Apr 19 2012

Responding to a Szaszian

I have a strict “do not feed the trolls” policy on this blog. OK – so it’s more of a strong suggestion frequently flouted. It’s very difficult to enforce. Even saying, “Do not feed the trolls,” is feeding them, and there always seems to be someone who caves to their goading, and then the troll is off to the races.

Commenter Dirk Steele has given us the latest example on my blog from Tuesday. He left a completely off-topic comment with the intent of derailing discussion on the actual topic of the blog post, and someone caved (no hard feelings, I sometimes do it myself, it’s hard to resist sometimes). Dirk was apparently frustrated that I was not responding to his comments on a five year old blog post. I rarely respond to comments on posts more than a week old, let alone five years (I trust you understand why I cannot maintain active discussions on over a thousand posts).  I also did not respond because Dirk did not address any of the points I made in the post (actually a series of five posts), but was simply regurgitating Thomas Szasz mental illness denial talking points. My responses, in other words, were already in the posts and did not need repeating.

But it has been a while since I have addressed the issue of mental illness denial head on. I also receive frequent requests to discuss this topic, and ADHD (attention deficit and hyperactivity disorder) directly, so this is as good an excuse as any to revisit this topic. I predict my response will not satisfy Dirk, but at least it will keep him out of other threads for awhile. This is Dirk’s most relevant comment, in which he gives us a Gish gallop of standard mental-illness denial talking points:

Szasz would point out the very concept of a ‘mind disease’ or mental ‘health’ or ‘hygiene’ of the mind is not a scientific concept. It is a metaphor. Szasz points out that psychiatry is a political ideology. I agree with the views of Dr. Novella when he discusses homeopathy, chiropractic techniques, or even crystal healing. Psychiatry has made great claims in the past. Without foundation. Neurology is a scientific discipline that deals with and attempts to resolve empirical objective events. Psychiatry is a pseudoscience. 100 years ago Emil Kraepelin identified 3 mental diseases in hospitals that were full of those suffering from neurosyphilis and encephalitis. Today the DSM describes over 350 distinct mental disorders. You show me the science behind this please. There is none. Zilch. I challenge you and Dr. Novella to demonstrate the science that underpins psychiatry.

I will point out that I have already addressed all of these points in my previous posts, which Dirk admits to reading. He is therefore behaving very much like a creationist, he has his points and will not be dissuaded from them, even when they are eviscerated by sound arguments. Dirk also appears to be like a creationist in that he appears to be basing his opinions entirely on secondary hostile sources. He therefore demonstrates as much knowledge about psychiatry and mental illness as your average creationist does about evolution. When he states, “You show me the science behind this please. There is none. Zilch,” that is about as accurate as a creationist saying confidently there are no transitional fossils.

Dirk begins with the “mental illness is just a metaphor” argument. This is a non sequitur. The neuroscientific model of the mind (and psychiatry is part of neuroscience) is that the mind is what the brain does. When we are talking about mental illness we are therefore talking about a brain disorder. What Szasz (and his acolytes, like Dirk) is doing is playing semantic games in order to cause confusion. Using words to obfuscate rather than illuminate is a classic denialist strategy.

I have debated with mental illness deniers many many times, enough that I know what their standard response is to my counterpoints. What they typically say in response to the “mind is the brain” point is another semantic game – arguing that brain diseases are treated by neurologists, not psychiatrists. This is both fallaciously and factually incorrect. This is a version of the “no true Scotsman” logical fallacy – using the definition of categories in order to force a point. The fallacy derives its name from the argument that all Scotsmen are brave, but when confronted with a counter example (a Scotsman that is cowardly) responding by saying, “Well then he is no true Scotsman.” This is a semantic way of dismissing counterexamples by definition, therefore making a circular argument.

Those who wish to maintain their premise that psychiatry is pseudoscience respond to all counterexamples by saying that, well then that disease or disorder is not psychiatric, is neurological. They therefore define psychiatry as encompassing any mental disorder that they do not believe is legitimate, and not including any demonstrably legitimate diagnoses.

