Ronald Pies, MD, and Mark Ruffalo, D Psa, were busy in June. They published two papers in defense of psychiatry: What Is Meant by a Psychiatric Diagnosis? (“Psychiatric diagnoses are not merely descriptive; they reflect genuine illness”); and Psychiatric Diagnosis 2.0: The Myth of the Symptom Checklist (“More on the meaning of psychiatric diagnosis”). Both were published by Psychology Today.
Here’s their opening to the first paper:
“It has become fashionable for some in the social sciences to assert that psychiatric diagnoses represent ‘constructs’ and not genuine disorders or diseases. During a recent Twitter exchange, one of us (Mark Ruffalo) was pointed to an article published here on Psychology Today in 2019 by the psychoanalytic psychologist Jonathan Shedler, Ph.D., titled, ‘A Psychiatric Diagnosis Is Not a Disease.'”
Note the word “fashionable”, as if those of us on this side of the issue dispute the validity of psychiatric diagnoses on the grounds of fashions or whims.
“We wish here to counter the claims made in the Shedler piece, particularly as they pertain to the meaning and implication of a psychiatric diagnosis. One of us (Ronald Pies), a psychiatrist, has spent a large part of his career thinking and writing about the philosophical foundations of psychiatry; and the other (Mark Ruffalo), a psychoanalytic psychotherapist, has developed a keen interest in discussions surrounding the meaning of psychiatric diagnosis.”
Most of the content of the two papers is simply a regurgitation of previous contentions of Dr. Pies, to which I have responded on several occasions. These I will address in a fairly cursory manner. But our dynamic defenders of the psychiatric corpus have also collated a few new points of contention to which I will devote more space.
Drs. Pies’ and Ruffalo’s initial tactic is to reduce Dr. Shedler’s position to four “claims”. The four claims are:
- That “Medical diagnoses describe underlying biological causes—and psychiatric diagnoses do not.”
- That “Psychiatric disorders and medical disorders are categorically different (i.e., are not ‘equivalent’).”
- That “Psychiatric diagnoses provide nothing more than a label or a description of the person’s problems.”
- That “Psychiatric disorders and their diagnostic criteria cannot be considered the ’cause’ of the patient’s problems.”
CRITIQUE OF DRS. PIES’ AND DR. RUFFALO’S ARTICLES
Here are some quotes from the Pies-Ruffalo articles, interspersed with my observations and critiques.
“A careful reading of history teaches us that there is no ‘essential’ definition of disease universally accepted by physicians (or by philosophers of science); however, historically, the concept of ‘disease’ has always been more intimately tied to the degree of suffering and incapacity experienced by the individual person than to demonstrable biological dysfunction (see Pies, 1979, 2019). While abnormal biological or laboratory findings can sometimes aid in the diagnosis of a disease—e.g., as confirmatory tests—they are neither necessary nor sufficient for an entity to be considered a disease, nor for the diagnosis of disease.”
“A careful reading of history…”
Note the blatant arrogance and condescension in the implication that Drs. Pies and Ruffalo are the “careful” readers of history, and that, presumably, those of us in the anti-psychiatry movement are simply being careless and slapdash in this regard.
“…there is no ‘essential’ definition of disease universally accepted by physicians (or by philosophers of science);”
Actually, there is an essential definition of disease. It’s to be found in dictionaries. It may not be universally accepted by physicians or by philosophers, but where is the justification for such a sweeping requirement?
I myself keep three reputable dictionaries on my desk. Here’s what they each say under the entry disease:
Merriam-Webster’s Collegiate Dictionary, Eleventh Edition, 2009:
“a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms; sickness; malady.”
Random House Webster’s College Dictionary, 1992:
“a disordered or abnormal condition of an organ or other part of an organism resulting from the effect of genetic or developmental errors, infection, nutritional deficiency, toxicity, or unfavorable environmental factors; illness; sickness.”
Webster’s New World Dictionary of American English, Third College Edition, 1988
“a particular destructive process in an organ or organism, with a specific cause and characteristic symptoms; specif., an illness; ailment”
Each of these dictionaries also gives analogical or extended uses of the word, e.g. any harmful condition, as of society (Random House). But the essential definition in each case is as presented above.
