013 at 10:01 am

    “It is relatively straightforward to generate a simple list of problems that can be reliably and validly defined. There is no reason to assume that these phenomena cluster into diagnostic categories or are the consequences of underlying illnesses.”

    When he says this is he denying that symptoms cluster, or is he saying that we shouldn’t assume clustering when generating a list of problems? The former is an untenable position -that symptoms don’t cluster, and the latter interpretation becomes a mundane point of not assuming that the “simple list of problems” will necessarily cluster into a diagnostic categories.

  3. Ori Vandewalleon 04 Feb 2013 at 10:06 am

    I have two comments on this issue.

    First, I find the distinction drawn by some between mental disorders that are biological in nature and those that are the result of abuse and other external factors to be rather silly. Unless any of us believes in mind-body dualism, all psychological disorders are biological in nature. The question is whether we’re able to identify the specific biological issue, and the degree to which an unhealthy state of mind is influenced by factors that are not biological. But ultimately, if we’re depressed or schizophrenic or binge-eating, it’s because of something happening to the fleshy gray lump inside our skull.

    Second, while I’m not entirely unsympathetic to the idea that we are overmedicating ourselves, I find the argument that we’re treating made-up syndromes to be somewhat clueless. Most people that criticize the treatment of oppositional defiant disorder, intermittent explosive disorder, or even binge-eating would probably agree that there are extreme cases of these types of behavior that require clinical intervention. The unstated assumption here is that there is some fundamental difference between having annoying personality traits and having a mental disorder. It’s as if there’s some switch in the brain that gets flipped: on the one side are rebellious, angry, and fat people, while on the other side are sick people requiring treatment. I don’t see any evidence to indicate our brains have such switches.

  4. Steven Novellaon 04 Feb 2013 at 10:15 am

    Ori – I agree. Some disorders are made obvious by the extreme cases (just watch the show, Horders, to see some examples). Hording is now a DSM-V diagnosis, BTW. The extremes demonstrate the validity of the categories.

    The real question is – where is the boundary between a disorder and the healthy range of human diversity of behavior? This is tricky, there is a spectrum with no clear demarcation. As you say, there is no switch.

    We need to avoid the false dichotomy of healthy vs disorder – it’s a spectrum

    We also need to avoid the fallacy of the false continuum – a spectrum does not mean the extremes are not real, and in this case constitute a disorder.

    However (it’s always more complicated) not all mental traits vary on a Bell curve. There are some bimodal distributions, meaning that there really is a discrete entity at work – perhaps a disease. Perhaps there are some “switches” – circuits in the brain that malfunction, or genetic variants. We tend to think of such disorders as neurological, rather than psychiatric – but as you say – it all has to do with the gray meat in our skulls.

  5. MKandeferon 04 Feb 2013 at 10:16 am

    Ori said,

    “Unless any of us believes in mind-body dualism, all psychological disorders are biological in nature. The question is whether we’re able to identify the specific biological issue, and the degree to which an unhealthy state of mind is influenced by factors that are not biological.”

    Interestingly enough, when designing the DSM-V those analyzing the definition for “mental disorder” raised a similar point about moving away from the word “mental illness” as it is a vestige of dualistic thinking. Their proposed alternative was “psychiatric disorder”.

    While I do agree it’s important to look at the biology and it is mostly about the brain, sometimes social-environmental factors are enough to construct “good enough” models for diagnosis and treatment.

  6. Ori Vandewalleon 04 Feb 2013 at 10:34 am

    Dr. Novella,

    Is there a particular reason why the switch-like disorders are thought of as neurological but the spectrum-like ones are thought of as psychiatric? Or is it just an historical accident?

  7. ccbowerson 04 Feb 2013 at 10:37 am

    “Second, while I’m not entirely unsympathetic to the idea that we are overmedicating ourselves”

    One of the better examples of this, I think, how often medications are prescribed for depression and anxiety and how often Cogntive behavioral therapy (CBT) is prescribed and/or used. There does seem to be some mismatch between the evidence and practice. I’m sure that there many factors at play: patient expectation, ease of use, insurance coverage, attitudes about therapy versus medication, etc, but it does deserve more attention. It is one thing to point out improvements that should be made, but its another to exaggerate or mischaracterize the problem as is often done.

  8. nowooon 04 Feb 2013 at 12:19 pm

    I think Dr. Rob Tarzwell’s latest One Minute Medical School video “What is a Psychiatric Disorder?” is relevant to this topic: https://www.youtube.com/watch?&v=BSC4CI7C6hI

  9. locutusbrgon 04 Feb 2013 at 12:33 pm

    @ccbowers
    I am a little confused by your point.
    Initially you seemed to be agreeing with over medication. Then you ended with a statement that seems to be saying the opposite?

