Some unanswered issues with the DSM and prescription medicat

Please do not be offended by the following. My synthesis of the antithesis and thesis of the psychiatric and psychological profession is quite honest and simply an attempt to be objective.

First and foremost...what is the thesis.

The thesis in a nutshell is that that we can analyze people and diagnose them with illness based on behavior.

Second we can correct this behavior based on prescribing medication, which alters the chemistry of the brain in known ways to alleviate the symptoms and/or cure the disease.

The issue with the first thesis is manifold:
1st, how do we determine what is pathological? By a comparison to the societal average? On that account, how do we honestly express objectivity? Let us give an example...if we use the correct model of averages and apply it across history, it would have been pathological in Nazi Germany to do what is actually morally acceptable.

2nd, can we honestly say that a society is not pathological in nature. For example, right now in Africa, kids are being slaughtered and starved left and right...there are mass genocides everywhere in the world. Can we honestly sit here and diagnose people as narcissistic and what not when we as a society ourselves are incredibly narcissistic? Are we not committing a form of existential cannibalism?

The issue with the second thesis is also manifold:
Can we reduce desease down to a neurocorrelate? If so, then medication might be prescribed justifiably. But can we also account for the affect of altering so many variables in the human system to ethically, without any guilt, honestly dictate what is occuring when we do? Based on my knowledge of statistics - which is vast and deep - the answer is no for several reasons.

First, we cannot because as a system increases with complexity the chances of something going wrong, or in this case, not understood, exponentiates, and as we all know, the human brain has more variables than the galaxy - or thus far we have observed.

Second, is the fact that reductionist is a fallacy as it relates to truth, meaning that it is incredibly useful as a philosophy in practice, but in truth, nothing is the sum of its parts, for their is truly no such thing as a closed system, and reductionist assumes that an object is closed to its parts.

This is why I believe that psychologists and psychiatrists are persecuted so frequently among "common" folk. It is because of an assumption and a lack of humility as demonstrated by its own denial of its own hubris.

First: I do see the positive aspects of therapy. I am not criticizing here...or saying psychology is useless. I am saying that there are fundamental errors as there are in all professions that must be confronted before it is to progress.

how do we determine what is pathological? By a comparison to the societal average? On that account, how do we honestly express objectivity? Let us give an example...if we use the correct model of averages and apply it across history, it would have been pathological in Nazi Germany to do what is actually morally acceptable.

Universal objectivity is not desirable at all, psychology and psychiatry would be useless if they didn't consider the subjective differences between societies. We can say that being sick in a sick society is a sign of sanity, but in the end of the day, you are still going to be miserable if you don't find a way of dealing with the fact that your parents, neighbors, friends and coworkers have very different values and will not simply "snap out of it". It's probably harder to get, say, a schizoid diagnosis in Japan than in the USA, since being quiet and minding your own business is much more valued over there, and therefore you are less likely to suffer just being the way you are. Which society is "right" in treating introversion and extraversion is irrelevant.

can we honestly say that a society is not pathological in nature. For example, right now in Africa, kids are being slaughtered and starved left and right...there are mass genocides everywhere in the world. Can we honestly sit here and diagnose people as narcissistic and what not when we as a society ourselves are incredibly narcissistic? Are we not committing a form of existential cannibalism?

Sure we can, if we are psychologists and psychiatrists. As I've said previously, judging societies and their values is a whole different thing with its own complexities and nuances. That's not to say that psychology/psychiatry is apolitical and can't stand for the principles it believes, questioning the status quo (there is plenty of activism regarding LGBT rights by psychiatrists and psychologists here in Brazil), but ultimately the practice remains unchanged: we still need to treat people.

Second we can correct this behavior based on prescribing medication, which alters the chemistry of the brain in known ways to alleviate the symptoms and/or cure the disease.

I'm pretty sure no one says this. Again, we consider things in a biopsychosocial dimension, not simply biological. Still, let's assume so for the sake of discussion.