PIES-RUFFALO: SUFFERING AND INCAPACITY ARE THE CRITICAL HALLMARKS OF DISEASE
“however, historically, the concept of ‘disease’ has always been more intimately tied to the degree of suffering and incapacity experienced by the individual person than to demonstrable biological dysfunction…”
Actually, for most of its history, the practice of medicine has been founded on error, superstition, and quackery. Physicians had little or no knowledge concerning the essential nature or causes of the various diseases. Bigotry and guesswork prevailed, and useless or even harmful “treatments” were used extensively. The fact that some physicians stressed the notions of suffering and incapacity is neither surprising nor helpful. These, after all, are very noteworthy and obvious properties of many diseases. The fact that historically there was relatively little emphasis on “demonstrable biological dysfunction” is also unsurprising and unhelpful because until about the mid-1800’s, little was known about human biology, normal or abnormal. It wasn’t until the second half of the 1800’s that John Snow, Louis Pasteur, and Robert Koch confirmed the existence of germs and developed the germ theory of disease, (here) and it wasn’t until the 1860’s that most biologists accepted the basic tenets of the cell theory!
To hold up earlier periods of pre-scientific quackery as the preferential source of our present-day definitions is pure, undiluted nonsense. It’s akin to citing unsplittability as the defining feature of an atom, on the basis that this was the accepted historical view prior to the first lab-controlled fission by Cockroft and Walton in Cambridge in 1932.
. . . . . . . . . . . . . . . .
“And history is replete with examples of disease states whose pathophysiological mechanisms were unknown for decades after the disease had first been described clinically. Parkinson’s disease is perhaps the best-known example.
On Dr. Shedler’s view, no physician in 1817—not even James Parkinson!—could have told a patient with “the shaking palsy” that he or she had bona fide disease—because, for Shedler, the sine qua non of a bona fide disease diagnosis requires a known etiology—or at least, the diagnosis must “point to” etiology, whatever that means. The illogical consequence of this view is that no patient with what we now recognize as Parkinson’s disease could have had actual disease until the etiology or pathophysiology was identified, in the 1960s.”
In the early days of scientific medicine, progress was by fits and starts. Great discoveries were made, but several issues remained poorly understood or not understood at all. The etiology of Parkinson’s disease was not understood. But – and this is the critical point – it was reasonable to believe that there was an underlying pathology, and that the “shaking palsy” was a genuine disease or illness. This, I believe, is what Dr. Shedler meant by the assertion that medical diagnoses “point to etiology—underlying biological causes”.
Apparently the learned doctors have failed to grasp this, so I’ll try a simple analogical explanation. Suppose I am riding a bicycle and I hear a loud grinding noise coming from the rear hub. Without even examining the hub, I surmise, probably correctly, that something has gone amiss in the hub and repairs are called for.
Similar considerations apply to Dr. Parkinson’s position in 1817, when he wrote his “Essay on the Shaking Palsy”. He described six cases of this condition and identified six characteristics: the tremor itself, abnormal posture, abnormal gait, paralysis, diminished muscular strength, and a deteriorating course. Any one of these problems would suggest a disease (in the dictionary-endorsed biological pathology sense of the term). The identification of six characteristics leaves little doubt. After all, there are no other plausible explanatory candidates.
In sharp contrast, most of the criteria items by which psychiatrists define their ever-growing list of mental “illnesses” are explainable in non-pathological terms. Depression in the face of overwhelming adversity does not point to a biological etiology; rather, it is an adaptive mechanism encouraging us to make appropriate changes in our lives and circumstances. Similarly, anxiety concerning the current world-wide pandemic does not point to a biological etiology, but is also adaptive, and encourages us to take such precautions as we can.
But the very learned doctors remain intractable. They list five illnesses for which “the exact cause is either unknown or poorly understood.”:
“Even today, many diseases—readily identified as such—have no known underlying biological cause. Alzheimer’s disease, migraine disorders, Kawasaki’s disease, fibromyalgia, and amyotrophic lateral sclerosis (Lou Gehrig’s disease) are but a few examples of conditions for which the exact cause is either unknown or poorly understood.”
And they conclude:
“Thus, the claim that medical diagnoses essentially or necessarily ‘point to’ etiologies is false.”
The essential issue here is that Drs. Pies and Ruffalo are confusing the disease (i.e. the actual biological pathology) with the degree of human knowledge concerning the disease (which could vary from very little to a great deal). Are the learned doctors actually suggesting that any disease which cannot “show its credentials” at the door be banned from hospitals and other healthcare facilities? I would guess not. What they are doing rather is using this bizarre caricature of the anti-psychiatry position to score cheap points in a debate that they have long since lost. The inescapable fact is that the pathologies underlying the great majority of general medical diseases are known and understood, while the total number of psychiatry’s functional “diseases” that have attained this status is still zero!