Further, it follows an understanding of modern psychiatry that is simply out of step with reality. It is more similar to what psychiatry was like 40 years ago – which is generally true of Thomas Szasz’s positions. He is a psychiatrist who campaigned against the abuses and weaknesses of psychiatry. He had some legitimate points – but all of them have already been conceded over the years. Others have argued that Szasz should just declare victory and move on, instead he has persisted in his anti-psychiatry campaign.

Also, the lines between neurology and psychiatry have blurred over the years as we have learned more and more about brain function and how it relates to illnesses. Psychiatry is now more of a clinical emphasis than a distinct discipline from neurology. Psychiatry still deals with brain disorders, but focuses on those that primarily manifest as disorders of mood, thought, and behavior. These are not fundamentally different from brain disorders that manifest as abnormal movements, pain, language or cognitive problems, but those are treated by neurologists. Psychiatrists have also been steadily moving toward biological treatments of psychiatric disorders, as we learn more about their neurological causes, increasingly leaving therapy to other mental health professions, such as counselors and psychologists.

Throughout his comments Dirk also refers over and over to mental “diseases.” I had already addressed this in my previous posts as well. Many psychiatric diagnoses are not classical diseases in that they do not involve pathology. They are classified as disorders, defined as a deficiency of a function or ability normally possessed by most healthy individuals resulting in demonstrable and specific harm. Let’s take ADHD as an example.

Like many diagnoses in medicine (not just psychiatry) ADHD was first identified as a clinically defined syndrome. Over the years researchers have tried to understand what is different in the brains of those who meet the clinical criteria for ADHD from those who do not. This is complex, because many brain disorders are actually a complex set of related disorders that manifest with similar symptoms. Even non-psychiatric disorders, like migraine and autism, and really categories that have many underlying biological influences. ADHD is no different.

But there are some consistent themes that have emerged. The most prominent theory of ADHD at this time is that it is mostly a deficiency in executive function (EF). EF is a function of the frontal lobes that allows us to focus our attention, to be goal-oriented, and to consider long-term strategies and consequences of our behaviors. Diminished EF explains many of the features of ADHD and the demonstrable harm that those with an ADHD diagnosis suffer. In one 2005 systematic review the authors concluded that there is robust evidence for EF disorder in those with ADHD, but that EF dysfunction is not a universal or required condition for ADHD. Therefore, “Difficulties with EF appear to be one important component of the complex neuropsychology of ADHD.” Other reviews agree, citing evidence for EF dysfunction in ADHD but pointing out that ADHD is a heterogeneous disorder and needs more study to define its subtypes.

If you read this study, and many others like it, you do not find the evasion and vague nonsense of a pseudoscience, but rather the process of legitimate science earnestly exploring a complex disorder, considering alternatives, probing for weaknesses in the data, etc. It does not, in other words, resemble the straw man that mental illness deniers attack.

ADHD is demonstrably a brain disorder and fits well into our current models of brain function, specifically the role of executive function in guiding our attention and behavior. It is also clearly more than that, and so further research is ongoing. The brain is complex and teasing apart the interaction of all of its various parts and systems takes time. It is not fair to dismiss all the science behind ADHD as pseudoscience. That opinion is not evidence-based, it’s outdated denialist propaganda.

There is much to criticize in psychiatry’s past, and it has been a long slow climb out of the infancy of this field when it was more pseudoscience than science. Modern psychiatry still has many challenges before it. Thomas Szasz began with legitimate concerns about the abuses of psychiatry. His complaints, however, are now mostly decades out of date. He has also thrown the baby out with the bathwater – not content to campaign against the deficiencies of psychiatry in practice, he went way too far in concluding that the very concept of mental illness itself is pseudoscience, making Szasz, in my opinion, a crank. His followers, in my experience, are hard core deniers. They are about as engaged in the modern science of psychiatry as creationists are with the modern science of evolution.

Share

472 responses so far

472 Responses to “Responding to a Szaszian”

  1. bluedevilRAon 19 Apr 2012 at 10:39 am

    I always enjoy reading about this topic and learning more about the science behind modern psychiatry. Mental illness affects so many and often goes undiagnosed. The deniers are only making the situation worse with their nonsense.