First, we cannot because as a system increases with complexity the chances of something going wrong, or in this case, not understood, exponentiates, and as we all know, the human brain has more variables than the galaxy - or thus far we have observed.

True, there are many mysteries hidden within the human brain, but by that logic, neurology should be criticized as well. Yes, many things can go wrong, which is why there are rigorous test procedures. Also, not every medication works for everyone, so usually there are alternatives that the doctor and the patient can try until things reach a balance.

Second, is the fact that reductionist is a fallacy as it relates to truth, meaning that it is incredibly useful as a philosophy in practice, but in truth, nothing is the sum of its parts, for their is truly no such thing as a closed system, and reductionist assumes that an object is closed to its parts.

This has been understood for a long time by medicine and pharmacology. Tests for drugs aren't "Oh, this does exactly what I wanted, so I won't even bother checking anything else!", it's way more complex, including side-effects and interactions with other substances. And doctors don't (well, they shouldn't) disregard environmental and psychological factors during their assessment.

alexdern wrote:The thesis in a nutshell is that that we can analyze people and diagnose them with illness based on behavior.

An imaginary conversation


1. What do psychoactive drugs do?
A: They change brain chemistry.

2. Why do you want to change the brain chemistry of small children?
A: Their brain chemistry is flawed.

3. What biologically based test do you use to determine that this is so?
A: We do not use such tests.

4. Why not?
A: There are no valid tests available.

5. How then do you diagnose and prescribe?
A: We use behavioral tests.

6. Are you saying that merely by observing a child's behavior you can tell exactly what problems he has with his or her brain chemistry and then prescribe the correct substance in the precise dose needed to correct it?
A: That's the theory.

7. Why do you suggest to some parents that they give their children a vacation from these drugs on the weekends and on holidays, including summer vacation?
A: These children have their biggest problems in the school environment.

8. Are you suggesting that the brain chemistry of these children is different on the weekend than it is Monday through Friday?
A: The problems are often more acute in the school environment.

9. Why do you think it is that countries with better health care systems and longer life spans than ours (Japan, Sweden, and Switzerland, for example) prescribe almost no Ritalin or Adderall for their children and that the US and Canada consume over 85% of the world's supply of these drugs?
A: They are not as advanced as we are in the diagnosis and treatment of ADD and ADHD as we are.

10. Since you have no biologically based test for the drugs you are prescribing and there is no scientifically valid evidence that proves these drugs are effective or even safe, how can you claim that your science on this subject is superior?

A: I'm an expert. How dare you question me? You are obviously anti-child and anti-progress. This interview is over.

Source: http://www.brasscheck.com/druggingkids/

IMO the biopsychosocial model is overrated. True, it sounds great and super-scientific, but maybe that’s the only thing it is supposed to do. It is in fact not much less reductionist than the pure biomedical model is. It basically says:
- a person might have a genetic predisposition
And then:
- he or she might have had some invasive childhood experiences or a birth trauma that added upon his or her predisposition
- if exposed to a stressor, the illness breaks out.
This explanation is so mechanistic it could be referring to a robot.

One might argue that it is in the nature of models to be reductionist and that science cannot function without models.

Rebuttal: In some languages, e.g. Dutch, Swedish or German, the word for science is “knowledge-ship” (Wissenschaft in my native language). To me that is a beautiful word because it expresses so accurately what science does: It seeks knowledge.
But there can be no knowledge without a knower. And psychiatry has systematically ignored the knower – who is me! Our emotional problems are about what we think and feel, aren’t they? I am the knower of what I think and feel. This most important notion of subjectivity has gone missing (or was never wanted) in psychiatry. What you explain in your post, Zen, is the acknowledgement of relativity by psychiatry, not of subjectivity.

