Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

Ronald W. Pies, MD

I very much appreciate Charles S. Burke, MD’s, 

 on my article about Russia and the notion of “paranoid government disorder.”

 I received several comments from readers who saw strong parallels between my comments on Russia and the matter of the so-called “Goldwater Rule.”1 However, I believe the deep structures of these issues are fundamentally different—roughly summed up as the difference between social psychiatry (observations on Russian society) and armchair psychiatry (comments on public figures we have not personally evaluated).

Dr Burke provided a partial quote from the article I coauthored with James L. Knoll IV, MD, in which we clarified the psychiatrist’s responsibility to assess dangerousness.

 The complete quote is as follows: “In short, the crux of the problem is the misapplication of psychiatric labels in order to vent displeasure at a public figure.”

Our article in no way advocated restrictions on psychiatrists venting displeasure with specific policies or practices of public figures and elected officials, or their administrations—only on what psychiatrists may ethically say about the mental state of living public figures they have not personally evaluated.

By the same token, Dr Knoll and I did not argue against psychiatrists expressing their views regarding “political and social issues,” nor did we wish to imply that such views should “only be expressed privately to the appropriate civil authorities, congressional representatives, or magistrates,” as Dr Burke seems to have inferred. After all, the American Psychiatric Association regularly expresses its views on such issues as structural racism

 and their effects on mental health. Some might call these political and social issues, but these issues clearly have implications for mental health and wellness. Psychiatrists have every right—indeed, an obligation—to speak out on such matters.

I believe the restrictions promulgated by the Goldwater Rule raise entirely different ethical issues than psychiatric commentary on societal trends and tendencies, such as undue suspiciousness (paranoia) and feelings of victimization within specific societies. I see such commentary as well within the purview of social psychiatry, which may address the “mental health needs of the international communities.”

In sum, I believe Dr Burke and I fully agree that “psychiatrists may be in a unique position to offer valuable commentary on political and societal concerns...” I would simply add: so long as such commentary adheres to the guidelines of the Goldwater Rule.

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of 

Dr Pies is the author of several books. A collection of his works can be found on Amazon.

1. Burke CS. Valuable insights to share with the psychiatric community. 

https://www.psychiatrictimes.com/view/valuable-insights-to-share-with-the-psychiatric-community

2. Knoll JL IV, Pies RW. Psychiatry, “dangerousness,” and the president. 

https://www.psychiatrictimes.com/view/psychiatry-dangerousness-president

3. Structural Racism Task Force. American Psychiatric Association. Accessed June 7, 2022. 

https://psychiatry.org/psychiatrists/diversity/governance/structural-racism-task-force

4. How extreme weather events affect mental health. American Psychiatric Association. November 2019. Accessed June 7, 2022. 

https://psychiatry.org/patients-families/climate-change-and-mental-health-connections/affects-on-mental-health

5. Aims and scope. International Journal of Social Psychiatry. Accessed June 7, 2022. 

https://journals.sagepub.com/aims-scope/isp

Articles

Psychiatrists may be in a unique position to offer valuable commentary on political and societal concerns, so long as they adhere to the Goldwater Rule. 

The Obligation to Speak Out

The horrific mass school shooting in Uvalde, Texas, is the deadliest such shooting at an American school in nearly a decade.

 A mass shooting is frequently defined as a single attack in a public place, in which 4 or more victims were killed. Sadly, there are few reasons to believe that the frequency of such tragedies will decline anytime soon. On the contrary, unless a wide range of contributing factors change, there are compelling reasons to expect more mass shootings in the US, some of which will target schools.

The reasons for this rather gloomy prediction are detailed below. It is not my intent to dissect the specific details of the Uvalde shooting or to speculate on the psychology or motives of the shooter; but rather, to provide a framework for understanding why the US seems caught in an endless, repeating loop of gun-related carnage.

1. There is an almost inexhaustible supply of marginalized, emotionally disturbed, rage-filled young men in this country

Since 1982, at least 123 mass shootings have been carried out in the US by male shooters, versus 3 by females.

 I will say more about the gender issue and its cultural roots presently. According to psychology professor 

, most of the perpetrators of K-12 shootings are under the age of 18.

And while there is no single psychological or demographic profile that can proactively identify likely school shooters, there are some general features school shooters tend to share, such as profound feelings of rejection and a history of having been bullied. Many shooters also display a fascination with guns and/or a preoccupation with violence.

