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.

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