    People like pills.
    social stigma and perception of mental illness drive them to seek out the infectious disease model of treatment. Easy to hide and justify pills. There is a societal stigma with CBT that makes it difficult to convince patients. In my opinion at least part of the reason that the numbers are disproportionate.

  10. chrisjon 04 Feb 2013 at 1:25 pm

    @Ori

    “I find the distinction drawn by some between mental disorders that are biological in nature and those that are the result of abuse and other external factors to be rather silly. Unless any of us believes in mind-body dualism, all psychological disorders are biological in nature.”

    While I am a dyed-in-the-wool physicalist, I think this is a bit uncharitable. While all of these disorders have biological causes and treatments, there does seem to be a reasonable distinction between causal factors that come from the environment (these still count as biological, but you get the point) and causal factors that are more directly chemical. It is also reasonable to distinguish between treatments that are less directly chemical (talk therapy) and those that are directly chemical (medications). Is there something wrong with these distinctions or is it just a terminological objection you are making?

  11. daedalus2uon 04 Feb 2013 at 1:38 pm

    The problem of what is “normal” and what is a “disorder” and what is a “disease” is not unique to mental health issues. Many aspects of physiology that are perceived to be problematic are actually completely “normal” in that that is how those systems evolved to function. An example I like to use is anaphylaxis. Is anaphylaxis “normal”? Yes, it is, but it can also kill you dead.

    Is PTSD “normal”?

    If you are living in a war-zone under constant threat of death, what would be the ideal phenotype to exhibit? Hypervigilance? Of course, you wouldn’t want anything dangerous to sneak up on you. Insomnia? Of course, you wouldn’t want anything dangerous to sneak up on you while you are asleep. Lightning quick temper? Of course, if it is kill or be killed, he/she who responds with violence first has an advantage. Flat affect? Of course, if you are surrounded by potential enemies, you wouldn’t want them to be able to read your body language. Flashbacks? Of course, it would enhance survival to relive traumatic events to “practice” responding to them both cognitively and with the neuroendocrine system. Flashbacks also have the “feature” of maintaining the PTSD state.

    In my conceptualization of physiology, I like to make a distinction as to things that are “normal as process”, that is all things that occur via “normal” development, that is all things that result from physiology acting and developing without external ongoing perturbation and things that are due to abnormal development, from toxicity responses, from genetic abnormalities, from physical trauma.

    From a “normal as process”, a great many disorders are not from physiology not working correctly, physiology is working, it is just working to a setpoint that causes outcomes that are not desired. Anaphylaxis for example. It is the immune system working “normally” when it encounters an antigen it has been sensitized to in a place where it should not be.

    Another example is excitotoxicity neuron death. Loss of neurons is unfortunate, but maintaining the viability of the brain and preventing future seizures is more important than the loss of a few neurons. I think this is what causes neuron loss following seizures and strokes. The brain is pruning neurons that lack sufficient inhibitory control so as to prevent a seizure in the future. A seizure while running from a bear would be fatal, loss of a few percent of your brain is not.

  12. Ori Vandewalleon 04 Feb 2013 at 1:42 pm

    chrisj,

    I think it’s fine to distinguish between different treatments for the purposes of determining which treatment is best, but I think it’s important to remember that it’s all chemical in the end. I’m very interested in studies that show the direct, biological effects of options such as therapy or meditation. If we can understand the specific mechanism of action rather than just the overall outcome, we can better tailor treatments in the future.

    That said, I understand this is somewhat of a problem with the current crop of anti-depressants as well, for example. We know SSRIs have an overall positive effect on mood, but we’re less clear on exactly why. Yes, they inhibit the reuptake of seratonin, but there’s a good deal of discussion as to whether or not that’s the primary effect, or if it is, why it’s effective.

  13. Kawarthajonon 04 Feb 2013 at 2:50 pm

    Based on the above-definition of Binge Eating, I would definitely qualify based on my behaviour last night at a Superbowl party! Oh, the heartburn from all those chips is still plaguing me!