There is no credible, clinically-based evidence that mass shooters, as a group, are psychotic or delusional when carrying out their violence.

 Furthermore, blaming “mental illness” for school shootings stigmatizes those with clinically-diagnosed psychiatric disorders, who are rarely violent when adequately treated.

 That said, Kowalski and her colleagues found that more than half of K-12 shooters had a history of “psychological problems” of various sorts.

2. Handguns are easily obtainable in the US, and are often poorly-secured by family members. 

Though the Uvalde shooter apparently used a rifle,Kowalski found that handguns were used in over 91% of the K-12 shootings, and almost half of the shooters stole the gun from a family member.

 According to Daniel Flannery, a professor at Case Western Reserve University and the director of the Begun Center for Violence Prevention Research and Education, “It’s way easier to get a handgun than it is to do just about anything else in this country…our background check is woefully inadequate.”

 Furthermore, more than half of gun owners do not safely store all their guns, according to a survey of 1444 US gun owners conducted by researchers at the Johns Hopkins Bloomberg School of Public Health.

3. Violent acts, including mass shootings, are on the rise nationwide, possibly related to the pandemic and its attendant socioeconomic dislocations.

Recent data from cities across the US show a trend of increased violent crimes as the COVID-19 pandemic has lingered on, though the numbers vary from city to city.

 Moreover, a cross-sectional study showed large increases in mass shootings with the start of the COVID-19 pandemic, “…consistent with the notion that mass shootings, an extreme form of violence, may be influenced by social and economic factors.”

 While acknowledging that such correlations do not necessarily represent causation, the recurrent and largely unpredictable surges of COVID-19 infection, coupled with their adverse socioeconomic repercussions, probably represent a risk factor for more mass shootings.

4. Psychological distress is increasing among teens and adolescents, and there is a shortage of mental health support for this age group.

In December 2021, the United States surgeon general, Vivek Murthy, MD, warned that young people are facing devastating mental health effects as a result of generational challenges, including the coronavirus pandemic. Dr Murthy’s report noted significant increases in self-reported depression and anxiety in younger age groups, along with more emergency room visits for mental health issues.

 Murthy observed that, “Young people are bombarded with messages through the media and popular culture that erode their sense of self-worth—telling them they are not good-looking enough, popular enough, smart enough or rich enough [and]…that comes as progress on legitimate, and distressing, issues like climate change, income inequality, racial injustice, the opioid epidemic and gun violence feels too slow.”

 While it is not clear that these trends will have a direct effect on the likelihood of school shootings, we need to recall Dr Kowalski’s finding that most perpetrators of K-12 shootings are under the age of 18.

 Unfortunately, obtaining professional help for this troubled age group has become increasingly difficult in the US, and shortages of mental health workers have only been worsened by the pandemic.

5. Media attention may encourage the copycat effect.

After mass shootings, the general media are often fixated on the shooter’s motives, family background, signs of mental disturbance, social media postings, etc. Almost inevitably, this lurid coverage is linked to the shooter’s name and face. Unfortunately, there is reason to believe that this sort of sensational publicity may encourage copy-cat killers, bent on outdoing the previous shooter.

 To the tens of thousands of disaffected, rejected, and bullied young men who imbibe this sort of cultural glorification, the temptation to “make history” by violent and vengeful means may prove irresistible. Alas, I see no sign that the media are becoming more restrained in their publicity of these horrific events—and this does not bode well for the future.

Though it is easy to give in to despair, there are ways, as a society, that we can reduce the frequency and lethality of mass shootings. As my colleague, James L. Knoll IV, MD, and I argued in a previous article,

“While solid, evidence-based methods of preventing mass shootings are still lacking, we believe that progress will come through work on a number of fronts. First, better reporting of ominous behaviors and careful use of extreme risk protection orders may avert at least some mass shootings. Second, the use of Threat Assessment and Management (TAM) teams in our schools may also help preempt planned attacks. TAM teams are interdisciplinary groups of professionals that include law enforcement, mental health providers, and other security stakeholders, collaborating in a structured effort to accurately assess and mitigate the risk of violence.”

Beyond these remedies, I believe that we Americans, as a society, need to do some serious introspection. That begins by asking ourselves some serious questions, like: what must we do to reduce the likelihood that troubled adolescents with violent intentions will get hold of unsecured firearms? What resources are required to address the mental health needs of younger populations? And what must we do to counteract the allure and glamor of these unspeakably violent deeds?