“Similarly, serious mental illnesses (SMI) like schizophrenia, bipolar disorder, and major depression are rightly grouped in the broad family of disease entities not because they are ‘equivalent’ to diabetes or pneumonia, but because—as Wittgenstein explained in his later work (e.g., Philosophical Investigations)—there are ‘family resemblances’ between SMI and certain conventionally ‘medical’ disease states; i.e., like diabetes or pneumonia, schizophrenia (or major depression, bipolar disorder, autism, and others) produce characteristic types of suffering and incapacity.”
Note firstly that Drs. Pies and Ruffalo are here referring only to “serious mental illnesses (SMI)” such as “schizophrenia”, “bipolar disorder”, and “major depression”. Should we conclude from this that they are excluding the hundreds of other psychiatric “diagnoses” from these considerations?
Secondly, the use of “family resemblances” as a basis for categorizing anything is extremely problematic, in that they are notoriously unreliable and arbitrary. Suppose, for instance, that I wish to identify and demark the fundamental axis for categorizing animals. I observe a great many animals and I conclude that the most obvious family resemblance is the presence (or absence) of fur. And with that as my fundamental distinction, I set about the task of further study and subdivision. But what I’ve done will have very little value, because the presence (or absence) of a backbone (vertebrates vs. invertebrates) is a much more fundamental distinction. Fur (or its lack) probably had a good measure of importance historically if one were hunting animals to make fur coats, but it is way down the road in categorical significance. But from several prima facie aspects, and particularly from the historical aspect, it is one of the dominant characteristic.
Wittgenstein, of course, was considered to be a great thinker, and he is so regarded by many today. It is not my place to challenge these kinds of sentiments. Bertrand Russell, however, one of the greatest philosophers and logicians of the twentieth century, who knew Wittgenstein well and was very familiar with his writings, wrote this:
“I have not found in Wittgenstein’s Philosophical Investigations anything that seemed to me interesting and I do not understand why a whole school finds important wisdom in its pages.” (here)
There is an unfortunate tendency in modern philosophy to attribute wisdom to philosophers in direct proportion to the obscurity of their reflections, and I fear that Drs. Pies and Ruffalo may have allowed themselves to fall into this trap.
Regardless of what Wittgenstein might or might not have written, suffering and incapacity are not the defining features of disease. Affording disease status to psychiatry’s loose collections of vaguely-defined thoughts, feelings, and behaviors on the grounds that they bear family resemblances to certain conventionally “medical” disease states is unsound logically and scientifically. This is particularly the case in that there are available perfectly reasonable and accurate definitions of disease which can serve the discrimination purpose more effectively and more accurately. Of course, such discriminations would exclude all psychiatry’s functional “illnesses” from the disease category. It is tempting to speculate that the learned doctors’ affinity for this notion is the only way they can see to rescue their beloved psychiatry from the scrap-pile of medical errors, where it rightfully belongs.
To recap: The very learned and eminent Drs. Pies and Ruffalo realize that psychiatry can no longer peddle the absurdity of the chemical imbalance pathology. But they desperately need to maintain the fiction that their diagnoses refer to real illnesses. Despite the efforts of psychiatric researchers, no substitutes for the chemical imbalance theory (using the word theory in the dictionary-endorsed sense of guess or conjecture) are to hand. So Drs. Pies and Ruffalo, with characteristic psychiatric arrogance, proclaim the blatant falsehood that there is no essential definition of disease, but that suffering and incapacity are its most critical properties, which for psychiatry is tautologous, in that these properties are built into the definition, and voila, psychiatric validity is established once and for all.
So, according to our learned and eminent doctors, pneumonia, diabetes, and epilepsy are diseases not because they are caused by biological pathology as we had all, in our profound ignorance, imagined, but rather because of their tendency to produce certain kinds of suffering/distress. There are almost no limits of inanity to which proponents of psychiatric nonsense will go to defend their prestige, turf, and earning power.
PIES-RUFFALO: PSYCHIATRIC DIAGNOSES ARE NOT MERELY LABELS
“Claim #3: Psychiatric diagnoses provide nothing more than a label or a description of the person’s problems.
This claim is based on the fallacy that psychiatric diagnoses are made solely on the basis of the patient’s symptoms (subjective complaints). In reality, they also include signs (observable features) such as psychomotor agitation, weight loss, abnormal sleep patterns, cognitive impairment (as demonstrated with psychometric testing) and other objectively observable phenomena. Thus, insofar as this claim alleges that psychiatric diagnoses describe only symptoms, it is false.”
