Apr 24 2007

Mental Illness Denial Part II

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.

First, it is not clear if the traits that are considered symptoms of any particular mental illness are simply the ends of the bell curve. It may be, in some cases, that there is not a simple bell curve of variation, but the illness represents a bi-modal distribution – a separate group off the bell curve.

But even if we assume that, say, the ability to attend to a task varies on a bell curve (a matter of contention, but let’s grant this for hypothetical purposes) that does not mean that we should consider every point on the curve as equally normal or healthy. Let’s take blood pressure, for example. The upper end of biological variation of blood pressure is considered a disorder (more on this definition later). It is a risk factor for several diseases. Considering high blood pressure as unhealthy and worthy of treatment is not controversial. There are numerous examples of this in medicine. There are certain parameters for healthy biological function and if variation strays sufficiently outside of these parameters health or function is compromised.

There is no reason to exclude mental functions from this classification. For example, we evolved mood for a reason. It is adaptive to be depressed when bad things happen and happy when life is good. But when someone is extremely happy (manic) all the time, mood is no longer adaptive, it is disruptive. Some people are so depressed, and for no apparent reason, that they cannot get out of bed. Or they are so manic that they spend their money recklessly and destroy the practical necessities of their life. By what logic should such maladaptive extremes be considered healthy?

The response of the deniers is simply that without disease we cannot call something unhealthy – a return to their premise which is little more than an unsupported assertion.

Disease vs Disorder and Semantic Arguments

To avoid confusion of terminology the word “disorder” is often used to refer to the malfunction of some biological process when no underlying classical pathology is present. The term “disease” is reserved for a known pathophysiological process. Admittedly, the terms are sometimes carelessly interchanged, and this leads to confusion.

It is common for physicians to recognize that a constellation of signs and symptoms tend to occur together, with a characteristic natural history. Before anything is understood about the underlying cause, such clinical entities can be recognized and even well characterized. Methods can be developed to reliably diagnose them based upon the presence of enough of the typical signs and symptoms. It may be recognized as a medical disorder long before the underlying pathophysiology (disease) is identified. To qualify as a disorder, the symptoms must also cause demonstrable harm. To be considered a biological disorder, vs a purely psychological disorder, there needs to be evidence that the symptoms emerge from internal rather than only external factors.

So how do we know such disorders are real? Well, sometimes, admittedly, it can be tricky. For example, is Gulf War Syndrome a real medical disorder, or an illusion? Other disorders, like migraine headaches, have several specific symptoms and many identifiable epidemiological factors that allow it to be recognized and diagnosed with a high degree of confidence.

Many mental illness entities are disorders, like migraine, in that they can be reliably diagnosed, the diagnostic criteria have been validated, and they have a specific epidemiology and natural history. To dismiss the reality of all medical disorders where a specific pathology has not been identified is to reject much of modern medicine.

When applied to many psychiatric disorders the terms become a bit fuzzy. In my opinion, terminology has simply not kept up with the advance of neuroscience. If we can identify that a specific neurotransmitter is deficient in certain parts of the brain, is this a disease or a disorder? Well, it depends on whether or not you count brain structure and neurotransmitter function as a criteria for “disease.”

But this is all a semantic argument – it does not get to the real point, that the “soft” problems that can occur in the brain, problems with the pattern and strength of signaling, can result in real mental dysfunction. Baughman retreats to the semantic argument as a way of glossing over the real question. During the debate he argued that the terms disorder and disease are synonymous because psychiatrists use them that way. Even if true, which I do not accept, it is a non-sequitur.

But Baughman is operating within a very simple paradigm (no disease = normal) and must constrain all arguments to this narrow (and arbitrary) box that he has constructed. He cannot allow for any broadening of the definition of what counts as biological dysfunction, because then mental illnesses might sneak in.

During the debate I gave him the example of migraine headaches, as it is the closest non-controversial analogy for mental disorders. He was taken aback by this and did not have a good response. He eventually latched onto the notion that migraines are associated with visual scotoma (black spots) and that this was an objective finding. Mental disorders, he argues, have no objective findings. But this is patently untrue, and I find it hard to believe that Dr. Baughman, as a neurologist, does not know it. Not all patients with migraine have a scotoma, or any objective findings. I have diagnosed hundreds of patients with migraine – never on the basis of objective findings on neurological exam. The international classification of headache disorders (ICHD) diagnostic criteria for migraine does not even mention scotoma, and includes no objective exam findings, only reported symptoms.