One might argue that all this is is completely irrelevant as long as psychiatry “works” or is of any use to somebody. But is it? If we look closely, psychiatry might help to solve some problems, but first and foremost it creates problems by its mere existence. The invention of more problems/illnesses makes the world more complicated and thus creates more ill people (great Israeli sociologist Eva Illouz has dealt with that matter).
And what happens then? First, it makes the world more complicated, thus makes society and individuals hand their problems over to the professionals. That is really disempowering because we unlearn how to deal with complex issues.
Second, it then re-reduces these problems to a medical (biopsychosocial) model. The reductionist model hereby replaces the person’s own complex, subjective explanation and solution and actually prevents! the kind of knowledge that is relevant for what we think and feel.

Psychiatry therefore cannot be referred to as knowledge-ship aka science.

I was using the term subjectivity for contrasting it to objectivity, but yes, relativity probably fits better when talking about cultural differences. Anyway, it's not very clear to me what you meant by subjectivity being ignored. Are you talking about psychiatrists just getting a diagnosis, prescribing medications and sending the patient home or forwarding him to a therapist? Overuse of medication? Wrong labels, wrong use of labels? Something else?

And while deviating from the norm or feeling unhappy doesn't mean you need treatment, shouldn't the patient be respected, as you say, and be allowed to decide? Why not seek help if you feel it's necessary? Sure, you need to learn how to deal with issues by your own, but who is supposed to teach you in the first place? Your parents and social circles don't know all the answers. Self-help, like self-teaching, requires discipline that not everyone has. Only a few can afford the time and mental fortitude to meditate deeply and find an answer on their own.

Then there's the issue of society handling its problems to individuals, something I've seen Eva Illouz discuss (didn't know her, did a quick research just now). That's a very complicated subject, I have written and rewritten this post at least 4 times because of it, needs some more thinking. Regardless, I still don't see why "too much people" getting treatment is a bad thing. It doesn't help that she says things such as anger management silencing anger and preventing it from being used for protest, which shows that she's either unaware of different approaches to anger management, doesn't want to explore the subject, or cherry-picked the most convenient information. I'm yet to see any sane person, specialist or not, convinced that anger is bad and shouldn't motivate you to take meaningful actions, just that destructive and misdirected anger must be managed in a healthy way.

What I meant when I was writing about subjectivity was the subjective experience of hearing voices, feeling suicidal, angry and so on. The world of mind and spirit is a world of feelings and meanings. What psychiatry does is dehumanize all that and put it into terms of the natural sciences. This does not only happen in "diagnosis" and "treatment" (these are already consequences of this dehumanization - one could as well be talking about biochemical robots in need of reparation), but it is especially happening in research. The dangerous thing is, psychiatry has the power to generate knowledge which in turn dominates the discourse about emotional and mental difficulties.

These are not a priori diseases. Talking about illness, symptoms and therapy (instead of hopes, fears, wishes, love, hurt, anger and so on) is a learned thing. And I do not see any indication that it be a helpful thing: Tons of people enter the mental health system as "mentally ill" but virtually none leave the system "mentally healthy". The argument that this is only because we are more advanced in figuring out who is ill loses credibility in light of the number of "mentally ill" increasing for about 40 years (!!), considering the claim that we have precise diagnostic methods that are followed by very effective treatments.
Don't you find that absurd?

That is the reason why I cannot see much positive in more and more people seeking help in the system. Most of these problems could formerly be handled by people themselves, in the family, with the partner or people sought help from god, pastors, their wise grandma, shamans or someone in their community they knew is good at listening and providing spiritual guidance (whereas today psychiatrists and psychologists are considered some overall wisemen concerning human suffering).
If you tell this to a person who consideres themselves "mentally ill", some will even be insulted and say: "I am ILL, no pastor can help me with an illness, only a professional can." But that is, as I said, a learned thing, a result of a new paradigm.

I am not saying that I know which way is the "right one" or what emotional problems or hearing voices actually are. I am saying that it is important to become aware of our belief systems and challenge them on the basis of lacking evidence that they be helpful.