Here again, Drs. Pies and Ruffalo miss the point. The issue is not whether the criteria are subjective or objective; but rather whether they singly or collectively have any explanatory value. And the clear reality is that none of the criteria for psychiatry’s functional “diseases” have any explanatory value. They provide no answers to the critical why questions. What we find in psychiatry are widespread but spurious claims that their “diagnoses” constitute real illnesses “just like diabetes”, but nothing in the criteria to substantiate these claims. Drs. Pies’ and Ruffalo’s response is that their so-called diseases are real diseases because they entail suffering and distress. (Interestingly, the DSM requires only suffering or distress, but the distinction is immaterial in that neither constitutes an acceptable definition of illness.)
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PIES-RUFFALO: PSYCHIATRIC DISEASES HAVE PREDICTIVE VALIDITY, GENETIC RISK FACTORS, NEUROLOGICAL CORRELATES, AND PSYCHOMETRIC CHARACTERISTICS
So far, Drs. Pies and Ruffalo have stuck pretty much to their usual script. But at this juncture they introduce a notion that I haven’t seen (or at least don’t recall seeing) in their earlier writings.
“Furthermore, psychiatric diagnoses provide more than a shorthand or label. Many also have predictive validity, genetic risk factors, neurobiological correlates, and psychometric characteristics that may be objectively demonstrated. For example, DSM-5 states that one-third of the risk of developing generalized anxiety disorder is genetic, and that these genetic factors overlap with the risk of ‘neuroticism.’ Thus, Shedler’s claim that a diagnosis of generalized anxiety disorder means “nothing else” than a description of the patient’s prolonged worry or anxiety is false.”
Let’s examine the second sentence above, taking each item in turn:
Predictive validity: The predictive validity of a diagnosis is the extent to which the diagnosis either remains constant over time or accurately predicts the progression of the illness and treatment response. Since all the criteria for “generalized anxiety disorder” are either thoughts, feelings, or behaviors, what’s being asserted here by Drs. Pies and Ruffalo is that previous patterns of thought, feelings and/or behavior are valid predictors of future thoughts, feelings, and/or behaviors. This is not particularly profound, nor is it entirely true. People can and do change their patterns of thinking, feeling, and or/behaving without any kind of professional help. With regards to the power of the diagnoses to predict treatment response, it needs to be pointed out that in a great many psychiatric situations, the first drug prescribed for a given problem is ineffective and is followed by another and even a third before any positive effect is noted. Of course, it’s entirely possible, though seldom acknowledged by psychiatry, that the passage of time might have been the critical factor in these cases.
Genetic risk factors:
“…DSM-5 states that one-third of the risk of developing generalized anxiety disorder is genetic, and that these genetic factors overlap with the risk of ‘neuroticism.'”
DSM-5 does indeed contain this statement. It’s on page 224. But like all such statements in the DSM, no reference is provided, so we can’t check out the quality or otherwise of the assertion.
As a general matter, however, it needs to be pointed out that most psychiatric studies of genetic risk rely on comparisons of monozygotic twins vs. same-gender fraternal twins, and are based on the assumption that the twins were raised in equal environments – an assumption that is known to be false. For further discussion of this complex matter, see posts written by Jay Joseph, PsyD, on Mad in America here, here, and here. Here are two quotes from two of Dr. Joseph’s articles:
“The bottom line is this: despite being cited in countless textbooks, scholarly journal publications, and popular books and articles, the little-disputed finding that identical pairs experience much more similar environments than fraternal pairs means that non-genetic factors plausibly explain twin method results. The fact that psychiatric twin studies continue to be cited in support of genetics, largely uncritically, speaks volumes about the scientific status of psychiatry in the 21rst century. Psychiatry’s acceptance of twin studies is even more remarkable in the context of the decades-long failure of molecular genetic research to uncover genes that investigators believe cause psychiatric disorders (see my February 15th MIA posting)—research that is based largely on genetic interpretations of the results of psychiatric twin studies.” [Emphasis added] [The Trouble with Twin Studies, Jay Joseph, PsyD, MIA, March 13, 2013]
“The classical twin method as a measure of ‘heritability’ and of genetic influences on psychiatric disorders and other behavioral characteristics remains one of the great pseudoscientific methods of our time, and will eventually be added to the list of discarded pseudosciences where we now find alchemy, craniometry, and mesmerism.” [Has a New Twin Study Meta-Analysis Finally “Settled” the Nature-Nurture Debate?, Jay Joseph, PsyD, MIA, June1, 2015]
Incidentally, the fact that violations of the equal environment assumption invalidate these kinds of twin studies is widely accepted even by the genetic researchers themselves. Here is a quote from a highly-influential group of psychiatric genetic researchers:
“Finally, as previously discussed, since our genetic information is limited to twin samples, any undetected violations of the equal-environments assumption might lower the heritability estimates from those presented.” [A Review and Meta-Analysis of the Genetic Epidemiology of Anxiety Disorders, Hettema, Neale, and Kendler, Am J Psychiatry, 2001: 158: 1568-1578]
Neurobiological correlates: Everything that a person does, from the twitch of a finger, to solving differential equations, to playing lead violin in a symphony orchestra, has neurobiological correlates. There is no “ghost” inside the head pulling levers or pushing buttons. The human organism is just that: an organized whole in which sensory input modifies neural activity, which in turn modifies overt and covert behavior. Confusion in this area arises because psychiatrists unjustifiably assume that any neurobiological correlate of anxiety, or depression, or inattention, etc., must be pathological in nature. They assume that unpleasant or otherwise troublesome emotions, thoughts, or behaviors inevitably constitute disorders, provided certain vague thresholds of severity, duration, and impact are met. And it is this unwarranted assumption that routinely leads them into error.