    On a more serious note, I am interested to hear people say they have a chemical imbalance when discussing their mental illness (I work with people with mental illnesses). There is no chemical test to determine whether this is true. The diagnosis of mental illnesses is entirely symptom based and sometimes very haphazard, imo. I’m not disagreeing with the fact that mental illnesses exist or that they are often biologically based (although I would argue that you need a perfect combination of environment and genetics to make a mental illness), but I have never come across someone who has had any kind of chemical test to determine whether they have depression or Bipolar Disorder. I also see tremendous hit and miss diagnoses, especially when you cross over into the tricky area of personality disorders. People who are eventually diagnosed with personality disorders are often first diagnosed with other disorders first, as they repeatedly show up at the hospital mental health department in crisis, including depression, anxiety and bipolar disorder. This kind of trial and error diagnosis definitely plays a role in promoting the idea that mental illnesses are made-up labels, even if they are not. There has been research on the poor reliability of a psychiatrist’s ability to diagnose a patient – different physicians will diagnose the same patient with the same symptoms with different disorders. Clearly there is much work to be done here.

    Also, I take exception to the idea that all clinical psychologists are on one side of this debate and all psychiatrists are on the other. There is much more diversity in the field than this article supposes. I work with many psychologists who are supportive of the idea of mental illnesses as distinct disorders. In fact, clinical psychologists (in my experience) are much more likely to use actuarial assessments to determine whether people have behaviour that falls into the norm or whether they are more likely to have a mental illness (i.e Beck Depression Inventory, ironically developed by a psychiatrist but mostly used by psychologists). Psychiatrists typically do not use any actuarial assessments (in my experience) and base their diagnoses on brief (30 minutes) interviews with their patient, sometiems without having any independent information to support their opinions. Clinical psychologists in Canada have made many attempts to be given the right to diagnose patients with recognized mental illnesses and to prescribe medication, although they have been unsuccessful up to this point (whether or not you agree with psychologists prescribing medicine, this at least suggests that they recognize mental illnesses as legitimate categories).

  14. ivoryboneson 04 Feb 2013 at 3:30 pm

    It seems like there is a functional limit to these diagnostic techniques. If a hoarder had alot of space for his material possessions then he would be functioning fine or not hoarding. Or a doomsday prepper spending little percent of his/her resources for bunkers and supplies would be not be very unreasonable. I guess the strategy for GP’s if a patient is on a fine line would be to push them a little towards a balanced lifestyle but not necessarily diagnose them as mentally ill. very interesting!

  15. ccbowerson 04 Feb 2013 at 4:02 pm

    “I am a little confused by your point.
    Initially you seemed to be agreeing with over medication. Then you ended with a statement that seems to be saying the opposite?”

    I didn’t think I was confusing, but I guess I don’t write as clearly as I think I do. I was agreeing that there are examples of medications getting priority over other therapies that are at least as effective (in reaction to Ori’s overmedication comment), but on the other hand not granting that we need to throw the whole thing out (the mental illess deniers at the extreme of this).

  16. ccbowerson 04 Feb 2013 at 4:07 pm

    “Is PTSD “normal”?”
    D2u – Perhaps I’m stating the obvious, but in your example of PTSD the issue is that once the environment of constant threat is removed, the previously adaptive behaviors/symptoms persist as maladaptive ones.

  17. daedalus2uon 04 Feb 2013 at 7:18 pm

    CC, yes you are stating the obvious, but that is not how the military, or the VA, or psychologists or psychiatrists think about it.

    The “problem” isn’t the PTSD state, it is the persistence of the PTSD state in a non-threat situation. It is the persistence of the fight-or-flight state and a persistent low activation threshold for entering the fight-or-flight state that is the problem.

    What is needed is more of what ever it is that turns off the fight-or-flight state.

    I know it is obvious, but essentially no one working in the field wants to think about what might be the opposite of what triggers the fight-or-flight state because they are caught up in the false paradigm of homeostasis.

    One of the things that turns off the fight-or-flight state is the placebo effect. A mother’s “kiss it and make it better” helps a child to get over a fight-or-flight state from a boo-boo. Presumably something that triggered the placebo effect would help with PTSD too.

    The fight-or-flight state has to be controlled psychologically because only the CNS can do threat analysis and trigger fight-or-flight and then also trigger the anti-fight-or-flight mechanism after determining that it is safe to do so.

    What is perturbed in PTSD are the various thresholds for state transitions. These are controlled by physiology, but if the underlying pathways are interfered with, physiology can’t compensate because the compensatory pathways themselves are affected.

  18. ConspicuousCarlon 04 Feb 2013 at 7:40 pm

    Steven Novella on 04 Feb 2013 at 10:15 am

    There are some bimodal distributions, meaning that there really is a discrete entity at work – perhaps a disease.

    Can you give us an example or two? Maybe I already know them and don’t realize it, but it seems like most of the subjects we run into in skeptic land tend to be merely the fringe-of-normal kind of thinking (over stimulation, paranoia, confabulation, loose associations). Or does bimodal merely mean that there is little/no central distribution to some of those very things?

