Some thoughts - on points of disagreement. I’m not going to check off the many points of agreement, or the many things I learned from reading your blog; nor am I am listing all the points of disagreement. I will just bring up three or four that I think are worth discussing.

Arguments about DSM tend to be strawman arguments; you do a better job than most I’ve encountered, but I do think that you overstate the importance of DSM for psychiatry (which is necessary whenever anybody wants to construct a critique of psychiatry by way of DSM). Outside of psychiatric and psychological circles, I have heard it often said that DSM is considered a bible in psychiatric circles, but have yet to meet a single person within psychiatry or psychology - not one - who considers it the word of God – or any secular variant thereof; it is nothing close to being the central text, the final explanation, much less the organising tomeetc. of psychiatry and psychology. It is not an unimportant text at all, but it is hardly biblical. The most extraordinary thing about the claim that psychiatry holds the DSM in such high holy regard is that it misses the frackin’ point: the DSM was set out as something that was to be examined, critiqued, studied, and as something subject to change, not as a final authority or a law. It is explicitly intended as a research tool to provide a common language for researchers, with its own assumptions and definitions subject to scrutiny. First, it was designed to test the reliability and validity of the diagnoses (where reliability is agreement between observers, and validity is correspondence with gold standards or objective reality: if three people see something red and round and call it an apple, the term “apple” has high reliability; if in fact the red and round thing is a rubber ball, the term “apple” still has high reliability, but no validity). Second, it was designed so that when an article describes CBT for “major depressive disorder” there can be agreement on what the author of the article is talking about. There is no claim that DSM necessarily describes the only type of depression, but when a researcher in Brazil gives 30 subjects disulfiram to patients diagnosed with “alcohol abuse”, someone in the Netherlands knows how that researcher is selecting subjects for the study. These are hardly goals of biblical proportions! And, something that is subject to such scrutiny, debate, empirical (or at least transparent and reproducible) testing, and revision is hardly establishing itself as normative! Perhaps there is a Talmudic quality to the DSM”s genesis, and perhaps one may take a Foucauldian perspective and suggest that by subjecting its formulations to the benediction of empiricism the DSM takes on the form of a law – but these are not the arguments that are generally made, nor are they the arguments you are making, and finally, even if they were the arguments, they would not be entirely damning.

So, DSM is not an organising principle in psychiatry, though it has been essential to psychiatric research; for all the scorn generally heaped upon it (not by you, I would note), it really isn’t that bad, and serves a fairly useful purpose. But “bible” it ain’t. BTW, if you have not already encountered McHugh and Slavney’s The Four Perspectives of Psychiatry, consider reading it for a far more interesting take on the organisation of the discipline; McHugh’s more recent collection of essays, The Mind Has Mountains contains a useful synopsis of The Four Perspectives, as well as some of his (contentedly, if not archly) conservative analyses - some of which I reject, some of which are quite impressive. Also, if you are not familiar with it, I would suggest taking a look at Nassir Ghaemi’s The Concepts of Psychiatry, at times quite fascinating, although ultimately dissatisfying. I would certainly recommend reading McHugh before Ghaemi. Also consider Goldberg and Goodyer’s The Origin and Course of Common Mental Disorders. Somebody who can engage critically with these texts is challenging and thinking about psychiatry; “deconstructing” the DSM as a way of challenging psychiatry, though much more convenient and prevalent, tends to miss the point.

BTW, McHugh, Ghaemi, Goodyer, etc. will provide some assistance in conceptualising how psychiatry can address this:

And, even supposing that mental illnesses are not “natural kinds” like tigers or tuberculosis, is it really practical to imagine attempting to treat the vast panoply of “emotional distress” on a purely ad hominen basis, providing a customized therapy for everyone, without reference to some form of consensually-determined criteria?

I wrote a lengthy passage on how people tend to be reckless in their comparisons between psychiatry and medicine: the problem is not that it misrepresents psychiatry, but that it misunderstands medicine. You come close to doing this, although take a subtler approach than most. Rather than include the entire passage I wrote, for the sake of brevity, let me just synopsise thus:
Consensus – Diabetes.
Spectrum – Hypertension.
Diagnostic certainty in medicine – No such thing.
Controversy – Lyme Disease
Socially constructed – all disease (if not all etiology)
Disease vs Disorder – GERD
Objective? - Keep reading Foucault past Mad & Civ – Birth of the Clinic comes next.

