Niall McLaren, MBBS, FRANZCP

In July 2009, the NIMH hosted a meeting with the World Health Organization and the American Psychiatric Association at which it launched its research program for the foreseeable future.

 project is intended to replace the former framework, Research Diagnostic Criteria, that formed the basis of the DSM system over a number of iterations.

RDoC is essentially a laboratory-based program directed at seeing mental disorder in biological terms: “First, the RDoC framework conceptualizes mental illnesses as brain disorders . . . mental disorders can be addressed as disorders of brain circuits. . . . Second, . . . the dysfunction in neural circuits can be identified with the tools of clinical neuroscience, including electrophysiology, functional neuroimaging, and new methods for quantifying connections in vivo. Third, . . . data from genetics and clinical neuroscience will yield biosignatures that will augment clinical symptoms and signs for clinical management.” Essentially, RDoC will transform psychiatry into a clinical neuroscience.

In introducing this major reorientation, 

, warned that it represents a huge investment of time, effort, and necessarily, of money, and it would be unrealistic to expect even preliminary results in under a decade: “We are still a long way from knowing if this approach will succeed. . . . We recognize that the creation of such a new approach is a daunting task, which will likely require several mid-course corrections and may ultimately fail to deliver the transformation we seek in clinical care.”

This message has been repeated in influential journals and widely read periodicals.

 The program itself has been criticized as unachievable, but that is a separate issue.

 My concern here is the claim that biology can tell us everything we need to know about mental disorder, with no questions unanswered: “One of the fundamental insights emerging from contemporary neuroscience is that mental illnesses are brain disorders.”

 Indeed, the entire success of this program and most of the current research in psychiatry hinges on this claim.

To our lasting humiliation, psychiatry has already had 1 or 2 “lost generations,” when all our efforts were directed toward the wrong goal. It is worth noting that the problems inherent in psychoanalysis and behaviorism were known many years before psychiatrists finally relented and abandoned their dreams. In 1922, Popper had demonstrated that psychoanalysis was not and could not be scientific, while Chomsky’s remarkable dissection of Skinner’s theories in 1959 will never be outdated.

 Therefore, before the profession commits to the biological path, we should be certain of our intellectual grounds.

In brief, the central issue is the claim that all mental disorders are, in some essential sense, brain disorders (that brain disorder is both necessary and sufficient for mental disorder). I began to check the references in each of the articles cited above (and many others of the same nature). To my surprise, the bold claims were never referenced. Instead, they are presented as flat statements, as though utterly beyond question. I found this rather strange. In any other science, it is possible to track back through the references to find the earliest discoveries that set the discipline on that particular course.

For example, it is easy to find the first articles from the early 1980s describing a strange and deadly new immune deficiency. Similarly, every basic medical and physiology text will refer to Banting and Best, to Ramon y Cajal, Fleming, and so many others (and rightly so: it is highly appropriate that medical students study the greats). However, despite poring over these articles, checking each reference then each author’s publication list, it seems modern psychiatry is not following in the footsteps of our medical brethren: we alone have no history. Who proved that mental disorder is just brain disorder? Nobody seems to have examined this vital point.

This question has troubled me for years: If we claim to know the nature of mental disorder, what exactly are we assuming? No proposition exists in isolation. Every belief comes nested in earlier beliefs, explicit and implicit, each of which has to be understood clearly so that bias can be detected and eliminated. Yet here, at the very heart of psychiatry, people seem totally unconcerned about making claims that, for example, philosophers have never been able to prove. What are the options? The first explanation is that as a matter of strict identity, mental disorder is just a brain disorder. This reflects a theory from the 1950s and 1960s-the Mind-Brain Identity Theory (MBIT). In fact, it could only make sense in psychiatry if the MBIT itself were true. Nobody accepts this now, as I showed in 1992, and it is rare for people to claim it for psychiatry.

The next option is that mental disorder can be reduced to brain disorder. The concept of reductionism is absolutely basic to Western science; it has been the most successful scientific program in human history and is nowhere near reaching its end. In psychiatry, it would be a case of mental disorder reducing to brain disorder. This would be part of a broader program, or reducing mind to brain; unfortunately, there is no support for the notion that the phenomena of mind can be explained in terms of the phenomena of physical science.

 Philosophers have moved on because the properties of molecules do not explain the properties of the entities constructed from them.

