Still reading the article, and this likely is addressed therein, but I think the problem or "difficulty" with the "strong" medical model of psychiatry, which seeks to know the underlying biological pathology involved in mental disorders (as opposed to the "minimal" model, which treats mental disorders as heuristic labels of bundles of symptoms that tend to follow similar evolutions in most cases) ... is that there will be many conditions, traits, behaviors that society sees as pathological that won't be distinguishable on the "hardware" / brain structure & abnormalities level, but will be purely seen on the software level alone. It likely will take a long time for us to see, or will be never, that we'll manage to observe brains running at this level ... and too many pathologies will be completely unknowable to a strong medical modelist.
I also hope and believe that humanity transcends biology / hardware / strange-loopiness-in-software. We see less and less of a transcending viewpoint in "the [rational] West", and that belief still present comes less now from traditional sources and more from the influence of Eastern religion / philosophy. From a Screwtape Letters viewpoint the ultimate prosecuting lawyer is comfortable with the West in its current materialistic stupor ... but I grew up in circumstances where transcending factors were much more plausible and understood.
> They worry that we are lumping together different groups of people based on behavioral evidence alone, when in fact their observable similarities mask important underlying differences, including differences between normal people who are troubled but basically healthy, and their pathological counterparts.
I think the pile of circumstantial evidence for this being the case is pretty large at this point. There is no single treatment that works for a majority of people with major depressive disorder. The types of schizophrenia are sufficiently different that using the same term for them is practically misleading and seems to be driven more by tradition than by any consistent system (cf. diabetes). There's at least one lab test that is believed to identify a type of depression; it seemingly fell out of favor because nobody figured out how to choose a treatment based on it and a negative result doesn't exclude an MDD diagnosis [1].
Psychiatry is a failed science. False promises of cures that usually do more harm with debilitating "side effects" to their drugs and barbaric shock treatments. Best to seek the help of a real medical professional, nutritionist, fitness trainer, etc. All these have a better chance to help you than the dice roll of a psychiatric "diagnosis".
People have such terrible diets in the US. Deficiency in certain vitamins and other essential nutrients is scientifically proven by medical science to lead to mental health-type symptoms.
Some people need help to learn what foods to eat properly because their parents never taught them how or they just have bad eating habits.
"Some people need help to learn what foods to eat properly because their parents never taught them how or they just have bad eating habits."
You don't need a nutritionist to tell you to stop eating junk/processed food. All other diet advice are pure b.s. as there's no scientific answer to what "a proper diet" is. What is "healthy" and what is not changes on a similar rate as weather broadcast i.e. see a recent turn on fat.
There is actual science behind finding nutritional deficiencies. You surely don't think vit D deficiency is "BS" or calcium deficiencies. Maybe consider your point of view is not as strongly supported as you think.
Also there's a very easy experiment you can use to prove this out at your next family reunion, Christmas or Thanksgiving party, etc. Feed a small child only sugar, watch him turn on first ADD then complete depression as you fail to continue to feed him sugar...
1. I hope you don't actually think you should do this sort of thing to kids.
2. You don't seem to understand what ADD and depression are. They're vastly more serious and prolonged than the sort of candy-induced, momentary fit-throwing you're suggesting.
> a real medical professional, nutritionist, fitness trainer, etc
Family practitioners also commonly prescribe antidepressants and the like. I'd say there is still wild debate about what is a healthy diet. Until recently (and maybe even still) most nutritionists would prescribe something aligning with the Nixon-administration-guided carbohydrate pyramid. Anything a fitness trainer guides you to do is likely less effective than the basics (squats, deadlifts, running).
There is substantial B.S. in all of the professions you mention. The least one can do is find the person dishing it in the right realm.
If a person has schizophrenia, it still massively behooves them or their family to seek the aid of a psychiatrist. A hot mess of conflicting theory and pseudoscience, yes, but it's all we have.
I can honestly only appreciate this comment as a form of sarcasm ?
If instead you were serious please consider the following,
our understanding of psychiatry is constantly evolving and psychiatrists are trained MDs, please don't confuse badly trained psychologists and the pharma industry trying to pump you full of drugs and nutritional supplements, with the science of psychiatry.
I don't buy this view that pharma companies are the bad greedy ones, and psychiatrist are noble wise doctors participating in clean science.
Pych doctors more than willing participants in the prescribing of stimulants and mild euphoriants. They get rich also doing so - 4/5 $200 appointments an hour is common, and if you look at the highest paid public employees in some states you'll see state-hired prison and other psychiatrists towards the top below university basketball coaches.
Sadly enough a lot of doctors are complicit in it, after all a lot of doctors didn't get into it out of altruism, then again the same can be said to apply to a lot of developers, lawyers, and several other professions. My comment was in no way denying that our society is messed up.
Just please don't equate a medical profession and body with nutritionists, that is just grossly disproportionate and just outright weird. If you like I can have a rant as to how little we understand cell uptake pathways and metabolic pathways another day.
> please don't confuse badly trained psychologists and the pharma industry trying to pump you full of drugs and nutritional supplements, with the science of psychiatry.
69% of psychiatrists defining mental illnesses and their treatments in the DSM-5 reported having financial ties to big pharma.