Psychometric characteristics: There are psychological tests for psychiatric constructs such as depression and anxiety. Many of these tests are of the pencil and paper, or questionnaire, variety. The testees or their caregivers are presented with a series of questions or statements, and are asked to indicate which are true at this particular time. A commonly-used example is the Hamilton Depression Rating Scale. There are 17 items on the Depression scale, at least 8 of which correspond to items on the DSM “major depression” checklist.
So, finding positive correlates between psychiatry’s “diagnostic” criteria and psychometric characteristics is a bit like finding a positive correlation between a severe hail-storm in a mid-Western town and the number of roofing shingles sold in the following month. The only sensible response to which is: Duh!
PIES-RUFFALO: PSYCHIATRIC DISORDERS AND THEIR DIAGNOSTIC CRITERIA CAN LEGITIMATELY BE CONSIDERED THE CAUSE OF THE CUSTOMER’S PROBLEM
“Claim #4: Psychiatric disorders and their diagnostic criteria cannot be considered the “cause” of the patient’s problems.
Whereas Shedler (2019) claims that psychiatric diagnoses do not ’cause’ symptoms, we contend that it is completely appropriate and correct to state, for instance, that a patient’s extreme mood swings are caused by their underlying bipolar disorder; or that a patient’s auditory hallucinations, paranoid delusions, and thought process disorder are caused by their having schizophrenia.”
“Shedler appears to take the stance that (1) psychiatric disorders and their diagnostic criteria do not speak to the cause or etiology of the particular condition (which is generally true); and therefore, (2) (a diagnosis of) condition X cannot be considered a cause of the patient’s problem.“
Note that the eminent doctors have conceded that “psychiatric disorders and their diagnostic criteria do not speak to the cause or etiology of the particular condition.” In other words, they don’t provide any answers to the question “what has caused this problem?”.
But then it gets a little abstruse or perhaps absurd.
“This is a non sequitur, because we are really talking about two distinct kinds of causality: let’s call them “cause 1” and “cause 2.” That we don’t know the “cause 1” of, say, schizophrenia does not mean that schizophrenia (by current criteria) is not the “cause 2″ of the patient’s hallucinations, delusions, etc. To put it another way, we may not know the cause of schizophrenia, but we can still say, quite accurately, that schizophrenia is the cause of the patient’s suffering and incapacity. In his 2019 piece, Shedler confuses and conflates these two very different types of causality.”
Actually, there is confusion here, but it’s largely to be found in the verbal gymnastics of our two learned doctors. Let’s illustrate this by comparing the real disease pneumonia with the psychiatric “disease” known as schizophrenia”.
Signs and symptoms: cough; shortness of breath; fever; chest pain, etc.
Cause: inflammation of lung tissue, usually due to infection with bacteria, viruses, or other pathogens.
The pneumonia CAUSES the symptoms and signs. If a patient were to ask: Why am I coughing all the time; Why does my chest hurt? etc., the correct answer would be: Because you have pneumonia. And, if the patient asked for more information, a well-informed doctor could talk to him about the nature of the inflammation; he could show him the X-ray pictures and the culture results, etc. In short, the doctor could “connect the dots” from the signs and symptoms that the patient is experiencing to the actual biological pathology that is called pneumonia and could say without a doubt that the former are caused by the latter. In fact, he could go further and explain that the object of treatment is the elimination of the offending organisms and the reduction of the inflammation to ordinary levels.