    I see at least 2 classes of deniers: the hardcore deniers like the Szasz followers and then the people that acknowledge the possible existence of mental illness but think the majority of mental illness is actually a medical illness with presenting psychiatric symptoms (i.e. hypothyroidism). See the link below for more on this type of denial. The latter group also loves to claim that we are overmedicating/overdiagnosing mental illness. I freely acknowledge that this is a possibility. Our society loves to find a pill for every problem, but that does not mean there we should not ever medicate or diagnose mental illness.

    I know this day will probably never come, but I really hope we do have a blood test or MRI scan someday that can objectively diagnose mental illness. I know that won’t shut up the hardcore deniers, but I hope it will help convince the fence sitters that psychiatry is a science-based medical specialty.

    http://www.blockcenter.com/sitemap-navigation.html

  2. daedalus2uon 19 Apr 2012 at 11:06 am

    I plead guilty to feeding the troll. I was in the midst of writing up my “grand unified theory of neuropsychiatric disorders”, but got sidetracked into writing up my “grand unified theory of physiology”, of which it is a subset, so it was difficult for me to resist. ;)

    But seriously, most people have a difficult time thinking logically while doing anything, including science. They default into the ways of thinking that Feynman called “cargo cult science”. Motivated reasoning to try and fit observations into a schema that they understand.

    The brain is complex enough that on some levels there is insufficient commonality to do “statistics”, that is every example of a human brain is a unique piece of data so one really does have a collection of anecdotes and not necessarily “data”. That doesn’t mean scientific study is not possible, it just means it is more difficult and less certain. It also means that the results that humans generated using anecdotes, folk medicine, folk psychology, folk physics are more difficult to distinguish from results based on scientific study.

    What I have recently been thinking about is how human hyperactive agency detection makes it difficult for humans to look at things like physiology and not “see” top-down agency. In the past this top-down agency was attributed to God, to “spirits”, to “the mind” or “the will”, and now it is mostly attributed to “genes”, even as the ever larger GWAS don’t show evidence of such a thing. There is no top-down control of anything in physiology or neurophysiology. That will be a very difficult thing for some people to accept.

    Even though I share some of their conclusions that some specific ideas about psychiatry are not correct, I do not share the denialist mindset that Szasz followers have. I have specific logical reasons why specific ideas are or are not correct. The analogy with creationists is apt. They have no arguments for a unified model that fits the data better than current models, they just want the current model to be rejected.

    To understand something as “science”, you need to be able to cognitively manipulate data using logic to make conclusions and predictions. There is no such thing as “intuitive science”. If you have good intuition about science, then your intuition can be a starting point, but it isn’t “science” until it can be reduced to facts manipulated logically.

  3. mufion 19 Apr 2012 at 11:52 am

    Speaking as a parent with a child who was diagnosed a couple of years ago with a life-threatening mental/brain disorder (anorexia nervosa), which turned me into a lay consumer of relevant research, I find this Szaszian business to be patently absurd.

    Sure, not all of the research in this dept. is equally compelling (and, sad to say, it appears that most therapists who advertise treatments for eating disorders are working with out-dated, evidence-challenged models), but that judgment comes from acquiring critical thinking skills that these Szaszians must willfully lack in order to preserve their tribal identity.

  4. Dirk Steeleon 19 Apr 2012 at 12:19 pm

    Thanks for taking the time to respond. You state.

    ‘ADHD is demonstrably a brain disorder and fits well into our current models of brain function, specifically the role of executive function in guiding our attention and behavior.’

    The studies you refer to have the following conclusions.

    ‘ADHD may be best conceptualized as a neuropsychologically heterogeneous condition. More work is needed to characterize this heterogeneity’

    ‘However, moderate effect sizes and lack of universality of EF deficits among individuals with ADHD suggest that EF weaknesses are neither necessary nor sufficient to cause all cases of ADHD.’

    Then I read this study.

    http://www.publicaffairs.ubc.ca/2012/03/05/younger-children-in-the-classroom-likely-over-diagnosed-with-adhd-ubc-research/

    My obvious confusion leads me to challenge the prevailing notions in psychiatry.