There's good psychiatrists and bad psychiatrists, good and bad psychologists, and the pharm industry has done a lot of good for society as well as harm.
I'm not even sure where to start. Take, for example, psychologists: a lot of whatever progress has been made in mental health comes from psychology (quantitative measurements, moving away from monolithic, homogenous diagnostic categories, lots of research, even neurobiological research--hell, the head of federal mental health research recently was a psychologist with a neuroscience research focus); the pushback is often from entrenched MD political groups who play off the "trained doctor" stereotype. Pharm research, too, often complains about the overly simplistic disease models, but are required by the FDA to follow them in clinical protocols, further entrenching them (a different former head of NIMH has complained about this). Psychiatrists often are screwed by the health care industry, trying to care for the most ostracized segments of society (see the recent GOP health care bill, which basically gutted mental health care services completely).
These sorts of discussions are always frustrating, because they're full of armchair, backseat scientists who are all too-happy to declare bad science, etc. without any solutions themselves. Behavioral health is a very challenging subject, and slapping on physics, chemistry, or mech engineering as some kind of perfect model just doesn't work. The irony is that it's more challenging than those fields in a lot of ways; if someone could just drop down from their physics throne and solve all the mental health problems, it would have been done already. It's been tried, believe me, and what usually happens is they grossly underestimate the complexity of what they're getting involved with.
1. Psychiatry is not bound to the medical ethic of patient autonomy. Medical doctors cannot lock someone in a cell and forcibly drug them because they have an STI.
2. Psychiatric illnesses are defined based on "fallible subjective judgments". Medical illnesses (pathologies) are defined based on objective biological tests.
1. Because an STI doesn't cause you to go murder your spouse.
2. A behavioral record is no less objective than a biological one. Facebook and Google make a ton of money this way; if you want to offer a biological alternative, no one is stopping you.
1) Yep, and you'll be locked up if you murder someone. Someone with dementia or frontal syndrome after a stroke or tertiary syphilis may become paranoid enough to cause/contribute to violence, but we don't lock people up based on diagnosis.
Nobody is locked up simply because they are diagnosed with a "mental illness" which is what you apparently want people to believe - you edited your parent comment, where you claimed that a diagnosis of schizophrenia was grounds for 5150. It's not.
2) No, there is no opinion about "good or bad" in diagnosing mental illness. The almost ubiquitous criteria is significant impairment - which almost always is an impairment the patient themselves identify (not someone else) and are seeking help for.
Oh. You want to swab someone's throat to see if they should be detained to protect themselves or others.
Please let's you and I spend some time together in the emergency department. Last week we had a patient there who'd been brought in against his will by the police, and who claimed that the chip implanted in their brain was telling him to remove his eyes and everyone else's eyes with the spoon he carried in his back pocket.
He'd already removed his left eye, with the spoon he carried in his back pocket.
Please tell us your plan. I'm sorry that I can't find a throat swab to assist us.
Or perhaps we could have lunch down at the dementia care facility, where the neurologists would love you to tell them they're not legitimate medical doctors because they don't have a throat swab for dementia yet, and because they "lock up" dementia sufferers with a few signatures at the request of dementia-sufferer families so they, the dementia patients, don't walk onto the freeway. They actually lock people up protectively before "the crime" of actually walking onto the freeway.
Imagine that.
Aren't a few signatures (even sans diagnosis) all that's needed to place children in what in effect is protective custody?
Pertaining to (2), there's actually a lot of empirical data bout what behavior is predictive of good or bad outcomes. It's not just a subjective opinion.
Now, you can argue about what outcomes are good or bad, but that's a different issue.
In any event, these things aren't as different from other areas of medicine as you think.
For example, you're full of microbes at the moment. Some of them might make you feel a little off sometimes, some of them might make you incapacitated, and sometimes it might depend. The decision to seek care and/or intervene is a subjective decision, based on your subjective appraisal of how you're doing, and a provider's appraisal. Does that mean that infectious disease medicine is subjective?
Subjectivity enters into all medicine at some point, via ethical decisions about whether and/or how to intervene. Because ethics involves some level of subjectivity, it's unavoidable.
1. Just as in treatment of tuberculosis, there are times when autonomy is overridden by danger to self or others. This is no different to other fields of medicine.
2. Many aspects of diagnosis are subjective, even when tied to objective measurements. For example, cutoffs for high blood pressure, diabetes, and hyperlipidemia.
You're exhibiting either a woeful lack of knowledge about medicine, or you have a particular axe you want to sharpen repeatedly here.
1) Medical doctors (including psychiatrists), police, social workers, judges, and other trained personnel all can lock someone up for a brief time (and with all sorts of legal protections and due process) if:
a) They are a danger to themselves or others.
b) They are unable to care for themselves.
Please tell us your alternative plan for dealing with those issues.
2) I'd love to be drill a hole in your well-protected cranium and stick a needle in your brain to obtain a sample to diagnose major depression, schizophrenia, or PTSD. Just a small sample, ok?. Let me know if you're ok with that. And if you think there are "objective biological tests" for most common illnesses that are diagnosed and treated, day in and day out, by physicians, I'd invite you to accompany me to clinic where, off the top of my head" we'll see tons of upper respiratory infections, real chronic pain without any demonstrable pathology, "ear infections", etc. This is the bread-and-butter of primary care physicians, and we don't order "objective biological tests" in order to diagnose and treat "medical illnesses" - in many cases because the tests simply don't exist, or are too expensive or too invasive.