  19. mnestison 04 Feb 2013 at 11:06 pm

    Just a quick note Steve. I am a psychologist, technically a clinical neuropsychologist, and definitely do not agree with Klinderman or the late Szasz. You kind of lumped psychologists together, but I’d venture that the vast majority do not ascribe to such views. With some certainty I’d say that neuropsychologists as a group do not. As most neurologists we view the brain and biology as central to behavior – brain behavior relationships are the central theme we study. Environment is important factor to consider, for some conditions more than others.
    What I will say is that if there is a weakness in the dsm, it is that some of the criteria proposed for certain disorders have a better foundation in scientific evidence than others. The autism study group, for all the criticism they recieved, appeared to be advancing diagnostic criteria based upon good research and science. Same with dementing and cognitive/developmental disorders to varying extents. However other proposed guidelines lacked much evidence base, such as temper dysregulation disorder. I haven’t read up on all of the changes, but some of the better science based practitioners have mentioned the lack of evidence base in other categories, such as some of the proposed changes to personality disorders. It will likely be an uneven project, but so were past iterations. It will serve a purpose as a guide, a rough one for some disorders and a better one for others.

  20. Steven Novellaon 05 Feb 2013 at 6:54 am

    Sorry for the implication that most clinical psychologists share Kinderman’s view. What I meant to express was that when I encounter people expressing Kinderman’s view, they tend to be psychologists, and there tends to be an anti-psychiatry undertone. I am glad that this is not the common view.

  21. arnieon 05 Feb 2013 at 8:12 am

    mnestis, As a psychiatrist, I am very much in agreement with you and you expressed the DSM issue nicely. Now if only more clinicians would use it more as you suggested and less as “revealed truth”, patients might feel less labeled and pigeon-holed and more related to as the unique and complex individuals that they are.

    I’m still a bit puzzled, Steve, by your insistence on “discreet entities”. I struggle to think of any behavioral, cognitive, or mood patterns that I don’t see on a continuum or spectrum basis in both my clinical work as well as non-clinical interpersonal relationships. That is not to say that there aren’t ranges from essentially less-dysfunctional (or less-pathological, -adaptive, -productive, -normal — choose your term) to more-dysfunctional etc.) But the point on the continuum at which mood, thought patterns, or behavior qualify for a label of “disorder”, is highly arbitrary and often depends on context such as culture, work, school, etc. Of course, in the extremes of the continuum, it is often easy to make the designation, but very frequently the persons life as a whole has to be taken into account and the context of the “pathos” to determine both the degree of function-dysfunction as well as the choice or combination of therapeutic approaches chosen to assist someone to move further toward the desired end of the spectrum. At least in my specialty work with “personality disorders” that seems to be a useful approach. And yes, I do see it as all fundamentally biological, with the psychological-mental-interpersonal-cultural “languages” being ways to conceptualize and communicate about the activities of the brain interacting with other brains and environmental experiences. Do we disagree?

  22. pseudonymoniaeon 05 Feb 2013 at 7:41 pm

    Dr. Novella you suggest that the following features of mental illness diagnosis and treatment may be independent of each other:

    “how should we identify and categorize those with mental complaints, how should we approach research and diagnosis into underlying causes, and which therapeutic interventions are most effective? In my opinion these are independent variables.” [emphasis mine]

    However, it is not clear to me how this could be the case. In fact, it is my impression that diagnostic categories, research into causes and the development and validation of interventions tend to be inextricably linked. Perhaps not at the level of the individual clinician in his or her daily activities, but certainly in how the research literature is organized. Indeed, your own words support this interpretation:

    “psychiatrists understand that the categories, or clusters of symptoms, with labels in the DSM are partly labels of convenience – for research, clinical reporting, and insurance coverage” [emphasis mine]

    And because the literature is used (at least explicitly) as a key determinant of best (that is, evidence-based) clinical practice, it is difficult for me to understand how we can extract the process of categorization, as performed by the DSM, from inherently influencing how we understand and treat these illnesses.

    For example, I’m not quite sure how you can make the argument that:

    “the question as to which therapeutic approach is most effective can be completely disconnected to how we approach labeling symptoms”

    On the one hand I will accept that within a diagnostic cluster individuals may receive different treatments. But this is fundamentally different than arguing a complete disconnect between diagnostic categories and treatments.

    I know that regularly your perspectives are quite consistent, so would you mind to clarify on what your position is regarding this topic?

  23. Steven Novellaon 05 Feb 2013 at 8:40 pm

    Kinderman was making the specific point that labeling syndromes and suggesting they are chemical imbalances implies they should be treated with drugs.

    My point is that – the clinical evidence determines which treatments are effective, independent from our theories of causation.