    By the way, your attempts to ridicule me by comparing me to a ‘creationist’ or a ‘denier’ are a bit pathetic but hey I have been called worse. A Scientologist for example.

  5. Enzoon 19 Apr 2012 at 12:38 pm

    I would ask these questions to any denier of psychiatry/psychology as a science as a basis for having a debate:

    1. You have a population that is in some kind of distress. There is some problem (behavioral usually) affecting the quality of their personal and/or professional life. Do you acknowledge that this constitutes a need for some intervention?

    2. Do you acknowledge that the brain is something we have an incomplete understanding of? We do not yet completely understand the interplay been been neuroanatomy, neurochemistry (neurotransmitters and signaling, etc.), environment and brain functions like memory, mood and personality. So I am really just asking do you acknowledge that we do not have a precise, mechanic’s insight into what leads to what in the brain?

    3. Do you acknowledge that alternations to the brain (its anatomy and its signaling) can have effects on its functions (like memory, mood and personality)?

    4. Given that we cannot completely trace a behavioral problems (as in #1) to its precise physical and chemical cause because we do not yet have that complete level of understanding (as in #2)…What would you have scientists interested in the problem do? Do you feel these problems cannot be studied scientifically?

    What I’m getting at:

    Are you in favor of completely ignoring behavioral problems (#1) causing people distress? Basic scientists are studying the brain from every angle we know how (physiology, molecular biology, biochemistry, etc.), so that’s covered. But what we see, clinically, are populations that have difficult to pin down spectrums of problems (“disorders”) that people are trying very hard to categorize so we can be consistent and apply a field of knowledge to. It’s incomplete; it’s a mess; everyone acknowledges that. But there is a stage of science where things aren’t crystal clear. It doesn’t mean you can’t study it scientifically. It means it needs to be studied MORE until we arrive at a complete, satisfactory picture. Until then, we have to do the best we can to alleviate distress.

    Last point: the first thing a scientist learns is that science is messy. It takes decades of building upon foundations to learn anything. No simple answers for complex conditions.

  6. Steven Novellaon 19 Apr 2012 at 12:48 pm

    Dirk – it was not ridicule, it was an apt comparison. Your argument style is that of a denialist. Deal with it.

    I acknowledged in my post that ADHD is heterogeneous. This does not mean it does not exist as a clinical entity. Arguing that because it is complex that the core claim is not real is not a valid argument and is a classic denialist strategy. It is doubt-mongering – pointing to current uncertainty or exceptions, which will always exist, even in rock solid sciences.

    You then go on to cherry pick a study and imply is casts doubt on the reality of ADHD. First, even if ADHD were overdiagnosed that would not mean it’s not a real diagnosis (so that’s a non sequitur). The very concept of overdiagnosis only applies if the diagnosis is real, so the point does not even make sense.

    Further, what the study you linked to indicates is that teachers may not be accounting for relative age when considering which children should be screened for ADHD. There was a difference when considering children 11 months apart in age but in the same grade, something the teachers were probably not adjusting for. Also this is a single study and does not allow a conclusion of cause and effect.

    There is also a lot of research on the question of overdiagnosis of ADHD. The most recent review of this data concludes: (http://www.ncbi.nlm.nih.gov/pubmed/17709814)

    “Based on the review of prevalence studies and research on the diagnostic process, there does not appear to be sufficient justification for the conclusion that ADHD is systematically overdiagnosed.”

  7. clgoodon 19 Apr 2012 at 1:03 pm

    Dr. Novella:

    Thanks for this review. I harbored strong suspicions that psychiatry was a pseudoscience. (I mean, Jung was just bugnutty crazy.) After reading this my opinion is now “It used to be, but not anymore.” I appreciate your bundling up the arguments here.

  8. SARAon 19 Apr 2012 at 1:13 pm

    Dirk, I guess I’m confused. How can you claim the validity of over diagnosis, with out claiming the validity of any diagnosis, which assumes that the disorder is real.

  9. robmon 19 Apr 2012 at 1:28 pm

    @clgood notice psychiatry changes, but mental illness denial stays the same.