It is clear that explaining mental disorder depends on explaining mind: we need an account of normal mental function before we can give account to abnormal function. In philosophy, there are not many options. Functionalism, the dominant theory of mind, says nothing about mental disorder. The most popular form of functionalism, from the philosopher Daniel Dennett, offers no clues as to how mental disorder may arise. I have argued that his program is at an end, just because it is covertly dualist in nature, so anybody wishing to use his work to explain mental disorder would be wise to take this into account.

 This also applies to other theories of mind, but that is not germane to the question of whether psychiatrists have explained why a research program in mental disorder devolves to a research program in the neurosciences.

Eventually, I surveyed 11 of the most influential English-language journals in psychiatry, from January 2001 to December 2011.

 This yielded some 1465 issues totalling 154,000 pages. If the explanation of why mental disorder is a form of brain disorder lies anywhere, it should be somewhere in that very large pile. There were something like 19,250 original research papers, editorials, commentaries, reviews, surveys, and opinions, including every significant figure in psychiatry today. I found nothing to indicate that any person of any stature in modern psychiatry has offered anything that would justify the belief expressed above: “. . . mental illnesses are brain disorders.”

 This proposition is an opinion, but it is nothing more than opinion. In fact, opinions held very firmly without formal justification amount to an ideology.

At this stage of its development, biological psychiatry amounts to an ideology, and no more. It does not have a theory of mind and it has no formal model of mental disorder, no theory of personality or personality disorder, and no understanding of how these concepts would fit together. The claim that mental disorder is brain disorder is not a theory of mental disorder because it has no basis in a broader understanding of what constitutes science.

This is very important, because it says all our claims to have a solid intellectual grip on the nature of mental disorder, sufficient to launch a 20- to 30-year research program at $1.5 billion a year, lack the most elementary intellectual basis. We are, in fact, heading down the same path as the psychoanalysts and behaviorists: we are launching a massive scientific research program without first examining the nested beliefs on which that program depends. Yes, by chance, it may turn out to be correct, but that is not, I suggest, sufficient basis for this type of program. People’s lives depend on it. In general medicine, we demand the most stringent intellectual standards, yet in psychiatry, we rely on opinions.

People sometimes refer to articles by Samuel Guze

 from several decades ago in which he expressed the belief that there cannot be a psychiatry that is too biological. In fact, there can be: any attempt to explain language in biological terms will fail, as philosophers have long argued (for example, see Chomsky

). Others refer to the neurophysiologist Eric Kandel,

 who has repeatedly stated that neurosciences will give an account of mental disorder by some program he calls “radical reductionism.” Again, he offers nothing more than opinion, unsupported by anything that would amount to a cogent argument.

 Within neurophysiology, his opinions are worth noting; outside his discipline, they carry no more weight than those of other “greats” who have been proved wrong (Lord Kelvin, for example, believed that the sun would not last long enough for evolution to occur; he assumed the sun was made of coal).

This gloomy conclusion is not popular, and psychiatrists who have devoted their careers to exploring the biology of mental disorder often react with resentment. That is their problem; I am merely the messenger, the little boy who said, “But the emperor is wearing no clothes.” Rather than argue, I leave it with them: Please give me the name of the model of mental disorder you use in your daily practice, your teaching and your research, and provide me with 3 seminal references where it is articulated as a series of testable propositions that meet the minimal standards of our modern concept of a scientific theory.

Nobody has ever done it, but until somebody does, psychiatry could well be on the wrong path. I think we should sort out whether biological psychiatry has a formal basis in science before we spend another penny on it.

Dr McLaren is Psychiatrist with the Northern Psychiatric Services of Brisbane, Queensland, Australia. He reports no conflicts of interest concerning the subject matter of this article.

Insel T, Cuthbert B, Garvey M, et al. Research Domain Criteria (RDoC): toward a new classification framework for research on mental disorders. 

 Cuthbert BN, Insel TR. Toward new approaches to psychotic disorders: the NIMH Research Domain Criteria project. 

 Insel TR, Freund M. Shedding light on brain circuits. 

 Morris SE, Cuthbert BN. Research Domain Criteria: cognitive systems, neural circuits, and dimensions of behavior. 

 Yan J. NIMH builds new framework for understanding mental illness. 

 McLaren N. Cells, circuits and syndromes: a critical commentary on the NIMH Research Domain Criteria project. 

 Insel TR, Quirion R. Psychiatry as a clinical neuroscience discipline. 