    Of course these are not completely disconnected, and I never said that. Categories are used to research treatments. But what determines those categories is independent from what determines treatment, or what determines our conclusions about cause.

    They are determined independently, but they do conceptually play off each other.

  24. Boondockson 05 Feb 2013 at 11:35 pm

    “Research is trying to tease apart whether binge eating is due to an underlying problem with eating regulation, or if it is produced by dietary restraint (severe forms of dieting). There is no assumption of biology here, nor is there an assumption that the best treatment approach is medical.”

    There is most definitely an assumption of biology when you declare overeating to be a “medical” problem and set about researching “eating regulation”.

    “nor is there an assumption that the best treatment approach is medical.”

    The word treatment is synonymous with medicine and medical approaches.

    This entire article shows the author is in the tank for psychiatry’s medicalization of humanity. Comparing critics to, or even bringing up the small fringe religion of Scientology, is a cheap shot at best. When people pose as the parsers of logical fallacies and then throw in the Scientology jibes, they undermine themselves.

    “My point is that – the clinical evidence determines which treatments are effective, independent from our theories of causation. ”

    The “clinical evidence” determines the outcomes in people’s lives who’ve been told a story by psychiatrists, a creation story. To say the outcomes in people’s lives are independent from “theories of causation” is just patently ridiculous.

    “Ori – I agree. Some disorders are made obvious by the extreme cases (just watch the show, Horders, to see some examples). Hording is now a DSM-V diagnosis, BTW. The extremes demonstrate the validity of the categories.”

    Oh it’s so obvious!!! Look at the “diseased” people collecting too many things in their house. Their behavior “demonstrates the validity” of declaring behaviors “symptoms”.

    “It’s easy to get bogged down in semantics in this area, and I am not saying that language is not important to how we think about such things, but semantics aside I think there is general agreement (Szaszians and Scientologists notwithstanding) that many people have mental symptoms that they find unpleasant or functionally impairing with which they would like help.”

    The completely bad faith argument that people who don’t believe problems in life are “symptoms”, don’t agree the problems are unpleasant and that people would like to solve them or find “help”.

    For a neurologist, it is a shame to see you defending a profession that has done more brain damage to millions of people than any other human endeavor in history.

    Psychiatry is misguided and harmful. You might agree collecting too many objects or having a certain set of thoughts is harmful, but believing human behavior is a disease is also a harmful problem to have, too.

    “I disagree. With respect to mental illness “the language of illness” is much more complex and nuanced than Kinderman is indicating. Many of the diagnoses in the DSM are “disorders” or otherwise contain no implication at all that the underlying cause is a chemical imbalance.”

    Your reading of the DSM doesn’t matter. The facts on the ground are, that psychiatry has told the entire world, (who don’t use or read the DSM), that people labeled with a DSM label are chemically imbalanced. Society didn’t just come to this conclusion, they were helped along by psychiatry’s propaganda. Furthermore even having the “helpers” of the extremes of life in the category of branch of the medical profession, sends the indelible message that the problems they attempt to address are medical in nature.

    Obviously you’re a believer in the psychiatric faith. There is no point even posting this. Next time you turn on the TV to watch “Hoarders”, that will be all the evidence you need of how “obviously” diseased such behavior is.

    Stick to actually talking about what science knows about brains. People like Kinderman rescue people from biological reductionist scientism and they are to be commended, not compared to Scientologists by people who claim to be the parsers of logical fallacies but neglect to mention their own strategic mention of Scientology is a guilt by association drive-by.

    For someone that lectures in “Medical Myths”, a faith in psychiatry requiring the wheeling in of Scientology specters to prop it up, is easy to see through.

  25. arnieon 06 Feb 2013 at 1:21 pm

    Boondocks — Should you someday feel adventuresome, you might venture a return to Planet Earth and discover that there are reams of scientific research studies and clinical reports (not to mention testimonials, if that is what you prefer) documenting the fact that psychiatry (more accurately, psychiatrists) has helped enrich (emotionally, cognitively, interpersonally) the lives of countless people throughout the world and not one shred of evidence that the “profession…..has done more brain damage to millions of people than any other human endeavor in human history”.

    That one assertion pretty much catches the tone of your entire attack on Dr. Novella and psychiatry.