1. Kornfeld M, Iati M, Knowles H, et al. Biden says Second Amendment ‘not absolute’ as more details of school shooting emerge. 

https://www.washingtonpost.com/nation/2022/05/25/texas-school-shooting-uvalde-victims-live-updates/

2. Statista Research Department. Mass shootings in the U.S.: shooters by gender, as of May 2022. May 25, 2022. Accessed May 26, 2022. 

https://www.statista.com/statistics/476445/mass-shootings-in-the-us-by-shooter-s-gender/

3. Kowalski RM. School shootings: What we know about them, and what we can do to prevent them. Brookings. January 26, 2022. May 26, 2022. 

https://www.brookings.edu/blog/brown-center-chalkboard/2022/01/26/school-shootings-what-we-know-about-them-and-what-we-can-do-to-prevent-them/

Mass murder: causes, classification, and prevention. 

6. Shapiro E, Andreano C. The type of gun used in most US homicides is not an AR-15. ABC News. October 26, 2021. Accessed May 26, 2022. 

https://abcnews.go.com/US/type-gun-us-homicides-ar-15/story?id=78689504

7. Survey: more than half of U.S. gun owners do not safely store their guns. Johns Hopkins Bloomberg School of Public Health. February 22, 2018. Accessed May 26, 2022. 

https://publichealth.jhu.edu/2018/survey-more-than-half-of-u-s-gun-owners-do-not-safely-store-their-guns

8. Beals M. How violent crime has gone up since the pandemic. 

. February 15, 2022.Accessed May 26, 2022. 

https://thehill.com/policy/national-security/594291-how-violent-crime-has-gone-up-since-the-pandemic/

Mass shootings in the US during the COVID-19 pandemic.

10. Richtel M. Surgeon General warns of youth mental health crisis. 

 December 7, 2021. Accessed May 26, 2022. 

https://www.nytimes.com/2021/12/07/science/pandemic-adolescents-depression-anxiety.html

11. Axelson D. Addressing the youth mental health crisis with coordinated systems of care. 

https://www.psychiatrictimes.com/view/addressing-the-youth-mental-health-crisis-with-coordinated-systems-of-care

Reducing media-induced mass killings: lessons from suicide prevention. 

13. Pies RW. After Las Vegas, the danger of copy-cat killers. 

http://www.psychiatrictimes.com/trauma-and-violence/after-las-vegas-danger-copy-cat-killers

14. Knoll JL IV, Pies RW. Moving beyond “motives” in mass shootings. 

. January 14, 2019. Accessed May 26, 2022. 

https://www.psychiatrictimes.com/view/moving-beyond-motives-mass-shootings

Kowalski RM, Leary M, Hendley T, et al. 

K-12, college/university, and mass shootings: similarities and differences

Unless there are substantive societal changes at many levels, the answer may be yes.

Is the Plague of Mass School Shootings in the US Here to Stay?

Dedicated to the memory of W.V.O Quine (1908-2000)

In many ways, this is a particularly exciting and fruitful time for psychiatry. In the past decade, psychiatrists have developed 2 new forms of psychotherapy: dynamic deconstructive 

, an evidence-based therapy for borderline personality disorder

; and complicated grief therapy (CGT) for patients whose grieving process has become dysfunctional and “derailed.”

 In the somatic treatment realm, recent evidence suggests that ketamine—an N-methyl-D-aspartate (NMDA) receptor blocker—is effective in reducing acute suicidal ideation, perhaps pointing to new molecular mechanisms in antidepressant treatment.

 Meanwhile, data on psychiatry residency matching shows that an increasing number of medical school graduates are being drawn to psychiatry.

All this is good news. The not-so-good news is that psychiatry continues to be attacked and disparaged by a loosely organized movement usually referred to as “antipsychiatry,” comprehensively reviewed by Rob Whitley, PhD.

 In addition, the movement known as “critical psychiatry” has emerged over the past 2 decades, and—in principle, if not in practice—is distinct from antipsychiatry. As psychiatrist D.B. Double, MD, has noted, critical psychiatry encourages the integration of mind and body, and argues that “minds are enabled but not reducible to brains” and that “mental disorders show 

 More broadly, there are many responsible critics of psychiatry—both within and outside the profession—whose aim is, so to speak, to “build a better psychiatry” rather than to disparage, undermine, and ultimately destroy it. The latter is arguably the main goal of antipsychiatry.