 Chomsky N. A Review of B. F. Skinner’s 

 McLaren N. Is mental disease just brain disease? The limits to biological psychiatry.

 McLaren N. The irreducible mentality of mind. In: 

The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry.

 Ann Arbor, MI: Future Psychiatry Press; 2012:3-18.

McLaren N. Emergent logic and antimonism. In: 

 Ann Arbor, MI: Future Psychiatry Press; 2012:21-41.

 Guze SB. Biological psychiatry: is there any other kind? 

New Horizons in the Study of Language and Mind.

 New York: Cambridge University Press; 2000.

Psychiatry, Psychoanalysis, and the New Biology of Mind.

 Washington, DC: American Psychiatric Publishing; 2005.

McLaren N. Defining limits to biological reductionism. In: 

Humanizing Psychiatry: The Biocognitive Model.

 Ann Arbor, MI: Future Psychiatry Press; 2009:1-21.

Articles

At the very heart of psychiatry, people seem totally unconcerned about making claims that, for example, philosophers have never been able to prove.

Will Biology Tell Us All We Need to Know About Mental Disorder?

Using data from the replication of the National Comorbidity Survey (NCS-R), undertaken in the 2years to April 2003, Kessler et al

 explored the epidemiology of DSM-IV Intermittent Explosive Disorder (312.34: IED). One of the impulse-control disorders, this includes serious acts of aggression against person or property that are completely out of proportion to any provocation.

The NCS-R used trained lay interviewers to administer the third edition of the World Health Organization Composite International Diagnostic Interview (CIDI),

 a fully-structured instrument which generates diagnoses according to WHO and DSM-IV standards. For the purpose, they operationalized the DSM criteria, detailing how the interviewers scored the responses, and their methodology appears sound. Using broad and narrow definitions, they concluded that the incidence of this condition is somewhere between 5.5% to 7.5% of the population, with onset in early teenage years and a high level of persistence. It also has a very high rate of comorbidity, with a range of other psychiatric conditions such as affective disorder, anxiety disorders, substance abuse, and other impulse control disorders (the study did not screen for all personality disorders but excluded Antisocial PD). It is associated with being a young adult male, with poor education, low socioeconomic status and disturbed interpersonal relationships. The level of total disability associated with this diagnosis is high. In the main, these people are not recognized and rarely accessed treatment.

At the same time, throughout psychiatry, there has been a continuing debate over the status of aggressive behavior in children and in relation to other disorders. Lee and Galynker

 reported that “just under 50% of people with bipolar disorder have some history of violent behavior.” Violence can occur in manic or in depressive states, or even in euthymic moods. They saw a close and compounding relationship between childhood trauma and violence in adult Bipolar Affective Disorder (BAD): “A history of 2 or more types of trauma has been associated with a 3-fold increased risk of bipolar disorder, as well as a worse clinical course that includes early onset, faster cycling, and increased rates of suicide.” Early trauma complicates adult affective disorder by predisposing to substance abuse, criminality, and personality disorder. In general, early onset of aggressive behavior indicates a poorer prognosis, and not just for the affective disorder. So what is the disorder, and what should be treated?

While the diagnosis rates of pediatric bipolar disorder (PBD) have leapt by some 4000% in 20 years

 (and by twice that in this country), the diagnostic criteria have been broadened to include children who are consistently (not episodically) irritable, impulsive and aggressive. Frances saw this as evidence of a “fad diagnosis,” the clear implication being that something beside science is driving the process: “

To become a fad, a psychiatric diagnosis requires three preconditions

: a pressing need, an engaging story, and influential prophets.” The “pressing need” is the presence of disturbed and disturbing children in schools, courts, and detention centers. The “engaging story” has a number of elements: that the disorder is extremely common; was previously under-diagnosed; and presents differently from in adults, including such diverse symptoms as “irritability, anger, agitation, aggression, distractibility, hyperactivity, and conduct problems.”

Dr Frances didn’t mention the obvious point--that there is intense social pressure to control just these behaviors before they harden into adult patterns of antisocial conduct. The “influential prophets” were, of course, names who have been unhappily linked to the decidedly partisan drug industry. The unstated agenda is that if all these children and adolescents can be prescribed (expensive) drugs to control their genetic disease, they will need them for life. Frances was greatly concerned by this process, and listed a number of very real complications of this “fad.” He supported moves by the DSM-5 Childhood and Adolescent Disorders Working Group

 to restrict the diagnosis by relocating irritable and/or aggressive behavior in another diagnostic category, such as “Severe Mood Dysregulation: SMD” (or Temper Dysregulation Disorder: TDD).  