  26. cannotsay2013on 09 Feb 2013 at 10:02 pm

    Mr Novella, let’s put it that way, there is and old saying that goes something like “a conservative is a liberal that has been mugged”. I think that the same is true about psychiatry. We are all for good medicine and good clinical practice, until we are abused. Statistically speaking, you are more likely to hear of “victims of psychiatry” than from people that have been “helped” by psychiatry. This is the exact of opposite of traditional medicine. While there are cases of medical malpractice on record, it’s more likely that you hear about some oncologist that cured someone than an oncologist “killing” someone. By “killing” I don’t mean that the cancer treatment failed but that the oncologist engaged in such unethical and abusive behavior that the patient died as a result. Most of us in the survivor movement, started with either an indifferent opinion about psychiatry or a positive one. We became what you call “szaszians” when we realized that we were abused and that psychiatry is basically a scam like astrology (compare Carson’s “A double-blind test of astrology” published by Nature in 1985 with the recent work by Irving Kirsch on antidepressants, you’ll see almost identical methods of analysis and yet, the psychiatric scam is still accepted by people like you). You don’t see a movement of those who survived oncology abuse for instance.

    I think that we can apply Occam’s razor thinking here. Thomas Szasz used to say that psychiatry is politics and economics, not science. And that explains very well why psychiatry is here. It serves the needs of Big Pharma and greedy psychiatrists (that’s the economics part) and it serves the interest of the powers that be to get rid of the undesirables (that’s the politics part). The symbiosis “greedy psychiatrists”-”Big Pharma”-”Powers that Be” is just too powerful to be broken. Essentially, psychiatry is this day and age’s inquisition. Nothing more, nothing less.

  27. Steven Novellaon 11 Feb 2013 at 7:46 am

    2013 – Do you have any reference to support the claim that psychiatry causes more harm than good, or do you just have your anecdotes and confirmation bias?

    Antidepressants work well for major depression, their effects are uncertain for mild to moderate depression. Don’t confuse the two.

    Invoking a grand conspiracy theory does not serve your position well. How, exactly, are the “powers that be” using psychiatry to get rid of undesirables? And please don’t give examples from the Soviet Union or more than 50 years ago.

    I agree that corporate greed is something that needs to be kept in check, which is why I favor effective regulation of the pharmaceutical industry (and supplement industry, and any health care). What regulation reforms do you advocate to make it more effective, or do you condemn all pharmaceuticals? (That would be throwing the baby out with the bathwater.)

  28. cannotsay2013on 13 Feb 2013 at 2:32 am

    Thanks for your reply.

    Several issues.

    First of all, let me be clear that I do not claim that there is a vast conspiracy. One of the most insidious accusations that I have had to endure when I express my criticism of psychiatry is to be labelled a “conspiracist” or to be put in company of AIDS denialists. There is no need to invent a conspiracy, it’s something as simple as human greed. In fact, it’s not even the deadliest scam that Big Pharma has ever perpetrated, there are much worse: http://www.youtube.com/watch?v=wg-52mHIjhs .

    Second, since I am sure that you are aware of Irving Kirsch’s work I am not going to bore you with the details. His conclusion, whose substance has not been seriously challenged by anybody, is not that they are effective in extreme cases of depression, rather that in those cases there is something we can call “statistical significance” (although not clinical significance). As Charles Seife explains well in his talk here http://www.youtube.com/watch?v=qiQwZ6inbOM (minute 30 and afterwards), statistical significance in this type of setting is completely meaningless. The bottom line is that antidepressants are no better than placebos or psychotherapy in the overwhelming majority of cases, and in the cases where they are slightly better, a better explanation seems to be the placebo effect amplified by the side effects of antidepressants. They are widely prescribed for one and only one reason: Big Pharma caches in, psychiatrists cash in. It is also a fact that the scandals of recent years in which Big Pharma companies have been forced to pay billions of dollars to settle civil and criminal charges have affected overwhelmingly the promotion of psychiatric drugs off label. It is also a fact that the 2008 investigation by US Senator Chuck Grassley that uncovered conflict of interests, undisclosed payments by Big Pharma to researchers receiving NIH money and ghost writing affected overwhelmingly psychiatrists. Psychiatric doctors have higher prevalence of corruption than other doctors, that’s a fact.

    Third, sure I have a proof that psychiatry does more harm than good. I could start with my own case http://www.madinamerica.com/2013/01/ny-times-invites-readers-to-a-dialogue-on-forced-treatment/#comment-19770 , which is far from unique. Before you throw at me an accusation that I am giving anecdotal evidence, you should consider the fact that there are plenty of associations of survivors of psychiatric abuse, whose members share stories similar to mine (or worse; in fact mine is on the mild side of the spectrum). You don’t see similar associations of survivors to “oncology abuse”. I, and many others, have been unfairly stigmatized for the rest of our lives. Because of what happened (even though it’s distant in the past) I cannot apply for jobs that require extensive background checks nor I can legally own guns according to federal law. I do not own guns and I do not intend to own any in the future but that said, I have been deprived of an American constitutional right without having committed any crime whatsoever. Not to mention that my marriage fell apart and I lost my parents for all practical purposes. I don’t know if they are still alive since I have no contact whatsoever with them.