But perhaps you'd care to explain to the sufferers and their families that we can do nothing for them without your "objective biological tests".
>I'd love to be drill a hole in your well-protected cranium and stick a needle in your brain to obtain a sample to diagnose major depression, schizophrenia, or PTSD. Just a small sample, ok?. Let me know if you're ok with that
Sure it's okay, post mortem. Many scientists have tried this. Unfortuntely, you would not be able to make a conclusive diagnosis, because the science isn't there.
Post-mortem doesn't do much for your current debilitating panic disorder that makes it impossible to leave your home, now does it?
Please. Give us your plan for relief of suffering while we sit around twiddling our thumbs waiting because "the science isn't there."
The history of the entire field of medicine (including psychiatry, which is as much science and medicine as any other medical specialty) is a march from partial understanding based on classification of symptoms to other measures. The brain, hidden away behind bone and blood-brain barrier, has been called the most complex object in the known universe.
That machine and it's foibles is a little more complicated than finding a buffer overrun or swabbing your throat for strep.
>The brain... the most complex object in the known universe
This is the honesty I'm looking for. It is disingenuous for psychiatry to claim to be "just as scientific" as medical pathology, because medical pathology has far fewer variables to control for, whereas the mind has virtually infinite variables to control for.
These criteria are, to some degree, subjective and also easily gamed since in many cases doctors are relying upon noisy / potentially flawed input from patients (i.e., it's possible to game the system to get adderall, etc). However, the DSM, in providing these criteria and the number that need to be expressed to constitute a disorder, are establishing some measure of objectivity. While it is certainly imperfect, it's far from the state of affairs in the 40s/50s and definitely not purely subjective.
More objective / less noisy and biased criteria would certainly be welcome, but they don't really exist and that's been a major goal of NIMH as late. Some people have attempted to predict the presence of mental illness using fMRI scans, with limited success:
However, even without reliable diagnosis via fMRI, I've noticed some psychiatrists using tasks from psychophysics to aid in diagnosis. Unfortunately they aren't always as savvy as scientists with respect to test-retest reliability, but it's a start.
i'm inclined to agree, but i'd also like to temper your use of the "f" word: it's a work in progress.
sure they've had decades to sort it out, but psychiatry is complex material. general shamanism has been replaced by its modern equivalent which is actually significantly better in quite a few different dimensions and can actually provide relief to some patients. if the science of psychiatry is incomplete and flawed and terrible, fine-- i agree entirely.
but if it can provide relief to the median patient-- even if it's only a little bit of relief-- so long as that relief outweighs the medication's side effects, it's worthwhile. and we won't get better without constantly trying things out and learning what works.
>usually do more harm with debilitating "side effects" to their drugs
this doesn't always follow. not all patients experience side effects, and most of those side effects are less debilitating than the disease symptoms which they are replacing. sure, there's the much shushed SSRI-induced sexual dysfunction (which may be permanent for some), the forcefully ignored antipsychotic-induced tardive dyskinesia (permanent and somewhat disfiguring).
but then there's also the upshot: many side effects reside with time, and in some contexts treatment can actually address the underlying condition.
remember, the psychiatrist's metric for successful treatment is that the patient stops reporting their detrimental symptoms.
for most conditions, there is a drug which will accomplish that end with acceptable casualties.
Mental diseases are not really understood the way, say, liver diseases are understood, as a pathology of the body and its tissues and cells. Researchers understand the underlying structure of very few mental ailments. What psychiatrists call a disease is usually just a label for a group of symptoms. As the eminent psychiatrist Allen Frances writes in his book, “Saving Normal,” a word like schizophrenia is a useful construct, not a disease: “It is a description of a particular set of psychiatric problems, not an explanation of their cause.” - David brooks.
Imagine you see a squadron of fighter jets flying in above in the sky. Then, one of the jets inexplicably breaks formation and flies off by itself.
How do you know which group is on the right course? It could be that the supposedly "rogue" jet that broke formation had realized the others had lost course, and thus reestablished the "correct" course.
Thus is the problem of psychiatry. It makes the subjective and critical judgement that the behavior exhibited by most people signifies health, and any deviance from the statistical mean is diseased; evolution be damned.
Such an assumption has led to a variety of compulsory "treatments": indefinite solitary confinement, electrocution, lobotomies[1], and gas chambers[2].
> It could be that the supposedly "rogue" jet that broke formation had realized the others had lost course, and thus reestablished the "correct" course.
This analogy is flawed: it assumes there is some objectively "correct" course that exists.
We could say that psychiatry is flawed because it assumes that the mean corresponds to "health," but this does not seem to be the point of psychiatry. Psychiatry isn't attempting to bring individuals into some objective "healthyness," rather it seems to be attempting to reincorporate deviant individuals back into society, flawed and unhealthy as that society (and treated individual) may be.