To emphasize this point, migraine is a clinical syndrome, diagnosed on the basis of having a certain number out of a list of characteristic symptoms. This is exactly how most psychiatric illnesses are diagnosed. So by Dr. Baughman’s criteria migraine is not a legitimate medical illness (except for those minority with objective exam findings).

False Dichotomy

Dr. Baughman also created what is essentially a false dichotomy when he said that disease (classic pathology) leads to physical ailments, and psychological symptoms do not have underlying disease. But this is not true. All of the objective physical problems that can affect biological organs – infection, trauma, metabolic derangement, etc., when they affect the brain may cause psychiatric symptoms. In fact, when a patient presents with a new onset of psychiatric symptoms (anxiety, psychosis, etc.) it is typical for an underlying disease to be first ruled out before psychiatric treatment begins.

I personally have treated patients who presented with symptoms of schizophrenia and were then found to have a brain tumor. Removal of the tumor cured the schizophrenia. I have had numerous patients with frontal brain damage from a motor vehicle accident who developed, as a direct consequence of their brain trauma, mania, disinhibition, poor executive function, or apathy and depression.

Dr. Baughman wants a clean separation between classical disease and mental illness – but no such separation exists. Even the disease states he says are the only real medical problems are known to cause symptoms of mental illness.

Further, the same mental symptoms can result from more subtle dysfunction – such as poor development, a paucity of connections, or abnormal neurotransmitter activity. If we consider two hypothetical patients: patient A has a congenitally underdeveloped frontal lobe which can be demonstrated to have low physiological function, and patient B had a motor vehicle accident that caused trauma to his frontal lobes. Both patients may now exhibit the exact same clinical symptoms – namely poor executive function (the ability to inhibit one’s desires and act strategically for long-term goals). It seems clear that both patients have a mental illness but with differing underlying causes. The symptoms are the same because the same part of the brain is affected. Dr. Baughman would say that patient A is normal, and patient B has a neurological disorder, and that mental illness does not exist.

Tomorrow I will write about the objective scientific evidence for a biological basis for various mental disorders and how Dr. Baughman dismisses such evidence.

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15 responses so far

15 Responses to “Mental Illness Denial Part II”

  1. Dirk Steeleon 26 Mar 2012 at 11:38 am

    Point by point.

    You misrepresent what Szasz and Baughman are saying if you attribute this to them.

    ‘All behavior is normal’

    Dr Baughman states ‘All traits vary, he argues, and it is not valid to simply label the extreme ends of this variation as abnormal.’

    This I have to agree with. For example, Mozart’s behaviour in spending an inordinate amount of time, compared to ‘normal’ people, in playing the piano and composing must therefore be seen as abnormal behaviour. Any person who has a ‘different’ or an original thought must therefore be defined by you as abnormal. Galileo was one such person and was defined in his time as being abnormal and thus subject to persecution by those in authority. So, Steven, how do you define both these individuals? Are they normal or abnormal? Do they therefore demonstrate a disease or disorder of the brain? Are they on the bell curve or can they be considered a separate group?

  2. Dirk Steeleon 26 Mar 2012 at 11:42 am

    Steven, when you say

    ‘But when someone is extremely happy (manic) all the time, mood is no longer adaptive, it is disruptive.’

    are you implying that feeling extreme happiness in life is a brain disorder? How would you treat this terrible condition?

  3. Dirk Steeleon 26 Mar 2012 at 11:56 am

    ‘Some people are so depressed, and for no apparent reason, that they cannot get out of bed. Or they are so manic that they spend their money recklessly and destroy the practical necessities of their life. By what logic should such maladaptive extremes be considered healthy?’

    In hindsight I have realised that my inability to get out of bed did have a reason which at the time I found it difficult to realise or articulate. Mainly because of the disapproval from others. After the wonderful freedom of a weekend, it was always difficult to get out of bed on the monday to go to school. I used to complain about feeling ill and I generally used the excuse of a tummy ache or a migraine. Unfortunately I never seemed to convince my parents. I wish then I had been able to use the unfalsifiable claim of having ADHD.

    Many times in my life I have been impulsive in my spending. In fact I believe that corporations such as Wall-Mart or Tesco or the TV adverts have manipulated me! Sometimes in hindsight I have regretted that compulsive expenditure. My ex-wife certainly did. My credit card bank did not. Do I suffer from a brain malfunction?

    By what logic should such maladaptive extremes be considered a medical disease? ‘ Can a swift dose of ECT cure me?