And no, I’m not saying that arachnophobia is the same thing as osteomyelitis. But I am saying that medicine has far more in common with psychiatry than most people think - especially in the areas where people use it to condemn psychiatry. And don’t even get me started on Narrative Medicine, which could be called Psychiatry for Internists.

Now, I had some more thoughts, but I just edited them out, because this was too long, and I wanted to get to a point of serious disagreement.

the APA’s 1973 decision to cave to gay activist pressure and remove homosexuality from its list of mental illnesses being perhaps the most salient and notorious case in point.

There are some places where I really do disagree with you but would gladly discuss the topic, exchange ideas, etc. This is the only place where I would write, “Rubbish” and simply walk away. It is a simplistic, pejorative and snide way of describing what is a source of great pride for me and others. 13 years before the disgrace that was Bowers v Hardwick, over a decade before AIDS became the consolidating force behind the gay rights movement, 3 decades (!) before Lawrence v Texas, 3 decades (!) before states decided to inscribe into their State Constitutions anti-Gay bigotry, psychiatry refused to pathologise homosexuality. This was not “caving in”: this was extraordinarily brave and extraordinarily farsighted. Oh, some (like Szasz) might scoff, why was homosexuality there in the first place? That’s another argument. But, in 1973, at the first opportunity since 1968, out it went. And since then, the APA has consistently argued against construing homosexuality as pathology. To portray this as “caving in” is slanderous (and somewhat naive, in that it fails to consider the relative paucity of power that “gay activist pressure” has ever exerted, anywhere). Does the rejection of homosexuality as psychopathology exemplify some social aspect to psychiatry? Yes, it does. But not as your analysis would have it. Psychiatry faced this issue and, as far as I am concerned, those psychiatrists who were debating this around the time I was born did a brave thing and the right thing and they did it for reasons that were clinically astute, thoughtful, difficult for the profession, and risked a great deal. Good on them!

Meanwhile, I think Oaks’s proposed name “Extreme overwhelm” is really apt. (It also sounds like a great name for a nu-metal band. Nu-metal is arguably a therapeutic genre: its lyrics are often, too, explicitly about mental health.)

Thanks for the insightful and rigorous comment. Firstly, I hope this redesign is a little easier on the eyes…please let me know.

Moving on to your three substantive points:

1. On the issue of the DSM’s “Biblical” veracity: yes, I absolutely take your point that the DSM-as-psychiatric-word-of-God is very much a straw target. Researching my essay, I was initially a little bewildered to discover that — despite the often very emotional reactions displayed by the DSM’s harshest critics in regard to the manual’s purported “scientific” basis (MindFreedom, and other “survivor” groups, for example) – I was having trouble finding a single practicing shrink who actually supported this idea of the DSM as a normative repository of infallible propositions on the nature of mental health. As you say: not one. Certainly not Michael First, editor of DSM IV-TR and director of the DSM-V Prelude Project who (as I illustrate) was eager to clarify the great extent to which the DSM still needs to evolve before it can even begin to approximate to a neurobiologically- or genetically based etiological system. As First makes clear, and as you argue, S, the primary purpose of the DSM at this stage of its evolution is to provide a practical document that gives clinicians and administrators an heuristic tool to discuss mental disorders with some reasonable degree of mutual comprehensibility – decidedly not to make assertions about the meaning of madness or sanity.

That said, why such a hostile clamor from the “survivors” – have First and the American Psychiatric Association really failed to get their message across so absolutely, or do the critics at some level have a point? One of my objectives in researching my essay was to attempt to understand the depth of the survivors’ anger towards the APA. To some extent, I sense the anger is directed towards a wide array of clinical malpractices (from forced electroshock treatments to misdiagnoses) with which the psychiatric profession has been historically identified, even if this reputation is inconsistent with the record of most modern psychiatrists or the APA. But at a deeper level, I believe the anger stems from an hostility towards the very idea of a normative paradigm of mental health, even if the DSM’s authors themselves explicitly reject such a paradigm. Mental illness is painful. To be discriminated against because you are mentally ill compounds the pain. The APA may not be an appropriate target for perpetuating discrimination, but they are big and powerful and perhaps provoke instinctive iconoclasm on that basis.