    @SARA my guess is dirk will respond that any number greater than 0 is over diagnosis, but his real intent is to blur the line to claim their is none. Any ambiguity or room for doubt allows him to claim the whole thing is false, whatever the rest of the evidence points to. Any little thing he can find in a large body of scientific literature will be construed as a crisis for psychiatry, because its not like physics, therefore pseudoscience.

  10. Dirk Steeleon 19 Apr 2012 at 1:31 pm

    ‘Your argument style is that of a denialist. Deal with it. ‘

    How about this guy? Is he a creationist and a denialist also?

    http://video.answers.com/sir-ken-robinson-on-adhd-516934213

    The fact that I am European may have a bearing on the matter. In the World Health Organisation’s International Classification of Disease, ICD-10, ADHD does not even exist! It is an American invention via the DSM. Even Allen Francis admits this fact.

    As Tom Insel states “We don’t talk much about this, but when it comes to mental illnesses, psychiatrists lag far behind their colleagues in other specialties. “Diagnosis is by observation, detection is late, prediction is poor. Etiology is unknown, prevention is undeveloped. Therapy is by trial-and-error. We have no cures, no vaccines. We’re not even working on vaccines. Prevalence has not decreased. Mortality has not decreased.”

    A sure sign of a pseudoscience is lack of progress.

  11. LivingWithMormonson 19 Apr 2012 at 1:31 pm

    Dr. Novella (and science types et al): takes time to read, understand, explain.

    Dirk: “but this blah gadfae fads daggeasd gead derp derp duuuuurp!!!! GOTCHA!!!’

    Dr. Novella: takes time to read, understand, explain.

    Dirp: “derpidy derp derp chirp dirk duuurp?!!! Pfff… GOTCHA!!”

    Dr. Novella: “you’re an idiot”… takes time to read, understand, explain… ad nauseum

    Derp: “I WIN!”

  12. Dirk Steeleon 19 Apr 2012 at 1:45 pm

    @LivingWithMormons

    I am not sure which mental disease you suffer from but I know that if I read the DSM from back to front I would find something appropriate for you. Keep taking the medication.

  13. Marvinon 19 Apr 2012 at 1:58 pm

    In my experience as a patient – and this is anecdotal of course, although it has happened many times – psychiatrists and clinical psychologists engage in numerous forms of dubious practice which border on pseudoscientific. A classic example is the frequent claim that by trying one antidepressant after another, they will eventually find one that works. It is a claim that can be proven but never falsified.

  14. Dirk Steeleon 19 Apr 2012 at 1:59 pm

    @ Dr Novella

    ‘You then go on to cherry pick a study and imply is casts doubt on the reality of ADHD.’

    Well you ‘cherry pick’ old studies all the time. Why shouldn’t I? Oh. Are your cherry picks far superior?

  15. robmon 19 Apr 2012 at 2:06 pm

    In the IDC-10 ADHD symptoms are called hyperkinetic disorders.

    “Are your cherry picks far superior?”

    Yes, Dr. Novella is looking up actual research to find facts and weigh evidence, you are looking for anything you can spin, see above. The latter is actual cherry picking.

  16. Dirk Steeleon 19 Apr 2012 at 2:25 pm

    @Enzoon

    ‘I would ask these questions to any denier of psychiatry/psychology as a science as a basis for having a debate:’

    Thanks for taking the time.

    1. You have a population that is in some kind of distress. There is some problem (behavioral usually) affecting the quality of their personal and/or professional life. Do you acknowledge that this constitutes a need for some intervention?

    Draptomania anyone?

    2. Do you acknowledge that the brain is something we have an incomplete understanding of?

    We have little idea how the brain/mind works.

    3. Do you acknowledge that alternations to the brain (its anatomy and its signaling) can have effects on its functions (like memory, mood and personality)?

    Yes obviously.

    4. Given that we cannot completely trace a behavioral problems (as in #1) to its precise physical and chemical cause because we do not yet have that complete level of understanding (as in #2)…What would you have scientists interested in the problem do? Do you feel these problems cannot be studied scientifically?

    We must be careful. USSR citizens were diagnosed as schizophrenic for anti-communist views. It is my view that ‘deviance’ from the norm has been defined as a medical issue. I am not sure that this is a credible scientific position. I could be proved wrong. I am just waiting.