  4. Dirk Steeleon 26 Mar 2012 at 12:06 pm

    ‘To dismiss the reality of all medical disorders where a specific pathology has not been identified is to reject much of modern medicine.’

    I have always thought that the opposite was true. That the advance in medicine has been totally the result of improvements in technology (microscope or X-ray) which can clearly show a specific pathology. That infectious diseases, for example, are caused by a known pathogen which can then lead to a cure via anti-biotics and vaccines.

  5. Dirk Steeleon 26 Mar 2012 at 12:28 pm

    ‘If we can identify that a specific neurotransmitter is deficient in certain parts of the brain, is this a disease or a disorder?’

    It could be either. But firstly one must establish that the deficiency in a specific neurotransmitter causes a ‘mental’ disease/illness/disorder/syndrome as defined by the DSM5. Despite 50 years of research this has not been scientifically demonstrated as yet.

  6. Dirk Steeleon 26 Mar 2012 at 12:44 pm

    ‘During the debate he argued that the terms disorder and disease are synonymous because psychiatrists use them that way. Even if true, which I do not accept, ‘

    Looking at the NIMH website for Schizophrenia I read…

    ‘Schizophrenia is a chronic, severe, and disabling brain disorder ‘

    ‘this work may help prevent and better treat the illness.’

    ‘In young people who develop the disease’

    How on earth can you not accept that?

  7. Dirk Steeleon 26 Mar 2012 at 12:58 pm

    ‘But Baughman is operating within a very simple paradigm (no disease = normal) and must constrain all arguments to this narrow (and arbitrary) box that he has constructed. He cannot allow for any broadening of the definition of what counts as biological dysfunction, because then mental illnesses might sneak in.’

    Exactly. If one broadens the definition of a biological disorder to include those that are not biological then we end up with the metaphor of mental disease.

    Allen Frances was chair of the DSM-IV Task Force. He states ‘My profession has not only redefined mental health by over-diagnosing and over-medicating an ever-expanding number of diagnoses, we are also taking away the hope of human nature by telling our patients that they are inherently “abnormal” and need to be fixed.’

    You can read his current views here.

    http://www.huffingtonpost.com/allen-frances/dangerous-man_b_1347521.html

    Steven – what are your thoughts on this?

  8. Dirk Steeleon 26 Mar 2012 at 1:07 pm

    ‘To emphasize this point, migraine is a clinical syndrome, diagnosed on the basis of having a certain number out of a list of characteristic symptoms. This is exactly how most psychiatric illnesses are diagnosed. So by Dr. Baughman’s criteria migraine is not a legitimate medical illness ‘

    So your logic is that because migraine is one of the few medical syndromes diagnosed purely on symptoms, then all of the psychiatriatic diagnoses are valid? This is how ‘most’ psychiatric illnesses are diagnosed. Or all? Can you refer me to one that is not ?

  9. locutusbrgon 26 Mar 2012 at 1:32 pm

    Dirk Steele

    You have a lot of thoughts all over the place but I thought I would address one.
    “I have always thought that the opposite was true. That the advance in medicine has been totally the result of improvements in technology (microscope or X-ray) which can clearly show a specific pathology. That infectious diseases, for example, are caused by a known pathogen which can then lead to a cure via anti-biotics and vaccines.”

    Despite lay interpretation, a great deal of what is understood about medicine is inferred from many different sources not a definitive test. In infectious disease and broken bones this can sometimes be true but not always.
    Knowing that something works does not always mean you know how. Often there is specific in vitro/vivo data but not always.
    For example:
    A spinal MRI may tell me with great detail that a disc is ruptured and pressing on a nerve. Why identical MRI’s with the same pathology has vastly different symptomatology in different patients is not clearly understood. Some require surgery some don’t. The effectiveness of the surgery is well understood. Why some need it, and some don’t is not.

    Hypertension has clearly defined and effective treatments, but what truly causes the hypertension is not usually understood. There are good theories supported by the treatment’s effectiveness, yet no definite factor.

    Historically, medicine has a much better track record treating the illness and then determining specifics of cause, rather than the opposite.
    Even in infectious disease, that you site, treatment preceded understanding. Sulfa drugs, penicillin and vaccines were all put into use before it was understood how they work.
    It was well known that they worked, just not how. How came later. Because the entire picture is now well understood people think infectious disease treatment followed understanding. On one level that is correct, Knowing that bacteria caused illness, and that Penicillin killed it, was instrumental to medicine evolution. It was however an accident with contaminated petri dishes that gave us that insight not a progressive knowledge about cell wall synthesis and fungal inhibitors.
    It was not until much later that we discovered why penicillin worked.