Many of the guests interviewed on these pages in 

 could be considered exemplars of “critical psychiatry.” As my Tufts colleague, Daniel Morehead, MD, has argued, our aim as a profession should not be to “squelch” responsible critics of psychiatry, but rather “…

to defend and affirm the ethical, practical, and scientific legitimacy of what we do as psychiatrists

One component of defending psychiatry involves clearing away the acres of conceptual underbrush that have fueled so many of antipsychiatry’s rhetorical fires. This has been a central preoccupation of mine since at least 1979, when I was still a resident and engaged in a polite but impassioned debate with the late Thomas Szasz, MD—perhaps the world’s most famous critic of psychiatry and a teacher of mine at SUNY Upstate Medical University.

 Since then, along with my Tufts colleagues—Morehead and Mark Ruffalo, MSW, DPsa—I have tried to debunk a number of fallacious arguments and claims proffered by various 

 (Some of these claims overlap with those of critical psychiatry, but, in my view, they stem from quite different motivations.) The remainder of this article is aimed at debunking 4 “dogmas” of antipsychiatry, with a respectful nod to the analytic philosopher W.V.O. Quine, author of the groundbreaking essay 

1. The essential definition dogma (“narrow materialism”)

A bit of background is needed to understand this dogma. In the philosophy of language, an essential definition is one that specifies the necessary and sufficient conditions for a particular idea or entity—in other words, the “essence” of the thing. So, an essential definition of a triangle would be “a 3-sided geometrical figure.” It is obviously much harder to come up with an essential definition of, say, justice or liberty. Indeed, the philosopher Ludwig Wittgenstein (1889-1951) famously argued that most words in common use do not have essential definitions; rather, the meaning of a word depends on its 

in various contexts or “language games.” Moreover, “…things which could be thought to be connected by 1 essential common feature may in fact be connected by a series of overlapping similarities, where no 1 feature is common to all of the things. He [termed] this concept 

Now, what does all this have to do with disease and antipsychiatry? Simply put, the Szaszian strain of antipsychiatry implicitly asserts that there is an essential definition of disease (or illness—Szasz uses the terms more or less synonymously). For Szasz, the necessary and sufficient (essential) condition for the ascription of disease is the demonstrable presence of some bodily abnormality, either anatomical or physiological.

 we are obliged to accept “…the pathologist’s materialist-scientific definition of illness as the structural or functional alteration of cells, tissues, and organs.”

 It follows, of course, that for Szasz, there could be no “mental” illness, which he regarded as merely a metaphor or a myth.

The problem with this vaunted “materialist-scientific definition of illness” is that it must compete with many other conceptions and definitions of illness and disease, including ones based on the presence of substantial suffering and incapacity

the “overlapping similarity” that connects many, if not most, conditions we call serious diseases or illnesses

 In contrast, as Morehead pointed out to me (email communication, April 23, 2022), Szasz’s definition of disease could be considered a “narrow materialist” position—what I call the “lumps and bumps” model of disease.

And yet, as I noted 40 years ago, “There has never been a single set of criteria for the ascription of disease,”

 and the definition remains ambiguous and contested to this day. This was vividly demonstrated when the American Medical Association, in its deliberations on obesity, requested an advisory opinion from its Council on Science and Public Health. The question before the council was, “Is obesity a disease?” The council’s considered response was a lesson in both the limits of language and the merits of humility: “Without a single, clear, authoritative, and widely accepted definition of disease, it is difficult to determine conclusively whether or not obesity is a medical disease state.”

 Finally, consider this remarkably expansive concept of disease in no less a source than 

Harrison’s Principles of Internal Medicine 

“The clinical method has as its object the collection of accurate data concerning all the diseases to which human beings are subject; namely, all conditions that limit life in its powers, enjoyment, and duration.”