    What I’m getting at:

    Are you in favor of completely ignoring behavioral problems (#1) causing people distress? it’s a mess; everyone acknowledges that. But there is a stage of science where things aren’t crystal clear. It doesn’t mean you can’t study it scientifically. It means it needs to be studied MORE until we arrive at a complete, satisfactory picture. Until then, we have to do the best we can to alleviate distress.

    I am a complete supporter of science and scientific methodology. I am not trying to ignore behavioural ‘problems’ or the great distress and suffering that people experience. I just do not accept that this is caused by a mental disease/illness/disorder/spectrum. It is my view that environmental causes should not be discounted.

    ‘Last point: the first thing a scientist learns is that science is messy. It takes decades of building upon foundations to learn anything. No simple answers for complex conditions.’

    Agree. I think that it is current psychiatry that attempts to provide the ‘simple’ explanation. I am not convinced.

  17. Dirk Steeleon 19 Apr 2012 at 2:35 pm

    @robmon

    ‘In the IDC-10 ADHD symptoms are called hyperkinetic disorders.’

    I am very familiar with hyperkinetic disorders. Less so with attention deficit rubbish. I have read Peter Conrad. A view that opposes mine but which at least raises the issues can be found here.

    http://www.jstor.org/discover/10.2307/800128?uid=3738032&uid=2129&uid=2&uid=70&uid=4&sid=21100730805291

    “Are your cherry picks far superior?”

    ‘Yes, Dr. Novella is looking up actual research to find facts and weigh evidence, you are looking for anything you can spin, see above. The latter is actual cherry picking.’

    I do attempt to quote scientific studies. Show me where I have not.

  18. gr8googlymooglyon 19 Apr 2012 at 2:40 pm

    Go Dirk!! We loves us some good trollness!!

  19. Dirk Steeleon 19 Apr 2012 at 2:55 pm

    @gr8googlymooglyon

    ‘Go Dirk!! We loves us some good trollness!!’

    Thanks for your contribution to the debate. . The fact that millions of American children are forced to take psycho-active drugs that very many scientists consider to be toxic and which actually cause brain damage, as proved by science, is irrelevent.

  20. HHCon 19 Apr 2012 at 3:00 pm

    We are busy building prisons in the U.S., and we have a justice system which provides sentences for offenders for US laws. If you don’t like psychiatry with its disorders and chemical restraints, then you can send your problem citizens directly to jail. My behavioral science work in the trenches of Midwestern state hospitals was counting assaults and batteries to staff and clients, and then trying to program the offenders to do these less often. How do you program someone who enjoys batteries and killing to do it less? Given this true state of affairs, the only real counselors are lawyers!

  21. gr8googlymooglyon 19 Apr 2012 at 3:12 pm

    Please spare us the feigned concern, sir. You are an attention whore and nothing more. I feel dirty in feeding you just by pointing this out.

  22. Nick Stuarton 19 Apr 2012 at 3:23 pm

    Yes – let us not feed this madman!

  23. Dirk Steeleon 19 Apr 2012 at 3:30 pm

    @gr8googlymooglyon

    ‘Please spare us the feigned concern, sir. You are an attention whore and nothing more. I feel dirty in feeding you just by pointing this out.’

    Blimey Steven. You sure have a few nutters following your blogs.

  24. LivingWithMormonson 19 Apr 2012 at 3:34 pm

    “I am not sure which mental disease you suffer from but I know that if I read the DSM from back to front I would find something appropriate for you. Keep taking the medication.”

    Wait, did Derp just say I have a mental disorder? And that I need to take medication for it?

    Holy crap, you’ve been pulling our legs this whole time!!!

    HAHAHA!!!! Good on ya, mate! Derp 1 – Us 0!

  25. Enzoon 19 Apr 2012 at 3:41 pm

    Back @Dirk

    Thanks for answering the questions, I know a lot of them were obvious but I’m trying to understand the basis of your perspective.