    That is the common medical evolution not the opposite.

  10. Dirk Steeleon 26 Mar 2012 at 3:56 pm

    Locutusbrg:

    I agree with most of what you say. Much scientific progress stems from happy accidents. But are you saying there are no definitive objective scientific tests that shows a person to have an infectious disease, heart disease, diabetes or cancer?

    ‘A spinal MRI may tell me with great detail that a disc is ruptured and pressing on a nerve. Why identical MRI’s with the same pathology has vastly different symptomatology in different patients is not clearly understood.’

    Which is where symptom based psychiatry, which has not one objective measurement, fails.

  11. locutusbrgon 26 Mar 2012 at 4:08 pm

    Again I think the statement” No Definitive tests” is a broad statement that is kind of a straw man argument I was not trying to make. The underpinning of my argument is that lack of knowledge about cause does not limit our ability to treat effectively given well controlled treatment trials.

    I would also like to point out that schizophrenia is able to be objectively diagnosed by PET scan so there is your one objective measurement.

    I am not digging in for a defense of psychology there are problems in all aspects of medicine. The illusion is believing that the MRI defines that persons symptomatology. It is a better indication of what can be done not what the treatment should be.

  12. Dirk Steeleon 26 Mar 2012 at 5:37 pm

    @locutusbrg

    ‘I would also like to point out that schizophrenia is able to be objectively diagnosed by PET scan so there is your one objective measurement.’

    Well I have read APA, NIMH and many other sites re schizophrenia. I have never come across this fact. Can you cite any published evidence please? Thanks

  13. Dirk Steeleon 30 Mar 2012 at 7:28 am

    ‘I personally have treated patients who presented with symptoms of schizophrenia and were then found to have a brain tumor.’

    Steven. You cannot see the woo from the trees. Szasz and others are not saying that neurology is not scientific medicine. Neurology has made tremendous advances over the past 100 years. The question is. If ‘mental illness’ is a confirmed brain disease why is it not treated by neurology. What purpose does psychiatry have? If all the current mental disorders were shown to have an underlying biological pathology then psychiatry would cease to exist. We would have only ‘brain illness’ or brain ‘disorder’

    Psychiatry exists for a different reason. It is for society to control behaviours that are deemed unacceptable. The ‘naughty child’, the ‘rebellious’ teenager, the ‘disobediant’ wife, the ‘delusional’ thinker. Read the DSM. It prescribes all activities that are disapproved of by authority or society.

    Draptomania, hysteria, masturbatory insanity, homosexuality. Psychiatry only exists now to medicalise deviant behaviour. Neurology is a science. Psychiatry is a pseudoscience. A checklist of behaviour supported by confirmation bias. As if an astrologer using a checklist can show that my creativity and stubborn traits that he can deduce, proves I suffer from Taureanism.

    Steven. I do not understand how you cannot see this aspect.

  14. Dirk Steeleon 04 Apr 2012 at 10:04 am

    ‘In fact, when a patient presents with a new onset of psychiatric symptoms (anxiety, psychosis, etc.) it is typical for an underlying disease to be first ruled out before psychiatric treatment begins.’

    I know, and you know this is untrue. Of the millions of those ‘diagnosed’ with a mental disorder such as ADHD, Bi-polar or even Multiple Personality Disorder, very rarely is there a significant effort to rule out an underlying disease.

    ‘If we consider two hypothetical patients: patient A has a congenitally underdeveloped frontal lobe (snip) and patient B had a motor vehicle accident that caused trauma to his frontal lobes. Both patients may now exhibit the exact same clinical symptoms – namely poor executive function (the ability to inhibit one’s desires and act strategically for long-term goals). It seems clear that both patients have a mental illness but with differing underlying causes.’

    No. It is clear, scientifically, that both suffer from a measurable brain malfunction.

  15. Dirk Steeleon 04 Apr 2012 at 8:46 pm

    ‘For example, is Gulf War Syndrome a real medical disorder, or an illusion? ‘

    It is you that that plays with semantics. For example, is PTSD caused by a biological disorder or the fact that someone has experienced life changing trauma? No-one, not Szasz nor Baughman are saying that the experiences or the mental conflict are illusions. This is a straw man argument. The mental conditions experienced are real. It is you that is saying that the mental illness is caused by a disease or disorder or illness of the brain. Others would say it is environmental conditions that have caused the ‘symptoms’.

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