2. On the issue of reckless comparisons between psychiatry and medicine that misunderstand medicine: yes, again, solid point. I’m not a physician, but based on my understanding of the philosophy of both medicine and psychiatry, I’m certainly alert to your suggestion that they have more in common than anti-psychiatric critics often typically realize. “Theories,” wrote the philosopher of science Karl Popper, “are nets cast to catch what we call ‘the world’: to rationalize, to explain, and to master it. We endeavor to make the mesh ever finer and finer.” Popper’s definition of scientific theory surely applies wonderfully to the nature and practice of medical (and psychiatric) diagnosis: in attempting to articulate the nature of a “disease,” the clinician casts a clinical and linguistic “net” over his or her patient. The net naturally has holes, which in most cases will be sufficiently small that the net “catches” the majority of cases in its diagnostic sweep, but not in all cases. Where anti-psychiatric critics misconstrue the epistemological foundation of their enemy’s enterprise is in imagining psychiatry not so much as a Popperian net (useful, improvable, yet fallible), but as tantamount to an array of unimpeachable axioms.

3. Re: the APA’s 1973 decision to remove homosexuality from DSM-II. My decision to characterize this decision as “caving” to gay activist pressure was an unfortunate turn of phrase that wrongly denies due acknowledgment to the brave and farsighted actions of a sizeable APA faction. However, we should remember that while homosexuality was removed from DSM-II in 1973, the APA retained “ego-dystonic homosexuality” in DSM-III under the category of “other psychosexual disorders.” As Paula Caplan and others have argued, the idea of a person being evaluated as mentally ill because he or she is unhappy (“ego-dystonic”) with his or her homosexuality misses the point that an emotionally adverse reaction is very understandable in a homophobic society: i.e. the “ego-dystonic homosexuality” diagnosis confuses a social pathology with an individual psychopathology. The “ego-dystonic” diagnosis was removed in DSM-III-TR. So, surely the 1973 decision needs to be understood with these later redefinitions in mind, as more of a gradual evolution towards the APA’s institutional acceptance of homosexuality than an overnight revolution?

1. I believe that those are exactly the right questions; I have thoughts on the answers, but little conviction, and will look forward to your further analysis. You bring up “discrimination”, which naturally leads to the question of stigma and labelling, important topics both. But I do worry that many discussions of stigma may be misguided: which comes first, stigmatisation through a taxonomy of madness or the stigmatisation of madness? I do not think that this is a chicken-and-egg question (which Popper also figured out, BTW, although not entirely to my satisfaction) - but it is a question worth exploring, and you are already doing so. You also raise the question of “clinical malpractices”, which is terribly complicated, and it is hard not to appreciate how careful you are with this claim. It’s long been understood, throughout medicine, that the future will look back on contemporary medical practice as barbaric; and we are probably unaware of some of the Tuskegees that are going on around us right now. This ought never justify malpractice, but is a sentiment that urges some caution in blithely condemning the practices of the past (again, I do not think that you are doing this).
2. Quite so. The “differential diagnosis”. One of the pleasures of receiving the New England Journal of Medicine every week is the clinical case conference, in which the good doctors of Mass General correctly diagnose some patient who has often, although not always, floundered outside of the ivory tower with a slew of misdiagnosed symptoms. The careful reader will often note that the patient gets sicker and sicker over several days while people try to patch up a medical net, which has very large holes.
3. Regarding your last question, I would have to answer “yes”. I also think that Paula Caplan et al are correct in their critique (why not ego-dystonic obesity, or ego-dystonic curly-haired?) These are topics worth dwelling on. But, you write that the diagnosis “confuses a social pathology with an individual psychopathology.” A challenge facing you in your ongoing research is how those two criteria (social pathology and individual psychopathology) are confused but also dependent - they are certainly not mutually exclusive. Again, I look forward to reading your thoughts on this matter.