The ethical implications of this are another question: a psychiatrist might argue that this is a good practice, as they are helping people remain within society, which will likely result in better outcomes along the broader society's axes of good and bad. Others, such as yourself, might argue that this is bad, for various reasons such as that the treatment results in suffering or that deviant individuals also have access to novel perspectives.
It also led to the classification of homosexuality as a mental disorder. And, e.g. the chemical castration of Alan Turing.
But at the same time if you've ever spent time with people with serious dehabilitating mental illness, it's clear there are a lot of people who are very seriously struggling and very much need help and aren't capable of seeking it out on their own. And if you've ever experienced any kind of mental illness or talked in depth to someone who has, it's clear it's a very real phenomena and not just someone daring to be different.
So while I agree with the general thrust of your post I think this:
>It makes the subjective and critical judgement that the behavior exhibited by most people signifies health, and any deviance from the statistical mean is diseased; evolution be damned.
Is unfair. It's a tough line to thread, which is why psychiatrists and philosophers spend lifetimes working on these issues and trying to figure out where the line is. It's absolutely not the case that "any deviance from the statistical mean is diseased"; this is not an unfair characterization of what was done at the inception of the field when people understood nothing, and it's certainly a good warning about how powerful and dangerous it is classify something or someone as 'insane' (read Foucault! Who is shockingly missing from this article!) but it's not a fair critique of modern day psychiatric medicine.
>Imagine you see a squadron of fighter jets flying in above in the sky. Then, one of the jets inexplicably breaks formation and flies off by itself.
I would think that maybe they are performing a 'missing man formation' [1] and would not find it inexplicable. Not sure what the moral of that is. Perhaps that deviance from the mean may be purposeful and not maladaptive?
I'm a psychiatrist. Much of the valid criticism in this thread could be applied equally to all branches of medicine. For example, the number of good randomized controlled trials for surgical interventions is probably smaller than you think. Also, consider how changing the cutoff score for diabetes makes thousands of people diabetic with the stroke of a pen. The dilemma of an applied science is that I have to make a decision today, not in 10 years when we have more data.
With regard to lumping disorders together, this is the camp that I fall in. I think we will look back at our present diagnoses the same way we look at a historical diagnosis of "fever;" it's correct but not as precise as it needs to be. The prevailing direction in research is to move toward clusters of symptoms rather than diagnostic labels. The relatively new NIMH RDoC will help with this:
One of the other things I'm seeing a lot in this thread has to do with the tension between autonomy and paternalism. This is a problem that keeps me and many of my colleagues up at night. At what point do you step in to limit a person's decisions? That's not something that most of us take lightly. I sure don't. At this point, in the US, the primary criterion for making decisions for someone is based on preventing injury to themselves or other people. This is a reasonable, but complex, dividing line. An unintended consequence is that it continues to over-emphasize and reinforce the connection between mental illness and violence.
Your profession is still largely a fraud. It votes into existence new "diseases" while the people that do the voting largely are on the payroll of the big pharma companies that will then market the same "diseases" via massive marketing campaigns to an uninformed public who thinks what you do is science. (https://en.wikipedia.org/wiki/DSM-5#Criticism)
In the medical field, no disease is ever voted into existence. There are lab tests, scans, x-rays, physical evidence of issues requiring medication. In psychiatry there are no tests to decide which medication to put someone on, and the profession largely admits to not knowing how the drugs they put patients on work.
Nevermind that most of these drugs cause horrible side effects in patients like massive weight gain, loss of sex drive, suicidal tendencies, psychotic episodes, etc...
Nevermind that most school shooters in the last 20 years were either coming off from or on some form of psychiatric medication.
Nevermind that over 100 000 toddlers are medicated, TODDLERS, with the same mind altering drugs in this country. How do you diagnose a toddler with depression?
Now your profession wants to go into prenatal and fetal psychiatry and start drugging the mother before the child is even born.
Nevermind you shamelessly do ECT, 450 volts through the brain which countless studies have proven is not a beneficial treatment once it is stopped and that patients do worse after (some who become complete human vegetables and require 24/7 care) as a form of "extreme treatment" when your pills don't work to numb the patient enough. (See http://emord.com/blawg/wp-content/uploads/2016/08/1-ECT-Citi... )
Your profession is a sham. The threads are coming loose and you can't hide it anymore. Please quit and go find another job.
Your post contains some good arguments, but it's couched in a tone that makes HN unwelcoming to professionals in all fields, not just psychiatry. When you try to put so much pressure on individuals (especially ones voluntarily spending their time here), they're less likely to see the error of their ways, and more likely to just disengage.
>Your profession is still largely a fraud. It votes into existence new "diseases" [...]
What's an example of a disease that people didn't denote as a disease?
> [...] while the people that do the voting largely are on the payroll of the big pharma companies that will then market the same "diseases" via massive marketing campaigns [...]
Like the previous commenter (and M.D.) said,
> Also, consider how changing the cutoff score for diabetes makes thousands of people diabetic with the stroke of a pen. The dilemma of an applied science is that I have to make a decision today, not in 10 years when we have more data.
Before there was "autistic psychopathy", now known as the ASD condition Asperger's syndrome, there existed people who exhibited all the symptoms. Before ADHD was a diagnosis there were people who had it. These conditions cause problems in people's lives -- health problems. Hence, medical professionals defined diagnoses accordingly and began treating them.