The Working Group is aware of the complexities they face in arriving at a universally accepted definition: “Indeed, a subgroup of the Attention Deficit/Hyperactivity Disorder and Disruptive Behavior Disorders and Childhood Disorder Work Groups expended considerable energy devising a proposal for a specifier for the Oppositional Defiant Disorder (ODD) diagnosis that would differentiate the SMD/TDD phenotype from the rest of ODD, given that new specifiers require a lower level of evidence than do new diagnoses…the two work groups decided that an ODD specifier would be unlikely to be used by clinicians to diagnose youth with SMD/TDD, since ODD is not a mood disorder (while TDD would be).”

In English, that asks whether we should put temper outbursts in with depression and other mood disorders (ie, in the clearly-defined cluster of genetically-determined chemical imbalances of the brain, or should they be lumped with the personality disorders?). Is an impulsively aggressive person with a long record of assault, drug and alcohol abuse, poor work record, and unstable interpersonal relations suffering a formal mental illness (with all the forensic and social complications that would imply), or is he or she simply choosing to act this way, and is therefore responsible for his/her actions? This is not a trivial question, but it flows directly from the question of whether “such diverse symptoms as irritability, anger, agitation, aggression, distractibility, hyperactivity, and conduct problems” are or are not of the same ontological nature as depression and hallucinations. For example, in Australia, which has universal welfare and treatment, if these behavioral factors are held to be mental illness per se, then the “sufferer” is entitled to a pension for life, unlimited (world class) treatment, and an endlessly renewable excuse for all manner of antisocial conduct. 

Axelson notes that TDD overlaps substantially with ODD, as it does with many other childhood disorders, mainly because “…all of its core diagnostic criteria are shared by other DSM disorders. There are no signs or symptoms that are unique to TDD.”

 He gives case vignettes to suggest that, in childhood, there are many syndromes presenting with the clinical features of TDD. A fortiori, this would be true in adults. He concluded: “It seems clear that TDD does not have a sufficient level of research support to justify creating a new psychiatric diagnosis. Then why has it been proposed? The primary reason … is the need to stem the tide of the perceived substantial overdiagnosis of bipolar disorder in children.” That is, symptoms which, in adults, are taken to indicate personality disorder are, in children, reclassified as mental illness for reasons of payment and, I suspect, because clinicians are loath to damn children with a diagnosis of PD.

It is my view that the drive to establish a novel mental illness consisting of ferocious outbursts of temper is driven by the same imperatives.

Why does mental illness trump personality disorder?

Echoing the alarming findings described by Axelson, Kessler’s group found very substantial levels of “comorbidity” in their study. Of people reaching criteria for IED, well over one third had a mood disorder and nearly two thirds had an anxiety disorder. Over one third described substance abuse while nearly half met criteria for another adult impulse control disorder. No less than one half of their subjects had three or more separate additional diagnoses. Remember that the NCS-R omitted a number of diagnostic categories; there is no reason why these should not have been found in their group, only that they didn’t look. Moreover, there was a consistent pattern of disturbed behavior over many years, with many associated features of psychosocial dysfunction. Property damage was common, as was injury of self or others (an average of 2.33 injuries per outburst). In the narrowly-defined group, starting early in life and continuing throughout adulthood, there had been as many as hundreds of outbursts, often averaging an event every couple of weeks for years.

We are left with the picture that dangerous temper outbursts are common to a considerable number of diagnostic categories; they start early and are persistent; and are seen in conjunction with many factors commonly seen in personality disorder Do they therefore represent a formal mental illness in their own right, or do they signify some deeper process-- perhaps even a universal mental factor? Compare this picture with the definition of personality disorder in DSM-IV-TR: “A. An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. The pattern is manifested in two or more of the following areas: cognition…affectivity…interpersonal functioning…impulse control. B. The enduring pattern is inflexible and pervasive across a broad range of personal and social situations…” It leads to distress or impairment in social, occupational or other areas, begins in childhood or adolescence and is stable. Other mental disorders and substance abuse are not causative but may coexist.

I submit that the pattern of disturbance outlined by Kessler’s group in their account of IED precisely meets the criteria for a personality disorder. They are searching for an illness when in fact all they have done is to isolate a common personality factor that is evidence of a more pervasive, underlying personality disorder. Why would they bother? We can diagnose personality disorder with the greatest of ease; all one has to do is take a longitudinal history and the diagnosis declares itself. Personality disorder can coexist with any number of formal mental disorders just because personality is logically before mental disorder.