You only treat people as robots when you say their problems are exclusively mechanical in nature, which is widely understood as false. There are, however, well-established physiological correlates, and these we are indeed able to objectively repair. I would suspect that a perhaps excessive objective approach is used in research because you need to isolate variables as much as possible: first make sure the mechanics work, then take a more holistic look. Everything in science arises from simplified and/or ideal models.

I can't really comment on issues related to how the system works without seeing some data and research. Are there really few people who leave therapy satisfied? Do therapists follow the plans made with patients or does the relationship persist even when it becomes unnecessary? Are new things being invented or old things being given more thought (such as bullying-related problems, which until a while ago were pretty much ignored)? Can we really go back to how it was previously, since we live in a very different context than that of our ancestors and not everything that worked continues to do so now? These are tough questions, but they are needed in order to answer the ultimate question of whether or not the current paradigms are helpful.

I was not talking about mechanical robots. I was talking about biochemical robots.

The correlates are not well-established. They are hypotheses and completely useless when it comes to diagnosis. When given brain scans such as MRI, PET or DTI, blood or liquor tests or the brains of deceased people, psychiatrists are not able to distinguish the "ill" from the "healthy". Likewise, if you tell a psychiatrist about the nature of your suffering, he will not be able to tell you the physiological correlate in need of correction.
In all medical books it is said "we do not know what causes it" yet when talking to a patient psychiatrists regularly lie by drawing comparisons with physical illnesses such as diabetes. The advances of neurosciences are exaggerated by the media. Few people know that some research/pharmaceutical companies are even shutting down their neuro/psych laboratories because the chance of innovation and profit is so low.
The claim that these correlates can be repaired is also incorrect. First the substances were discovered to have an effect, and in the second step scientists tried to causally explain these and to draw conclusions about the underlying condition. Until today, they have not come up with any proof of why these substances have certain effects on some people. Even if we assume the hypotheses to be accurate, we could not claim that the drugs repaired the underlying conditions, the best example are neuroleptics: The hypothesis is that the psychotic brain contains to much dopamin, but the neuroleptic blocks the receptors - postsynaptically! In the worst case, this is going to increase the vulnarability for the condition it is said to modify.
For antidepressants, the placebo effect must not be underestimated. Irving Kirsch, a psychologist who did overall research on the placebo effect in different fields of medicine, extimates it to be around 75% for inactive and up to 95% for active placebo for the SSRI drugs. (This again shows our potential for self-healing, and we should ask ourselves if taking drugs that have all kinds of risks are the best way to activate this potential.)

All the syndroms formerly prevalent in the state hospitals for which a real physical cause has been found have ceased to be classified as psychiatric disorders. That was the case with neurosyphilis, Morbus Huntington, Alzheimer's Disease or Down Syndrome. They are today classified in the chapters A, G and Q, not F, of the ICD.

As to whether or not the current paradigm is helpful, all the long term studies (5-20 years) I have read do not prove the treated to be in better condition than the untreated. For diagnoses of psychosis, the ones treated with neuroleptics often did worse mentally (plus it has been known that long-term treated patients have a decreased life-expectancy of, depending on the study, 18-32 years, 25 years on average. This may not all be attributed to the drug, but why on earth have these "great" treatment options not increased these people's life expectancy instead of decreasing it?).

I stick with the argument that the paradigm and the believes that come with it (the "need" for professional help) are disempowering us. Disempowerment is something we should not strive for. Sure conditions are different today from how they were formerly, but though giving up the paradigm is not going to solve the problems, it will open up a space for all kinds of strategies and is the only way to maybe achieve empowerment one day.
As an analogy, the abolition of slavery itself cannot make people richer or more educated or more intelligent or stronger or less black. But giving up the notion of slavery does, as Thomas Szasz exemplifies, free them from their masters and is the prerequisite for empowerment.