Regarding big pharma, that's more of a political issue. Where big corporations can put money before people, they often do. It's noncontroversial to say that the pharmaceutical industry has financial interests in getting people to take their drugs, as well as to jack up prices on drugs people need, and other unethical practices. But if you're trying to say that the DSM is developed by people who make up diseases for which they have drugs to give people, you're already assuming they have a mechanistic understanding of what to give people to treat the symptoms of diseases that you're claiming aren't diseases. While there are psychiatrists who probably push the limit and prescribe vyvanse to anyone who says "I can't pay attention in class, I have ADHD", there are likely physicians who prescribe blood pressure medications more liberally. Those can have side effects too, e.g. kidney damage.
>to an uninformed public who thinks what you do is science.
How are the relevant fields of psychology, neurology/cognitive science, etc., not science? Maybe you could also elaborate to explain what science is.
>In the medical field, no disease is ever voted into existence. There are lab tests, scans, x-rays, physical evidence of issues requiring medication. In psychiatry there are no tests to decide which medication to put someone on, and the profession largely admits to not knowing how the drugs they put patients on work.
Besides carrying on the same argumentative direction which the previous commenter already preempted you now assert that a difference between 'real' medical science and psychiatry is "physical evidence of issues". When a schizophrenic, say, pulls out their own teeth, or stabs themselves, or so on because they report hallucinations telling them to do so, what would be your criterion of "physical evidence of issues"? What about proper treatment? Would you at least consider forcing them to take benadryl to nap for a while?
The phrase "physical evidence" leads me to suspect you have some metaphysical motivation here akin to pseudo-philosophical internet forum-based atheism. Like you think that somehow psychotic ideation isn't "physical". If I'm headed in the right direction here feel free to unpack your philosophy of mind related issues with the questionably "physical" basis of psychology and such.
>Nevermind that most of these drugs cause horrible side effects in patients like massive weight gain, loss of sex drive, suicidal tendencies, psychotic episodes, etc...
All medicines have side effects. What conclusion should that yield specific to psychiatry?
>Nevermind that most school shooters in the last 20 years were either coming off from or on some form of psychiatric medication.
Do you have a source that compares perpetrators of mass shootings who received some form of psychiatric medication with those who hadn't? Regardless, ...
52 comments
[ 1.8 ms ] story [ 92.6 ms ] threadI also hope and believe that humanity transcends biology / hardware / strange-loopiness-in-software. We see less and less of a transcending viewpoint in "the [rational] West", and that belief still present comes less now from traditional sources and more from the influence of Eastern religion / philosophy. From a Screwtape Letters viewpoint the ultimate prosecuting lawyer is comfortable with the West in its current materialistic stupor ... but I grew up in circumstances where transcending factors were much more plausible and understood.
I think the pile of circumstantial evidence for this being the case is pretty large at this point. There is no single treatment that works for a majority of people with major depressive disorder. The types of schizophrenia are sufficiently different that using the same term for them is practically misleading and seems to be driven more by tradition than by any consistent system (cf. diabetes). There's at least one lab test that is believed to identify a type of depression; it seemingly fell out of favor because nobody figured out how to choose a treatment based on it and a negative result doesn't exclude an MDD diagnosis [1].
[1] https://en.wikipedia.org/wiki/Dexamethasone_suppression_test
Some people need help to learn what foods to eat properly because their parents never taught them how or they just have bad eating habits.
Which vitamin or mineral deficiency leads to psychosis? (With a link to this scientific proof please)
Both can cause mental symptoms (retardation for example). But both are rare.
You don't need a nutritionist to tell you to stop eating junk/processed food. All other diet advice are pure b.s. as there's no scientific answer to what "a proper diet" is. What is "healthy" and what is not changes on a similar rate as weather broadcast i.e. see a recent turn on fat.
2. You don't seem to understand what ADD and depression are. They're vastly more serious and prolonged than the sort of candy-induced, momentary fit-throwing you're suggesting.
Here's an example regarding hyperactivity and sugar: http://jamanetwork.com/journals/jama/article-abstract/391812
> a real medical professional, nutritionist, fitness trainer, etc
Family practitioners also commonly prescribe antidepressants and the like. I'd say there is still wild debate about what is a healthy diet. Until recently (and maybe even still) most nutritionists would prescribe something aligning with the Nixon-administration-guided carbohydrate pyramid. Anything a fitness trainer guides you to do is likely less effective than the basics (squats, deadlifts, running).
There is substantial B.S. in all of the professions you mention. The least one can do is find the person dishing it in the right realm.
If a person has schizophrenia, it still massively behooves them or their family to seek the aid of a psychiatrist. A hot mess of conflicting theory and pseudoscience, yes, but it's all we have.
Pych doctors more than willing participants in the prescribing of stimulants and mild euphoriants. They get rich also doing so - 4/5 $200 appointments an hour is common, and if you look at the highest paid public employees in some states you'll see state-hired prison and other psychiatrists towards the top below university basketball coaches.
69% of psychiatrists defining mental illnesses and their treatments in the DSM-5 reported having financial ties to big pharma.
https://en.wikipedia.org/wiki/DSM-5#Criticism
There's good psychiatrists and bad psychiatrists, good and bad psychologists, and the pharm industry has done a lot of good for society as well as harm.