    Fourth, you don’t have to go to 50 years ago or the Soviet Union to claim that psychiatry is used by the powers that be to get rid of the undesirables. Until very recently homosexuals were considered mentally ill (the WHO still considers ego dystonic homosexuality to be a mental illness). In an American context, psychiatric labeling can be used to deprive people from their second amendment rights despite the fact that by psychiatry’s own admission psychiatrists are very bad at predicting who’s likely to become violent. The expansionist nature of DSM-5, which I think was pushed again by Big Pharma’s greed, will make at least 30% of Americans eligible for a psychiatric label. Mr Obama just announced that he intends to make doctors “watchdogs” for people who shouldn’t be allowed to have guns. Which “doctors” do you think he had in mind? Oncologists? So there you go.

    Finally, psychiatry, particularly biological psychiatry, is one of the largest scams ever. The APA is on record that psychiatry doesn’t have any biological marker whatsoever (no blood test, no imaging, no anything) that can be used to reliably detect presence or absence of so called “mental illness” as described by the DSM. The reason the scam is allowed to continue, as I said, is because it serves the economic interests of Big Pharma and psychiatrists as well as the interests of the powers that be. Unlike oncology, psychiatry was not born to help anybody. It was born so that the powers that be could have a pseudoscientific tool to get rid of the undesirables. It’s this day and age’s inquisition.

  29. BuckarooSamuraion 13 Feb 2013 at 7:18 am

    Speaking about the DSM, here was a fun thread in r/Skeptic where an astrologer claims that psychology is barely scientific and astrology is just as valid. The astrologer initiates a challenge and asks for respectfulness then when his methodologies are question in a respectful manner resorts to personal vitriolic attacks.

    Here is the link:
    http://www.reddit.com/r/skeptic/comments/18deo5/so_astrology_is_bullshit_right/

    -Justin

  30. cannotsay2013on 13 Feb 2013 at 3:38 pm

    Samurai,

    You are spot on. The reality is that the pseudoscientific foundation of psychiatry is no better than that of astrology. I mentioned above the Shawn Carlson’s study that was published in Nature in 1985. Except for the fact that Kirsch’s work was a meta analysis, and thus had to rely on data collected over the years heterogeneously -and that fact does not affect the study’s conclusion-, the methodology and design of both studies was very similar, so was their conclusion. Just as astrology is no better than randomness in predicting people’s personalities, so are antidepressants no better than placebos in the treatment of so called “depression”. Although the Carlson’s study has been hailed by skeptics as a major debunk-er of astrology, to this day and age astrologers continue to spin the matter along the same lines as the supporters of anti depressants http://www.theoryofastrology.com/carlson/carlson.htm . You see defenders of antidepressants engaging in similar spinning exercises to support astrology.

    Now, while we, and I strongly support this because people should be free to buy whatever service they want, don’t ban astrology per se, we don’t give astrology the power of influencing legal decisions such as person X should be locked in preemptively because his natal chart shows that tomorrow he/she is likely to kill his/her neighbor. Or that person Y shouldn’t be convicted of a crime because his natal chart made him do it. And yet, despite similarly shaky foundations and predictive power, we give psychiatry the power to make similar legally binding decisions. Why this is the case, boggles my mind. And why so many “medical doctors”, such as Mr Novella, are willing to buy the psychiatric nonsense when they wouldn’t give a second of their time to analyze the claims of those who defend astrology with similar reasoning is also beyond my understanding. The only plausible reason I can think of is that these doctors have a hard time admitting that their colleagues who have a similar medical degree (MD) engage regularly in scientific misconduct. Rather than admitting that misconduct -and banning psychiatry as an AMA sanctioned specialty-, they close the ranks to protect their own. Again, no conspiracy implied here, just a basic human instinct: self-preservation.

  31. BillyJoe7on 14 Feb 2013 at 4:10 am

    Cannotsay,

    Apparently you have not had the experience of someone you know suffer an acute psychiatric illness and seen how psychiatry has helped restore that person back to normality.

  32. cannotsay2013on 14 Feb 2013 at 4:21 am

    As I said above, I had my life destroyed by psychiatry and so did the many people I know who are part of the different survivor organizations (MindFreedom, Icarus Project, etc).