It seems clear that IED is yet another “fad” diagnosis in the making. Where will it stop? More precisely, what intellectual process within the field of psychiatry limits the apparently endless drive to increase the number of psychiatric diagnoses at the expense of personality diagnoses? The answer, of course, is that there is no limit. Just because modern, orthodox psychiatry has not articulated a model of mental disorder

 nobody can say that a particular symptom or behavioral parameter belongs in the field of mental disorders or whether it should be left as a personality factor. In the absence of a declared model of mental disorder, psychiatry fails the first requirement of any field of science.

 Nosology becomes a matter of “interest groups” pressuring “the system” until it grants them what they want--a case example of the politics of committees rather than applied science.

I do not believe the interests of people with primary personality disorders are properly served by misclassifying them as mentally ill. They will simply be given large doses of unpleasant, expensive, and sometimes dangerous drugs with no prospect that their condition will improve or that their lives will benefit. Their hopes will be built up, then dashed, which is not a good idea in dealing with the personality-disordered. More to the point, they will not be offered whatever (limited) treatment options are appropriate to their diagnosis. In the longer term, failing to recognize personality disorder restricts it to a second or even third order consideration: there is very little primary psychiatric research on personality disorder. We don’t have a scientific model of personality disorder, just because we don’t have a model of personality, but spending all our time reclassifying personality-disordered people as mentally ill means that we will never see the problem as sufficiently important to divert resources from the biological industry. I am also unconvinced that the interests of the mentally ill are well-served by lumping them with dangerous and/or aggressive people, but that is another matter.

What counts is that psychiatry’s obsession with reaching valid diagnoses is taking place at the expense of generating a model of mental disorder. Influential figures already recognize that the massive resources being spent on DSM-5 are unlikely to achieve their goal

so why do we bother? As an outsider, I suggest that the major impetus to persist with what is clearly a non-scientific approach is the result, not of rational factors, but of the egos of the many people who have committed their professional lives to articulating a sterile vision of psychiatry. I have argued elsewhere

 that, at this stage of its development, DSM is the wrong program for psychiatry. The attempt to reclassify personality disorder as a new mental disorder known as IED demonstrates the point. When it comes to arguing that mental disorder and personality disorder can be conflated, the burden of proof rests with its advocates. So far, not one of them has offered a remotely convincing case. 

Kessler RC, Coccaro EF, Fava M, et al. The Prevalence and Correlates of DSM-IV Intermittent Explosive Disorder in the National Comorbidity Survey Replication. 

Kessler RC, Ustun TB. The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). 

Lee AMR, Galynker II. Violence in Bipolar Disorder: What Role Does Childhood Trauma Play? 

http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1727571

Francis A. Psychiatric Diagnosis Gone Wild: The "Epidemic" Of Childhood Bipolar Disorder. 

http://www.psychiatrictimes.com/bipolar-disorder/content/article/10168/1551005

Justification for Temper Dysregulation Disorder with Dysphoria DSM-5 Childhood and Adolescent Disorders Work Group. DSM-5. At: 

Axelson D. Adding the Diagnosis of Temper Dysregulation Disorder to DSM-5: Do We Really Need It? 

http://www.psychiatrictimes.com/display/article/10168/1745080

Humanizing Psychiatry: The Biocognitive Model

. 2009; Ann Arbor, Mi.: Future Psychiatry Press. ISBN 978 1 615990 11 5.


Humanizing Psychiatrists: Toward a Humane Psychiatry.

 Ann Arbor, Mi.: Future Psychiatry Press. ISBN 978 1 615990 60 3


The Structure of Scientific Revolutions. 

2nd Edition, 1970. Chicago, Ill: University Press (International Encyclopedia of Unified Science, Vol. 2, No. 2


 Insel T, Cuthbert B, Garvey M, et al. Research Domain Criteria (RDoC): Toward a new classification framework for research on mental disorders. Commentary. 

One of the impulse-control disorders, Intermittend Explosive Disorder includes serious acts of aggression against person or property that are completely out of proportion to any provocation.

Niall McLaren, MBBS, FRANZCP

Articles

Will Biology Tell Us All We Need to Know About Mental Disorder?

Temper Tantrums, Mental Disorder, and DSM-5: The Case for Caution