I'm not even sure where to start. Take, for example, psychologists: a lot of whatever progress has been made in mental health comes from psychology (quantitative measurements, moving away from monolithic, homogenous diagnostic categories, lots of research, even neurobiological research--hell, the head of federal mental health research recently was a psychologist with a neuroscience research focus); the pushback is often from entrenched MD political groups who play off the "trained doctor" stereotype. Pharm research, too, often complains about the overly simplistic disease models, but are required by the FDA to follow them in clinical protocols, further entrenching them (a different former head of NIMH has complained about this). Psychiatrists often are screwed by the health care industry, trying to care for the most ostracized segments of society (see the recent GOP health care bill, which basically gutted mental health care services completely).
These sorts of discussions are always frustrating, because they're full of armchair, backseat scientists who are all too-happy to declare bad science, etc. without any solutions themselves. Behavioral health is a very challenging subject, and slapping on physics, chemistry, or mech engineering as some kind of perfect model just doesn't work. The irony is that it's more challenging than those fields in a lot of ways; if someone could just drop down from their physics throne and solve all the mental health problems, it would have been done already. It's been tried, believe me, and what usually happens is they grossly underestimate the complexity of what they're getting involved with.
https://en.wikipedia.org/wiki/Psychiatrist
Psychiatrists are medical doctors.
Psychiatrists are the same kind of medical doctor as every other medical doctor.
2. Psychiatric illnesses are defined based on "fallible subjective judgments". Medical illnesses (pathologies) are defined based on objective biological tests.
2. A behavioral record is no less objective than a biological one. Facebook and Google make a ton of money this way; if you want to offer a biological alternative, no one is stopping you.
2. It is the opinion on the behavior as being good or bad that is subjective
Nobody is locked up simply because they are diagnosed with a "mental illness" which is what you apparently want people to believe - you edited your parent comment, where you claimed that a diagnosis of schizophrenia was grounds for 5150. It's not.
2) No, there is no opinion about "good or bad" in diagnosing mental illness. The almost ubiquitous criteria is significant impairment - which almost always is an impairment the patient themselves identify (not someone else) and are seeking help for.
Please let's you and I spend some time together in the emergency department. Last week we had a patient there who'd been brought in against his will by the police, and who claimed that the chip implanted in their brain was telling him to remove his eyes and everyone else's eyes with the spoon he carried in his back pocket.
He'd already removed his left eye, with the spoon he carried in his back pocket.
Please tell us your plan. I'm sorry that I can't find a throat swab to assist us.
Or perhaps we could have lunch down at the dementia care facility, where the neurologists would love you to tell them they're not legitimate medical doctors because they don't have a throat swab for dementia yet, and because they "lock up" dementia sufferers with a few signatures at the request of dementia-sufferer families so they, the dementia patients, don't walk onto the freeway. They actually lock people up protectively before "the crime" of actually walking onto the freeway.
Imagine that.
Aren't a few signatures (even sans diagnosis) all that's needed to place children in what in effect is protective custody?
Now, you can argue about what outcomes are good or bad, but that's a different issue.
In any event, these things aren't as different from other areas of medicine as you think.
For example, you're full of microbes at the moment. Some of them might make you feel a little off sometimes, some of them might make you incapacitated, and sometimes it might depend. The decision to seek care and/or intervene is a subjective decision, based on your subjective appraisal of how you're doing, and a provider's appraisal. Does that mean that infectious disease medicine is subjective?
Subjectivity enters into all medicine at some point, via ethical decisions about whether and/or how to intervene. Because ethics involves some level of subjectivity, it's unavoidable.
2. Many aspects of diagnosis are subjective, even when tied to objective measurements. For example, cutoffs for high blood pressure, diabetes, and hyperlipidemia.
1) Medical doctors (including psychiatrists), police, social workers, judges, and other trained personnel all can lock someone up for a brief time (and with all sorts of legal protections and due process) if:
a) They are a danger to themselves or others.
b) They are unable to care for themselves.
Please tell us your alternative plan for dealing with those issues.
2) I'd love to be drill a hole in your well-protected cranium and stick a needle in your brain to obtain a sample to diagnose major depression, schizophrenia, or PTSD. Just a small sample, ok?. Let me know if you're ok with that. And if you think there are "objective biological tests" for most common illnesses that are diagnosed and treated, day in and day out, by physicians, I'd invite you to accompany me to clinic where, off the top of my head" we'll see tons of upper respiratory infections, real chronic pain without any demonstrable pathology, "ear infections", etc. This is the bread-and-butter of primary care physicians, and we don't order "objective biological tests" in order to diagnose and treat "medical illnesses" - in many cases because the tests simply don't exist, or are too expensive or too invasive.
But perhaps you'd care to explain to the sufferers and their families that we can do nothing for them without your "objective biological tests".
Sure it's okay, post mortem. Many scientists have tried this. Unfortuntely, you would not be able to make a conclusive diagnosis, because the science isn't there.
Please. Give us your plan for relief of suffering while we sit around twiddling our thumbs waiting because "the science isn't there."