“[When Prozac] was taken to China for clinical trials, the local Chinese doctors were bemused that only one member of a social group should be dosed. In Chinese medicine, ‘depression’ is often seen as […] a sign that the group is malfunctioning.”

1. Hmm, yes, on the matter of stigma - I agree that the debate often elides any distinction between the stigma of madness per se and the stigma of madness defined through a given classificatory system. Michael First made this point when I spoke to him: the opprobrium attached to mental illness is regrettable, but the DSM cannot be blamed for it. By contrast, social constructivist critics, such as the sociologist Stuart Kirk (who has pursued a career criticizing the DSM, in books including “Making Us Crazy” and “The Selling of DSM”, both co-written with Herb Kutchins), argue that since mental disorders are merely “‘constructs” - socio-consensual fabulations, if you like - the DSM and the APA are responsible not simply for describing mental illness but for perpetuating its very existence, and thus for its associated stigma. In my analysis, this latter view inclines treacherously close to the relativistic canard that reality is whatever humans decide it to be, and it strikes me as disingenuous to lay the blame for all psychiatric stigma at the feet of the APA. When an employer treats a worker diagnosed with depression less compassionately than a diabetes patient, is the DSM really responsible? Even if one claimed the answer is “yes, in part,” we would still need to account for the actions of the employer, and the deeper mechanisms of the stigmatizing process as it relates to mental illness - a topic to which I will be returning in a future post.

3. Social pathology and individual psychopathology: a complex and fascinating relationship, which I will endeavor to disentangle through concrete examples going forward.

Yes, striking anecdote. Several brief thoughts: it’s known that the prevalence or manifestation of “depression” is culturally variable. What’s less readily acknowledged is that if we take the “biopsychosocial” model of mental illness seriously, then all disorders must surely be interpreted as to a certain degree socially constituted. Each culture, in this sense, speaks a different language of suffering. One might reasonably wonder, though, why Chinese depression should differ so markedly from, say, American depression, given the common genetic profile of those two populations. For those of a more reductive biomedical persuasion, it’s tempting to suppose that some common pathology must underlie these differing cultural manifestations. Following evolutionary psychiatrist Anthony Stevens, who has argued that depression in primates may serve a function (of enabling a group to reorganize after a challenge between two males vieing for dominance; the vanquished ape retreats to a corner and sulks), one might conceivably argue in these terms that in the more socially complex environment of human societies, psychological distress simply has a wider potential range of behavioral idioms, not a wider range of actual etiologies. “Depression,” in this sense, would actually be a culturally-variable signifier for a variety of deeper underlying processes that interconnect neurochemistry, cognitions and family and social dynamics in myriad individual ways. Similarly, as the Churchlands have argued, perhaps the language of “depression” and many other current diagnoses is really a form of “folk taxonomy” that will gradually recede into non-existence as our science and language evolve in sophistication, from “depression” to “dopamine deficit” and whatever lies beyond. But to follow this line of argument is to accept the “disease” model as psychiatry’s essential metanarrative. Perhaps neuroscience will ultimately prove so compelling that no other metanarrative will seem worth considering. Perhaps this neuroscentifically advanced disease model will even incorporate group social dynamics from an etiological perspective. Until that day comes, however, the materialist vs. constructivist debate seems set to continue.

Regarding your response about the Chinese and prozac: the whole field of medical anthropology (one of whose leading figures is the psychiatrist Arthur Kleinman - is that where the anecdote came from?) is devoted to such stories about diversity in conceptions of illness and experience of disease, and how it affects our understanding of what it is to be sick and healthy, who the patient is and why, as well as what these illnesses actually are etc.

I hope that you return to “biopsychosocial” - some of the books mentioned in my first blomment have quite an interesting take on this model. I also hope you return to evolutionary psychiatry.

On China: yes, I was thinking of Kleinman. Was Steve?