2. The diagnostic causality dogma (“self-validating diagnosis”)

This antipsychiatry dogma seems to be quite fashionable in recent years, both as a criticism of the DSM disorder categories and of psychiatry in general. In brief, this dogma holds that any legitimate, scientifically based set of disease criteria must be grounded in 

—and not consist merely of signs or symptoms that both define the disorder and purport to 

 it. Critics allege that the current mode of (DSM) psychiatric classification amounts to a kind of circular argument or self-validating claim (eg, “We know this patient’s hallucinations are due to schizophrenia, and we know she has schizophrenia because she fulfills the DSM’s symptomatic criteria for schizophrenia”). In effect, the critics’ claim is that psychiatric diagnoses, unlike medical diagnoses, are merely descriptive, not 

Put another way, this dogma holds that (1) if the DSM diagnostic criteria for disorder X do not address the 

 or etiology of disorder X; then, perforce (2) condition X cannot justifiably be considered 

 Ruffalo and I have dissected this fallacious argument in detail,

 and I will merely summarize our analysis here. In brief, disease categories—more accurately, the real-world conditions to which they point—can have 

 (be the cause of something) without themselves having a known cause. And, no—this does not amount to a circular argument.

Here is a rough analogy. Suppose we have devised a list of signs that compose our criteria for an earthquake—for example, “ground trembling,” “buildings shaking,” “loud rumbling,” etc. We need not know the actual cause of earthquakes (such as shifting of tectonic plates) to make the claim, “The apartment building collapsed 

 of the earthquake.” By the same token, we are justified in saying, for example, “John’s command auditory hallucinations are caused by his having schizophrenia” (per DSM-5 criteria) without knowing the underlying cause(s) of schizophrenia—provided we can tether the term

 to external validators, like course of illness, predictive validity, response to treatment, neuroimaging studies, etc.

claim, subject to empirical falsification. We may find, for example, that John’s hallucinations are actually caused by a traumatic experience or by complex partial seizures. Similarly, we may not know the cause of schizophrenia, but we can still say provisionally—and without courting circularity—that schizophrenia is the cause of John’s suffering and incapacity.

That said, as Aftab has pointed out to me (email communication, April 24, 2022), there is a risk of “reifying” our diagnostic categories and imputing more causal explanatory power to them than they merit. This is certainly true of very heterogeneous and nebulous diagnoses, such as major depressive disorder. And, of course, ideally, all medical diagnostic categories would be based on causal explanations—that, after all, is the royal road to successful treatment. But the history of medical practice is replete with examples of syndromes the precise causes of which have remained a mystery for decades, even to the present day (eg, incapacitating headaches known as 

 As Morehead has rightly observed, “We can know that an illness is 

 without knowing the specific cause or pathophysiology of that illness.”

The notion that psychiatric disease categories are merely “socially constructed” has become a widely disseminated claim in antipsychiatry circles, although the idea is not confined to antipsychiatry. By “socially constructed,” some critics of psychiatry want to claim that psychiatric disorders have no independent reality, apart from the subjective musings of psychiatrists—in contrast, say, to cancer and tertiary syphilis, which are held to be real diseases.

To back up a bit: The concept of social construction dates back to the 1960s and is described by social scientist Chitvan Trivedi as follows: “We do not find or discover knowledge or reality so much as we construct it. For example, we invent concepts, schemes, models, etc, to make sense of our experiences and we keep refining them as we gain more experience.”

Now, there is a limited sense in which psychiatry’s critics are right. If they want to claim that psychiatric disease categories are created through a process of consensual human decision-making—and are not preexisting, physical structures in the natural world—I have no quarrel with that. But the same can be said for literally 

medical disease categories. Hence, the social constructionist critique of psychiatry has very little cash value (to use William James’s term) as critiques go.

Take the example of cancer: It might be argued that when a pathologist looks through a microscope and identifies cancer cells, he or she is identifying a natural kind that exists in nature, independent of human cognition, opinion, and social construction. But this is simply wrong. The designation 

 is the socially constructed product of intense human discussion, debate, and medical conventions. Indeed, there is often intense disagreement among oncologists and pathologists regarding what should or should not count as cancer. For example, ductal carcinoma in situ (DCIS) is regarded as cancer by some but not all oncologists, with the result that “…women with DCIS are labelled as ‘cancer patients,’ with concomitant anxiety and negative impact on their lives, despite the fact that most DCIS lesions will probably never progress to invasive breast cancer.”

But there is a more crucial point to make regarding social construction and psychiatric disease. As clinical psychologist Hew Green, PhD, has put it

“…although we can still say that schizophrenia is socially constructed, we remain nonetheless able to entertain the possibility that there is a distinct neurocognitive ‘disorder’ in the organism towards which this construct is legitimately trying to point. The 

given in the DSM, which has changed in various ways over the years, is very obviously constructed; a definition after all is just a verbal attempt to capture some state of affairs in the world. Meanwhile, the reality (the ‘state of affairs’ itself) is something ‘out there’ beyond language and is 

‘constructed’ in the sense we are interested in here.”