The history of the entire field of medicine (including psychiatry, which is as much science and medicine as any other medical specialty) is a march from partial understanding based on classification of symptoms to other measures. The brain, hidden away behind bone and blood-brain barrier, has been called the most complex object in the known universe.
That machine and it's foibles is a little more complicated than finding a buffer overrun or swabbing your throat for strep.
"First, do no harm". Stop the dehumanization and torture that goes on in many mental institutions:
https://www.reddit.com/r/AskReddit/comments/29gr27/redditors...
>The brain... the most complex object in the known universe
This is the honesty I'm looking for. It is disingenuous for psychiatry to claim to be "just as scientific" as medical pathology, because medical pathology has far fewer variables to control for, whereas the mind has virtually infinite variables to control for.
These criteria are, to some degree, subjective and also easily gamed since in many cases doctors are relying upon noisy / potentially flawed input from patients (i.e., it's possible to game the system to get adderall, etc). However, the DSM, in providing these criteria and the number that need to be expressed to constitute a disorder, are establishing some measure of objectivity. While it is certainly imperfect, it's far from the state of affairs in the 40s/50s and definitely not purely subjective.
More objective / less noisy and biased criteria would certainly be welcome, but they don't really exist and that's been a major goal of NIMH as late. Some people have attempted to predict the presence of mental illness using fMRI scans, with limited success:
http://fcon_1000.projects.nitrc.org/indi/adhd200/results.htm...
However, even without reliable diagnosis via fMRI, I've noticed some psychiatrists using tasks from psychophysics to aid in diagnosis. Unfortunately they aren't always as savvy as scientists with respect to test-retest reliability, but it's a start.
i'm inclined to agree, but i'd also like to temper your use of the "f" word: it's a work in progress.
sure they've had decades to sort it out, but psychiatry is complex material. general shamanism has been replaced by its modern equivalent which is actually significantly better in quite a few different dimensions and can actually provide relief to some patients. if the science of psychiatry is incomplete and flawed and terrible, fine-- i agree entirely.
but if it can provide relief to the median patient-- even if it's only a little bit of relief-- so long as that relief outweighs the medication's side effects, it's worthwhile. and we won't get better without constantly trying things out and learning what works.
>usually do more harm with debilitating "side effects" to their drugs
this doesn't always follow. not all patients experience side effects, and most of those side effects are less debilitating than the disease symptoms which they are replacing. sure, there's the much shushed SSRI-induced sexual dysfunction (which may be permanent for some), the forcefully ignored antipsychotic-induced tardive dyskinesia (permanent and somewhat disfiguring).
but then there's also the upshot: many side effects reside with time, and in some contexts treatment can actually address the underlying condition.
remember, the psychiatrist's metric for successful treatment is that the patient stops reporting their detrimental symptoms.
for most conditions, there is a drug which will accomplish that end with acceptable casualties.
How do you know which group is on the right course? It could be that the supposedly "rogue" jet that broke formation had realized the others had lost course, and thus reestablished the "correct" course.
Thus is the problem of psychiatry. It makes the subjective and critical judgement that the behavior exhibited by most people signifies health, and any deviance from the statistical mean is diseased; evolution be damned.
Such an assumption has led to a variety of compulsory "treatments": indefinite solitary confinement, electrocution, lobotomies[1], and gas chambers[2].
[1]http://www.pbs.org/newshour/rundown/the-forgotten-lobotomies...
[2]https://www.ncbi.nlm.nih.gov/pubmed/23511221
A clear-cut case of Paternal Conflict Syndrome.
This analogy is flawed: it assumes there is some objectively "correct" course that exists.
We could say that psychiatry is flawed because it assumes that the mean corresponds to "health," but this does not seem to be the point of psychiatry. Psychiatry isn't attempting to bring individuals into some objective "healthyness," rather it seems to be attempting to reincorporate deviant individuals back into society, flawed and unhealthy as that society (and treated individual) may be.
The ethical implications of this are another question: a psychiatrist might argue that this is a good practice, as they are helping people remain within society, which will likely result in better outcomes along the broader society's axes of good and bad. Others, such as yourself, might argue that this is bad, for various reasons such as that the treatment results in suffering or that deviant individuals also have access to novel perspectives.
But at the same time if you've ever spent time with people with serious dehabilitating mental illness, it's clear there are a lot of people who are very seriously struggling and very much need help and aren't capable of seeking it out on their own. And if you've ever experienced any kind of mental illness or talked in depth to someone who has, it's clear it's a very real phenomena and not just someone daring to be different.
So while I agree with the general thrust of your post I think this:
>It makes the subjective and critical judgement that the behavior exhibited by most people signifies health, and any deviance from the statistical mean is diseased; evolution be damned.
Is unfair. It's a tough line to thread, which is why psychiatrists and philosophers spend lifetimes working on these issues and trying to figure out where the line is. It's absolutely not the case that "any deviance from the statistical mean is diseased"; this is not an unfair characterization of what was done at the inception of the field when people understood nothing, and it's certainly a good warning about how powerful and dangerous it is classify something or someone as 'insane' (read Foucault! Who is shockingly missing from this article!) but it's not a fair critique of modern day psychiatric medicine.
