These persistent fallacies have misled the public and undermined treatment of those with psychiatric illnesses.
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 psychotherapy (DDP), an evidence-based therapy for borderline personality disorder1; and complicated grief therapy (CGT) for patients whose grieving process has become dysfunctional and “derailed.”2 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.3 Meanwhile, data on psychiatry residency matching shows that an increasing number of medical school graduates are being drawn to psychiatry.4
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.5 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 through the brain but not necessarily in the brain.”6 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 Awais Aftab, MD’s, excellent column7 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.”8
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.9 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 antipsychiatry clinicians, groups, and bloggers.10-13 (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 Two Dogmas of Empiricism.14
Four Dogmas of Antipsychiatry
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 use 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 family resemblance.”15
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. As he put it in a recent update of The Myth of Mental Illness, we are obliged to accept “…the pathologist’s materialist-scientific definition of illness as the structural or functional alteration of cells, tissues, and organs.”16 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.9 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,”9 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.”17,18 Finally, consider this remarkably expansive concept of disease in no less a source than Harrison’s Principles of Internal Medicine (8th ed.)19:
“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 causation or etiology—and not consist merely of signs or symptoms that both define the disorder and purport to explain 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 explanatory.20
Put another way, this dogma holds that (1) if the DSM diagnostic criteria for disorder X do not address the cause or etiology of disorder X; then, perforce (2) condition X cannot justifiably be considered a cause of the patient’s problem.20 Ruffalo and I have dissected this fallacious argument in detail,20 and I will merely summarize our analysis here. In brief, disease categories—more accurately, the real-world conditions to which they point—can have causal efficacy (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 because 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 schizophrenia to external validators, like course of illness, predictive validity, response to treatment, neuroimaging studies, etc.
Of course, this is only a provisional 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 trigeminal autonomic cephalalgias).13 As Morehead has rightly observed, “We can know that an illness is medically and biologically real without knowing the specific cause or pathophysiology of that illness.”21
3. The “social construction” dogma
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.”22
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 all 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 cancer cell 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.”23
But there is a more crucial point to make regarding social construction and psychiatric disease. As clinical psychologist Hew Green, PhD, has put it24:
“…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 definition 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 not ‘constructed’ in the sense we are interested in here.”
Another way of putting the matter: The DSM diagnostic criteria for schizophrenia—like all medical categories—are indeed socially constructed. But the immense suffering and incapacity caused by the disease of schizophrenia is very, very real.
4. The “objectivity” dogma
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,25
“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 objective is never defined in the article; (2) the term objective evidence 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:
1. The definition of objective 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…”26
2. To the limited extent we can define objective, 1 measure of objectivity is interrater reliability, termed kappa. 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).27
3. By most definitions, objective evidence 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.”28
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.29
But to be clear: The finding of a specific biological abnormality is neither necessary nor sufficient for a condition validly to be deemed a disease. A putative disease’s validity 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.30,31 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.”31
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.
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 Psychiatric Times™ (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on Amazon.
Acknowledgement: 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
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