Another way of putting the matter: The DSM diagnostic criteria for schizophrenia—like 

 medical categories—are indeed socially constructed. But the immense suffering and incapacity caused by the disease of schizophrenia is very, very real.

In a sense, this dogma is another way of framing the social construction claim. The traditional position of antipsychiatry is that, unlike “real” medical specialties that have objective criteria for their disease categories, psychiatry is based solely on the subjective reports (ie, symptoms) of its patients and the equally subjective judgments of psychiatrists. As 1 psychiatrist known for strong criticism of psychiatric diagnosis has put it, “…the criteria for [psychiatric] diagnoses are arrived at by subjective judgments rather than objective evidence…” Specifically,

“The diagnoses listed in the major psychiatric diagnostic manuals have not yet been linked with any sort of physical test or other biological marker (apart from the dementias), and so, unlike the rest of medicine, psychiatric diagnoses do not have pathophysiological correlates and no independent data is available to the diagnostician to support their subjective assessment of diagnosis…”

There are several fallacies and confusions in this line of argument. In brief: (1) The term 

 is never defined in the article; (2) the term 

 is falsely conflated and identified with physical test[s] or other biological marker[s] that represent only 1 type of objective evidence; (3) the claim that “no independent data is available” to the psychiatric diagnostician is patently false; and (4) there are many well-established pathophysiological correlates linked with the most serious psychiatric disorders, such as schizophrenia and bipolar disorder (correlation, of course, is not causation).

Each of these rejoinders would take a good deal of space to unpack, but the key points are as follows:

 is itself contested—arguably, even socially constructed—and is the focus of considerable debate among philosophers of science. Indeed, “The prospects for a science providing a non-perspectival ‘view from nowhere’ or for proceeding in a way uninformed by human goals and values are fairly slim…”

2. To the limited extent we can define objective, 1 measure of objectivity is interrater reliability, termed 

. The higher the kappa, the more reliable the observation. The kappa for several major psychiatric disorders (though not all) compares favorably with kappas in several other medical specialties (eg, 0.53 for ischemic stroke versus 0.76 for bipolar disorder, depending on which DSM criteria are used).

 is not limited to lab tests and biomarkers. As psychiatrists, we carry out detailed mental status exams; perform limited neurological exams; interview family members; evaluate school records; and order a variety of ancillary studies, such as neuropsychological testing. All these modalities can provide objective evidence of disease, as can the vegetative signs we look for, such as weight loss and early morning awakening.

4. In performing a differential diagnosis, psychiatrists routinely obtain laboratory studies, brain imaging, and other independent data. As psychiatrist Nathaniel P. Morris, MD, notes, “We use objective tests all the time to evaluate patients with mental illness… we use blood work and imaging every day to evaluate patients with symptoms of mental illness. A vegan suffering from crippling depression might have B12 deficiency, while a patient who abuses IV drugs with progressive delusions and aggression could have HIV encephalopathy.”

5. There are literally hundreds of studies demonstrating pathophysiological correlates of schizophrenia, bipolar disorder, obsessive-compulsive disorder, and other psychiatric diseases. Although these findings may not point to causation, they are comparable to correlates in other areas of medicine. For example, enlargement of brain ventricles represents one of the most robust and consistent findings in schizophrenia and is likely related to neurodevelopmental and/or neurodegenerative causes.

The finding of a specific biological abnormality is neither necessary nor sufficient for a condition validly to be deemed a disease.

 is established through a painstaking, iterative process that compiles data on familial/genetic pattern; stability of diagnosis over time; course of illness; response to treatment; and many other validators.

 As the late Bernard J. Carroll, MD, observed, “…biomarkers are not an automatic gold standard of evidence for diagnostic validity…Laboratory measures are the servants of clinical science, not the other way around.”