Thanks for the very interesting survey of attitudes to this. Reasoning philosophically, I would be inclined to say that the (perhaps caricatured) “pure” neurochemical attitude has to be if not wrong then at least in principle and forever inadequate, since obviously what happens outside an individual’s skull has an effect on what happens inside his brain. And among things happening outside an individual’s skull are social interactions. It doesn’t even seem to matter whether we think that consciousness is epiphenomenal - ie, if we believe that the neurons just get on with their stuff and throw off a haze of consciousness, as of heat, which however cannot causally affect neuronal activity. In that case it might look difficult to cleave to the idea of the existence of a “social fact” which could affect the neural activity, but then one can translate it into the language of neural effects of sense data conveying information about the behaviour of others, and subsequent behaviour resulting from those neural affects and consequent processing - which seems to me to get at the same idea. And if consciousness is what it seems to be, ie a link in the causal chain, and so social facts and our conscious reaction to them can affect what happens in the brain too at a neural level.

So either way, it seems to me that “dopamine deficiency” is never going to be a thoroughly adequate explanation, because the causal evidence trail for what caused that deficiency might well lead outside the individual and into the social world. Hence it does not seem surprising on the face of it that eg the US and China, although their members are genetically almost indistinguishable, have different prevalences or experiences or attitudes to what each calls “depression”, if it is true that their social habits are different enough to be implicated in the causal chain.

Which I suppose is a long-winded way of saying that the biopsychosocial model looks pretty compelling to me.

Eliminative materialism: logically this sounds analogous to claiming that King Lear is “nothing but” biped hominids making noises.

It’s quite long as blog posts go. I wonder whether it might be useful to break posts up into smaller chunks, more digestable in a single sitting. Thats taken me over an hour to get through and absorb, which may scare off some of the people who would most usefully read it. The subtitles seem like obviious breaks and you wouldn’t lose the narrative or become tabloid, especially if you put in a intro/summary, then part 1, part 2, part 3 sort of thing. Its great stuff - keeep’m hungry.

hope alls well.

With regards to the “biopsychosocial model”: first, this has been exported wholesale throughout medicine as the paradigm of comprehending a patient. Everyone who comes under the scrutiny of a physician, at least if medical schools have done their job right (if not well), will have his or her presentation understood through the biopsychosocial model. Naturally, physicians spend a lot more time with the “bio” than the “psychosocial”; regarding this, can we agree that just because a person focuses somewhere, he or she might have substantial interest in and respect for other domains?

The biopsychosocial model has been subject to substantial critique in psychiatry, for one important reason as best I can tell: it is not really a model, because it is agnostic about or ignorant of how these three factors come together except in proximity in the word itself (which can also be an advantage, providing one is aware of this). There are other practical reasons for feeling a bit nervous about the model, but these are mostly dealing with misapplication, lazy application, etc

psychiatry is often criticized for paying lip service to the biopsychosocial model in theory, while pursuing the “biobiobio” model in practice.

This is absolutely true! Psychiatry is often criticized for this. Whether or not this is an adequate or meaningful assessment of psychiatry is another matter.

So either way, it seems to me that “dopamine deficiency” is never going to be a thoroughly adequate explanation, because the causal evidence trail for what caused that deficiency might well lead outside the individual and into the social world.

I quite agree - while we may accept that there are some people who are saying that “dopamine deficiency” (or a similar biological variant) is a “thoroughly adequate explanation”, perhaps including some psychiatrists and neuropsychologists, and maybe the good men and women of Eli Lilly, I think that we might also safely say that most people do not believe that such a biological variant is “thoroughly adequate”.

Hence it does not seem surprising on the face of it that eg the US and China, although their members are genetically almost indistinguishable, have different prevalences or experiences or attitudes to what each calls “depression”, if it is true that their social habits are different enough to be implicated in the causal chain.

Obviously Steve has spent some time studying epidemiology, because he’s absolutely right. The same principles also hold true of obesity, cancer, asthma, malaria, AIDS, etc

I’m glad that Steve has been the first to call someone “nuts” on this site. And I do agree with Steve R on length.

I have to say that this is a truly excellent article. I’m a big fan of Schore, Siegel, et al. Siegel has this great sentence in the opening of “The Developing Mind”:

“The mind emerges from the activity of the brain, whose structure and function are directly shaped by interpersonal experience.”