    First, I need you to clarify your position on #1. Drapetomania is not fair if you are meaning the completely racist take on it. Let’s just use depression. You have people that are depressed to the point where they cannot function in social or professional environments. Do you acknowledge this person could benefit from help? If not depression, let’s take the extreme of schizophrenia. In other words, do you believe that psychological problems (whether environmental or not) exist and that people disabled by them should receive help?

    I’m assuming your answer to the above is “yes” as I go on…

    It is my view that ‘deviance’ from the norm has been defined as a medical issue. I am not sure that this is a credible scientific position … I just do not accept that [behavioral problems/suffering therefrom] is caused by a mental disease/illness/disorder/spectrum. It is my view that environmental causes should not be discounted.”

    – Dirk

    From reading your answers to my questions, here is what the core of your argument boils down to. Please correct me if I am wrong (but it has to be a direct, concise statement like I am about to give!):

    You see psychiatry as trying to correct a problem that does not exist. For what problems do exist, you attribute suffering
    to environmental causes that do not manifest through brain changes.

    For the first part, I think I will have no trouble getting you to admit that psychiatry does not deal exclusively with “deviance from the norm” and the stigma that is associated with that; it deals with disability. There is a difference between a person that is weird and a person that cannot hold a job because they are depressed. For the most part, “disorders” are by definition situations that decrease the quality of life a person is experiencing to a significantly degree. Psychiatrists don’t diagnose someone that is autistic, for example, simply on the basis of being socially awkward.

    I think you are also trying to say that what we define as a disorder is a simple social construct with a sliding scale based on what people find convenient. Your “anti-communists are schizophrenics” thing from the USSR is an example of that. But that is not mainstream psychiatry; that is the same crazy camp in the field as homeopaths are in the field of medicine. Of course every field grows tighter over time, and psychiatry is is still maturing. There are bound to be things affected by the culture of the time, but these are flaws in people not in the science (which is self-correcting over time). We can’t have this discussion by sticking to extreme examples of political ideals or homosexuality being diagnosed as disorders. What do you have to say about a mother that cannot care for her children because of depression? Or the schizophrenic that is completely impaired because he feels persecuted by anyone he may have contact with? These ARE problems and they need help. They are not defined by cultural bias on any real, practical level and can’t be dismissed.

    Point 2. It is your view that environmental causes cause distress but that this distress is not a mental disease. Well, I’m not sure I follow you here. First, psychiatry does NOT exclude environmental causes. If a person is in a destructive environment, that is obvious. Often times, though, the environment is not obviously destructive and either way it cannot be changed. A person who is depressed must still live in this world. And for anything to be experienced, environment must translate into some mental input. There is just no getting around that. Some people have altered perspectives that are sufficiently outside their ability to cope.

    I see you looking at something like ADHD from your perspective as: “it’s nothing in the brain, it’s just lower than normal intelligence and the environment the person is in is not one where someone like that can succeed like that.”

    But this is an uninformed view on the science behind ADHD. It’s overly simplistic and dismissive of problems. And this view cannot be so easily applied to schizophrenics. It also doesn’t explain why pharmacological interventions show benefit or why there is a genetic component to many psychiatric disorders.

    Finally

    Agree. I think that it is current psychiatry that attempts to provide the ‘simple’ explanation. I am not convinced.

    We have models, hypotheses and theories. No one is reporting anything to be the definitive answer. Every psychiatrist worth noting understand the complexity involved. But we have to do something. We can’t just not study the problem. It all has to start somewhere. And if you doubt that scientific, rigorous methods are being applied to study where legitimate problems exist, then you have not seen the methodology in the studies (controlled, systematic, statistically approaches to understanding).

  26. Steven Novellaon 19 Apr 2012 at 4:00 pm

    Sir Ken Robinson does not seem like a denier, but he is misinformed, and he admits he is not expert. Medication for ADHD is not a sedative. It’s a stimulant – to increase executive function.

    I’m all for neurodiversity – but in order to be considered a disorder behavior does not only have to be different it has to be lacking in some definable way and cause demonstrable harm. Demonstrable harm – like a higher divorce, rate of incarceration, lower lifetime earning potential, greater propensity so suffer from accidents, poorer academic achievement, etc. The outcomes correlate with decreased executive function. They improve with treatment.