I would think that maybe they are performing a 'missing man formation' [1] and would not find it inexplicable. Not sure what the moral of that is. Perhaps that deviance from the mean may be purposeful and not maladaptive?
1. https://en.wikipedia.org/wiki/Missing_man_formation
With regard to lumping disorders together, this is the camp that I fall in. I think we will look back at our present diagnoses the same way we look at a historical diagnosis of "fever;" it's correct but not as precise as it needs to be. The prevailing direction in research is to move toward clusters of symptoms rather than diagnostic labels. The relatively new NIMH RDoC will help with this:
https://www.nimh.nih.gov/news/science-news/2015/the-nimh-res...
One of the other things I'm seeing a lot in this thread has to do with the tension between autonomy and paternalism. This is a problem that keeps me and many of my colleagues up at night. At what point do you step in to limit a person's decisions? That's not something that most of us take lightly. I sure don't. At this point, in the US, the primary criterion for making decisions for someone is based on preventing injury to themselves or other people. This is a reasonable, but complex, dividing line. An unintended consequence is that it continues to over-emphasize and reinforce the connection between mental illness and violence.
In the medical field, no disease is ever voted into existence. There are lab tests, scans, x-rays, physical evidence of issues requiring medication. In psychiatry there are no tests to decide which medication to put someone on, and the profession largely admits to not knowing how the drugs they put patients on work.
Nevermind that most of these drugs cause horrible side effects in patients like massive weight gain, loss of sex drive, suicidal tendencies, psychotic episodes, etc...
Nevermind that most school shooters in the last 20 years were either coming off from or on some form of psychiatric medication.
Nevermind that over 100 000 toddlers are medicated, TODDLERS, with the same mind altering drugs in this country. How do you diagnose a toddler with depression?
Now your profession wants to go into prenatal and fetal psychiatry and start drugging the mother before the child is even born.
Nevermind you shamelessly do ECT, 450 volts through the brain which countless studies have proven is not a beneficial treatment once it is stopped and that patients do worse after (some who become complete human vegetables and require 24/7 care) as a form of "extreme treatment" when your pills don't work to numb the patient enough. (See http://emord.com/blawg/wp-content/uploads/2016/08/1-ECT-Citi... )
Your profession is a sham. The threads are coming loose and you can't hide it anymore. Please quit and go find another job.
What's an example of a disease that people didn't denote as a disease?
> [...] while the people that do the voting largely are on the payroll of the big pharma companies that will then market the same "diseases" via massive marketing campaigns [...]
Like the previous commenter (and M.D.) said,
> Also, consider how changing the cutoff score for diabetes makes thousands of people diabetic with the stroke of a pen. The dilemma of an applied science is that I have to make a decision today, not in 10 years when we have more data.
Before there was "autistic psychopathy", now known as the ASD condition Asperger's syndrome, there existed people who exhibited all the symptoms. Before ADHD was a diagnosis there were people who had it. These conditions cause problems in people's lives -- health problems. Hence, medical professionals defined diagnoses accordingly and began treating them.
Regarding big pharma, that's more of a political issue. Where big corporations can put money before people, they often do. It's noncontroversial to say that the pharmaceutical industry has financial interests in getting people to take their drugs, as well as to jack up prices on drugs people need, and other unethical practices. But if you're trying to say that the DSM is developed by people who make up diseases for which they have drugs to give people, you're already assuming they have a mechanistic understanding of what to give people to treat the symptoms of diseases that you're claiming aren't diseases. While there are psychiatrists who probably push the limit and prescribe vyvanse to anyone who says "I can't pay attention in class, I have ADHD", there are likely physicians who prescribe blood pressure medications more liberally. Those can have side effects too, e.g. kidney damage.
>to an uninformed public who thinks what you do is science.
How are the relevant fields of psychology, neurology/cognitive science, etc., not science? Maybe you could also elaborate to explain what science is.
>In the medical field, no disease is ever voted into existence. There are lab tests, scans, x-rays, physical evidence of issues requiring medication. In psychiatry there are no tests to decide which medication to put someone on, and the profession largely admits to not knowing how the drugs they put patients on work.
Besides carrying on the same argumentative direction which the previous commenter already preempted you now assert that a difference between 'real' medical science and psychiatry is "physical evidence of issues". When a schizophrenic, say, pulls out their own teeth, or stabs themselves, or so on because they report hallucinations telling them to do so, what would be your criterion of "physical evidence of issues"? What about proper treatment? Would you at least consider forcing them to take benadryl to nap for a while?
The phrase "physical evidence" leads me to suspect you have some metaphysical motivation here akin to pseudo-philosophical internet forum-based atheism. Like you think that somehow psychotic ideation isn't "physical". If I'm headed in the right direction here feel free to unpack your philosophy of mind related issues with the questionably "physical" basis of psychology and such.
>Nevermind that most of these drugs cause horrible side effects in patients like massive weight gain, loss of sex drive, suicidal tendencies, psychotic episodes, etc...
All medicines have side effects. What conclusion should that yield specific to psychiatry?
>Nevermind that most school shooters in the last 20 years were either coming off from or on some form of psychiatric medication.
Do you have a source that compares perpetrators of mass shootings who received some form of psychiatric medication with those who hadn't? Regardless, ...