Right there you have a conceptual revolution. I open all my presentations with this quote.

Now, you have to understand that for me, David Oaks is a true American hero. I think you were a little unfair to him because David is not a clinician– he’s an activist (and a great one at that). More and more MindFreedom has come around to the idea of embracing & promoting alternatives, instead of reacting to an often times abusive mental health system.

But the question then comes down to: what exactly IS the alternative? And I think neuropsychoanalysis is pointing the way to the future. This future has to do with studying how human relationship is crucial to the creation and maintenance of “mental” disorders. And not only that, but studying the ways in which an active, intentional agent interprets, gives meaning to, and assimilates the effects of various traumas into his/her life. In other words, we do not meet trauma as passive agents but rather bring an activity to bear which shaps the effect of this trauma.

Psychotherapy is about helping people to understand how they have assimilated this trauma in the context of a real human relationship with the therapist– and then helping them to go through the painful and arduous task of creating new, satisfying ways of being in relationship.

Matthew Morrissey
San Francisco

It is widely understood that the general principles hold true for those phenomena. What is surprising to me, at least, is that anyone ever thought (if they really did or do so think) that the same principles don’t also hold true for mental “disorders”.

Re 16: stigma and treatability - not a connection I’d eat my hat to defend, just a casual idea at this point; watch this space for a stigma article coming soon…

Re 17: Matt, glad you liked the essay, and yes, in my endeavor to scrutinize the claims of the survivor movement, perhaps I came out seeming unduly hard on David Oaks. I certainly don’t doubt his passion or commitment to improving the lives of people coping with mental illness; but equally I’d attribute these same qualities to many psychiatrists, while I suspect he wouldn’t — which is partly the root of my critical point about MindFreedom.

The rapprochement of neuroscience and psychoanalysis, as pursued by Schore, Siegel et al. is, I agree, most exciting, and yes, I can well imagine a neuropsychoanalytical movement reinvigorating the good old-fashioned “talking cure.”

In fact the methods of almost all the Arts and Sciences converge on psychopathology. Biology and morphology, mensuration, calculation, statistics, mathematics, the Humanities, Sociology, all have their application. This dependence on other branches of learning and the proper taking over of their methods and concepts are both matters of some importance to the psychopathologist, who is concerned with the human being as a whole and more especially the human being in times of sickness. The essence of psychopathology as a study can only emerge clearly from a composite framework. It is true that methods taken over from elsewhere may lose thereby and are often misapplied, thus producing a pseudo-methodology, and this is a weakness. Yet psychopathology is impelled to make use of methods that have been perfected elsewhere in order to improve their status of its subject-matter, which is unique and irreplaceable for our apprehension of the world and humanity, and to bring it to a level where it can be properly grasped and its significance fully comprehended.

Karl Jaspers, General Psychopathology. In 1913.

What are the “determinants of falling ill”?

In the first place there is hereditary disposition […] Next there is the influence of early experiences in childhood, to which we are in the habit of giving prominence in analysis: they belong to the past and we cannot undo them. Then comes everything that we have summarized as ‘real frustration’ - the misfortunes of life from which arise deprivation of love, poverty, family quarrels, ill-judged choice of partner in marriage, unfavourable social circumstances, and the strictness of ethical standards to whose pressure the individual is subject.

Freud, Introductory Lectures. In 1917.

Existential psychiatry thrusts aside the term illness, substituting the human condition. Illness is only a category of retrospective understanding. There is no way of knowing, from moment to moment, what will in retrospect prove to be illness […] The goal of treatment is meeting, being with the other […] In unlivable situations crises occur which require extraordinary actions. These are sick only in the sense that they are part of sick human situations; blame is possible only when someone is not understood.

Leston Havens, Psychiatric Movements. In 1973.

Re comments 10, 16 and 19, I have researched and written about the relationship between stigma and the currently endorsed (enforced?) biogenetic explanations for mental illness here.

Although firmly in the ’survivor’ camp, I ‘m looking forward to further reading and reflection.

Thank you,

Andrew