    Dirk continues to attack pathetic straw men, a cite poor sources. First you have to understand psychiatry before you can criticize it. You are raising some points that have been brought up by psychiatrists decades ago and have been addressed in the research.

    Dirk then takes quotes out of context as if they cast doubt on the existence of mental illness – classic denialism.

    Regarding cherry picking – citing systematic reviews is by definition not cherry picking. I cited the two most recent (and therefore most up to date) systematic reviews. That’s a way of looking at all the evidence – the very opposite of cherry picking. You cited and misrepresented one study.

    An around we go – this is the denialist dance. Thanks for demonstrating.

  27. Watcheron 19 Apr 2012 at 4:07 pm

    It means it needs to be studied MORE until we arrive at a complete, satisfactory picture. Until then, we have to do the best we can to alleviate distress.

    But isn’t this exactly what is going on right now in these fields? Steve laid out some compelling evidence that ADHD can be related to abnormalities in executive function. We have a decent amount of knowledge of executive function processing, such that experiments could come about from this understanding. So, more work is being done so that we can arrive at a complete, satisfactory, picture.

    What I’m saying is that the work is being done now to validate these observations. However, that doesn’t give someone free reign to go around suggesting the whole practice of psychiatry is bogus just because the answer isn’t there yet.

    @Enzo

    Good post :)

  28. LivingWithMormonson 19 Apr 2012 at 4:11 pm

    “Blimey Steven. You sure have a few nutters following your blogs.”

    Derp… you are dead on.

    Dead on.

  29. Dirk Steeleon 19 Apr 2012 at 4:18 pm

    @Enzo

    Thanks for that post. It at least opens the debate with what I consider pertinent questions. Is depression the result of a mental disorder/biochemical imbalance or caused by environmental or societal pressure? Do children suffer from the brain disorder called ADHD or is this the result of changes to our educational environment in which certain children cannot cope? See the vid by Sir Ken Robinson. I am skeptical of the current psychiatric science which claims to know. I play the devil’s advocate in order to force people to challenge the current orthodoxy which I consider to be causing more harm than good. (I read Anatomy of an Epidemic by Robert Whitaker.) The alleviation of suffering is the ultimate goal. We may feel we have to do something but sometimes the wrong action is worse than doing nothing. I would like to reply in detail but my approaching bedtime and white wine inebriation suggests it is time to keep my mouth shut.. ;-) (for once…)

  30. mufion 19 Apr 2012 at 4:58 pm

    I think we can balance psychiatric diagnosis with social criticism.

    For example, I recognize that not all educational settings are appropriate for my children (again, one of whom was diagnosed with anorexia nervosa, and the other with Asperger syndrome), and sometimes the system (or at least its local branch) is partially to blame for the mismatch (e.g. if/when it provides inadequate understanding of and support for disabled children).

    Yet having a diagnosis can be a tool for parents to advocate for social change (e.g. via appeal to Section 504 of the Rehabilitation Act and the Americans with Disabilities Act here in the US), as it helps to communicate how/why one’s child’s behavior does not fit the norm.

    Of course, with or without a diagnosis, we all need to make an effort to adapt to whatever environment(s) we find ourselves in, if we wish to survive and flourish.

  31. DOYLEon 19 Apr 2012 at 5:09 pm

    Why is it so difficult to understand that the realm of science is manifold and inclusive of fields that organiclly build toward a better whole.Science is a partnership of evolving modes,methods and diagnostic tools.These continually provide interdisiplinary feedback that fashions a broader and sharper new model.And most importantly the new model has shed the previous biases and “resonable doubt” that has bullied it.Evolution is not only a process of physical change but,also, a process of cognitive change,piecemeal.

    As for the aspect of ADHD.

    It starts as intuition that there is some dimension of the ADHD condition that is removed a distance from the “typical” brain.At the beginning,only case study could
    point to a diagnosis.Psychiatry,however you want to view it provided the tender means of creating an association between a life in chaos and a biological cause.It’s a slow “evolving” process and partnership with neuroscience that will refine itself over time.

  32. Dirk Steeleon 19 Apr 2012 at 5:1