    Anecdotal evidence that person X was helped by psychiatry cannot be used as a rationale to justify psychiatry’s undue power and abuses. Using your logic, we should give astrology the same legal power that psychiatry has. I can assure you that you can find many people who were, using your terminology, “restored back to normality” after a few sessions with an astrologer. Not very convincing. Yet, this type of shaky, non scientific, anecdotal reasoning is what psychiatry uses to justify itself. As I said earlier, the explanation politics/economics is the only one that can help make sense of the situation.

  33. madmidgitzon 22 Feb 2013 at 4:18 pm

    @ Steven novella

    I wish I had doctors like you, I have had many doctors( psychologists and psychiatrists as well as regular m.d’s ) label me into “mental disorders” wich then would influence other doctors and psychiatrists to treat symptoms I didn’t have because they were on the list of symptoms for my ” mental illness.(though these doctors were chosen by my mother, a overly trusting gullible person who fell into cam so the doctors I met may not be representative of doctors at large)
    I agree with with you on almost all your points( the ones I don’t agree with is just me being pendantic (: ) and hope that more doctors take this viewpoint.
    I also think that “mental illness” should be described as a mental problem or personality trait that is causing(larger? More than the general populations? Amounts of) harm to that persons life, mental health And ability to live in society

  34. madmidgitzon 22 Feb 2013 at 4:42 pm

    @ cannotstay 2013

    So you take personal anecdotes as the fact that everyone is harmed by psychiatry, that’s bullsh!t and you know it( or should ). Your argument is about as biased as you can get. You’ve looked up no fact or empirical data, no studies or statistics just some YouTube videos, youtubes about as reliable as a sex addict telling you he doesn’t have STDs .

    Here’s some personal anecdotes for you : I have been diagnosed with everything you could think of, if it has an A and a D in it I’ve probably been diagnosed with it.
    I was diagnosed with Aspergers when I was 6, medicated and nothing changed, then I was diagnosed with: add,ADHD, antisocial disorder and a bunch of others, also medicated nothing changed. Then my mother got more into CAM ( I was about twelve ) and stopped my medication and switched to alt med stuff (homeopathy,naturopath stuff,acupuncture,pyrroluria,herbs that actually had negative effects ) and some of my symptoms abated a bit ( so she fell in deeper) but then Instead of being a drugged up zombie some of my symptoms were completely untreated (alot if the following also had to do with my home enviroment)and I got angry and depressed I was getting into fights I wanted to die I wanted everyone else to die I had anxiety attacks, I had violent episodes and all sorts of destructive behaviour then I went to a doctor who had a view more in line with dr.novellas , he sent me to a couple of psychologists till I found one I liked(my parents sending me to more pseudo sciency ones)
    hung back on medicating me heavily, and when things got bad advised my parents to send me to treatment( a therapeutic boarding school ) and for my parents to go to therapy because something was obviously not working in the family dynamic we had then, the boarding school sucked, it was a badly designed system ( my parents having chosen it because it was in Utah And my mothers Mormon ) but I still learned a lot and continued my psychiatric help, then I became heavily depressed and if I hadn’t gotten medication then I would have killed myself, with the help if those meds I pulled myself out of that heavy depression, still live in America (before I got sent to Utah I lived in Australia) am off meds and the only thing i have now us mild depression all because I found a good psychiatrist who helped my get through adolescence , with out him I would certainly be dead or in jail

    So to cannotstay 2013
    I’m sorry you think you were hurt by psychiatry but you were probably mis-diagnosed or had a bad doctor (possibly a alt med or just some weirdo who had weird medical beliefs)

  35. madmidgitzon 22 Feb 2013 at 4:45 pm

    Shit happens

  36. oxdroveron 22 Sep 2013 at 6:25 pm

    DNA is not destiny. While some genes may predispose any human to certain “dysfunctional” behaviors, alcoholism being one example, not everyone with the genes is an alcoholic. environment turns genes off or on.

    The fMRI studies of various individuals with various “problematic” issues, such as ADHD, and psychopathy, pedophilia, are now showing that some of these issues may be exacerbated or possibly even caused by biological differences in the brains of these individuals.

    Some mental illnesses tend to “cluster” and having one disorder means you will likely have another one as well, and having one disorder doesn’t mean you can’t have more.

    PTSD and other forms of stress can actually kill brain cells and change the brains of those effected. Having a severe case of PTSD myself 10 years ago when I saw my husband burned to death and three friends severely burned at the same time changed my brain, in ways that are still evident, such as decreased short term memory, though it has improved over the years. My brain is not the same as it was before the accident. Before the trauma.

    Was I more “prone” to having PTSD genetically than some others would be? Maybe so, it seems that people who tend to dissociate more are more prone than those who are not so likely to dissociate would be.

    I’m very glad to have found this site. Thank you for the many great articles here.

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