The medical discipline of psychiatry is still a work in progress. Despite many advances in the past 50 years, we continue to rely on a diagnostic framework that lacks a comprehensive, biopsychosocial foundation, and clear implications for treatment. Criticisms of psychiatry aimed at ameliorating these shortcomings should be met with open-minded appreciation. But antipsychiatry’s fallacious and baseless attacks are aimed at delegitimizing and ultimately destroying psychiatry. We need to push back forcefully against the 4 dogmas discussed in this article, while also attending closely to psychiatry’s responsible critics—and most of all, attending to the urgent needs of our patients.

: The author wishes to thank Drs Mark Ruffalo, Daniel Morehead, and Awais Aftab for their thoughtful comments and careful reading of an earlier draft of this article. For more on the complexities of “causality” in psychiatry, please see these 2 blogs from Dr Aftab:

Can Symptoms Be Caused by Descriptive Syndromes? An Analysis

An Exchange with Ruffalo & Pies: More on Diagnosis & Diagnostic Explanation

Naturalistic outcomes of evidence-based therapies for borderline personality disorder at a medical university clinic.

2. Shear MK, Reynolds CF 3rd, Simon NM, et al. 

Optimizing treatment of complicated grief: a randomized clinical trial.

3. Domany Y, Shelton RC, McCullumsmith CB. 

Ketamine for acute suicidal ideation. An emergency department intervention: a randomized, double-blind, placebo-controlled, proof-of-concept trial.

4. Moran M. Psychiatry residency match numbers climb again after unprecedented year in medical education. 

https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2021.5.27

The antipsychiatry movement: dead, diminishing, or developing?

Critical psychiatry: an embarrassing hangover from the 1970s

https://www.psychiatrictimes.com/authors/awais-aftab-md

8. Morehead D. It’s time for us to realize we are all on the same side. 

https://www.psychiatrictimes.com/view/its-time-for-us-to-realize-we-are-all-on-the-same-side

On myths and countermyths: more on Szaszian fallacies.

Psychiatric diagnosis and the pathologist’s view of schizophrenia

11. Ruffalo M, Pies RW. The reality of mental illness: responding to the criticisms of antipsychiatry. 

. August 19, 2018. Accessed May 5, 2022. 

https://www.psychologytoday.com/us/blog/freud-fluoxetine/201808/the-reality-mental-illness

12. Pies R. Thomas Szasz and the language of mental illness. In: Haldipur CV, Knoll JL, and Luft EvD, eds. 

13. Pies RW. Why Thomas Szasz did not write the myth of migraine. 

https://www.psychiatrictimes.com/view/thomas-szasz-myth-migraine

15. Guerra A. Wittgenstein’s philosophy of language: how to find the meaning of a word. Medium. April 14, 2020. Accessed May 5, 2022. 

https://medium.com/science-and-philosophy/finding-the-meaning-of-words-edefb2b5b80e

The myth of mental illness: 50 years later.

17. American Medical Association. Is obesity a disease? Report of the Council on Science and Public Health. Accessed May 5, 2022. 

https://www.ama-assn.org/sites/ama-assn.org/files/corp/media-browser/public/about-ama/councils/Council%20Reports/council-on-science-public-health/a13csaph3.pdf

18. Pies R. Positivism, humanism, and the case for psychiatric diagnosis. Medscape. August 20, 2014. Accessed May 5, 2022. 

https://www.medscape.com/viewarticle/830052_3

Harrison’s Principles of Internal Medicine

, 8th ed. G.W. Thorn et al, eds. McGraw-Hill; 1977.

20. Ruffalo ML, Pies RW. What is meant by a psychiatric diagnosis? 

https://www.psychologytoday.com/us/blog/freud-fluoxetine/202006/what-is-meant-psychiatric-diagnosis

21. Morehead D. The DSM: diagnostic manual or diabolical manipulation? 

https://www.psychiatrictimes.com/view/the-dsm-diagnostic-manual-or-diabolical-manipulation

22. Trivedi C. Social construction simplified! November 25, 2020. Accessed May 5, 2022. 

https://conceptshacked.com/social-construction/

23. van Seijen M, Lips EH, Thompson AM, et al

Ductal carcinoma in situ: to treat or not to treat, that is the question.

These persistent fallacies have misled the public and undermined treatment of those with psychiatric illnesses.

Ronald W. Pies, MD

Articles

The Obligation to Speak Out

Is the Plague of Mass School Shootings in the US Here to Stay?

Four Dogmas of Antipsychiatry

The Goldwater Rule: Raising Questions of Professional Priorities

Last Analysis in Marienbad - I.

Last Analysis in Marienbad - II.