Now let’s see how this compares to the psychiatric situation. Our learned doctors contend
“that it is completely appropriate and correct to state, for instance, that a patient’s extreme mood swings are caused by their underlying bipolar disorder; or that a patient’s auditory hallucinations, paranoid delusions, and thought process disorder are caused by their having schizophrenia.”
For the sake of brevity and simplicity, let’s focus on the “schizophrenia” example.
Signs and symptoms: auditory hallucinations; paranoid delusions; disordered thinking.
Cause: unknown, as conceded by the two learned doctors
And let’s see how a conversation between the “patient” and his psychiatrist might go.
“Patient”: Why am I here?
Psychiatrist: Because you are experiencing auditory hallucinations, paranoid delusions, and disordered thinking.
“Patient”: Why am I experiencing auditory hallucinations, paranoid delusions, and disordered thinking?
Psychiatrist: Because you have schizophrenia. It’s a serious illness and you need to be in a safe place.
“Patient”: So this disease – schizophrenia – is my diagnosis and it is causing me to have auditory hallucinations, paranoid delusions, and disordered thinking?
Psychiatrist: Precisely, yes.
“Patient”: How does that work?
Psychiatrist: What do you mean?
“Patient”: How does this disease – schizophrenia – cause me to have these experiences?
Psychiatrist: We don’t know enough about schizophrenia to say for sure how it has these negative effects.
Psychiatrist: We just know that you have it and that it produces or causes these problems.
“Patient”: But you don’t know how it causes these problems?
Psychiatrist: No. We don’t know that.
“Patient”: I’m confused. Tell me again, how do you know I have this disease called schizophrenia?
Psychiatrist: Because you are experiencing auditory hallucinations, paranoid delusions, and disordered thinking. Those are the diagnostic criteria.
“Patient”: OK. So I am experiencing auditory hallucinations, paranoid delusions, and disordered thinking because I have schizophrenia; but the only evidence for the schizophrenia is the auditory hallucinations, paranoid delusions, and disordered thinking.
Psychiatrist: Eh. Yes. That’s correct.
“Patient”: My last psychiatrist told me that I had a brain disease – a chemical imbalance in my brain.
Psychiatrist: We don’t know that for sure. But we do know that you are experiencing auditory hallucinations, paranoid delusions, and disordered thinking, which means you have schizophrenia.
“Patient”: So how do you even know that I’ve got a disease? Maybe I really am receiving messages from God, and I really am the last of the present-day prophets.
Psychiatrist: We know that you have a disease because you are experiencing distress and incapacity, and historically distress and incapacity have been intimately tied to the concept of disease.
“Patient”: What incapacity?
Psychiatrist: Well, you don’t seem to be able to keep a job.
“Patient”: And that’s because I have schizophrenia?
Psychiatrist: No, that’s one of the reasons that we know you have a disease.
“Patient”: What are the other reasons?
“Patient”: The only distress I’m feeling is because you’re keeping me locked up in this place.
Psychiatrist: Well, hopefully we’ll get you stabilized and back home soon.
“Patient”: So you’re telling me that I have to stay here because I experience auditory hallucinations, paranoid delusions, and disordered thinking, and that I’m experiencing these because I have a disease called schizophrenia. You don’t know the nature of this disease, but you know it’s a disease because it entails distress and incapacity. And you know I’ve got it because I’m experiencing auditory hallucinations, paranoid delusions, and disordered thinking.
“Patient”: And I’m the one with the thought disorder?
“Patient”: And if I’m feeling a little suspicious of all this, would that be considered paranoid delusion?
Psychiatrist: Quite possibly. Yes.
“Patient”: Well in that case, everything is crystal clear.
. . . . . . . . . . . . . . . .
Let’s move on to Dr. Pies’ and Dr. Ruffalo’s second paper. It’s called Psychiatric Diagnosis 2.0: The Myth of the Symptom Checklist: More on the meaning of psychiatric diagnosis, June 14, 2020. Here’s the opening paragraph:
“Following the publication of our last post, ‘What Is Meant by a Psychiatric Diagnosis?‘, we received feedback from a few individuals raising questions and counterarguments to our assertion that psychiatric disorders—as described by their DSM diagnostic categories—can accurately be said to cause symptoms. We wish here to clarify and expand on the points made in our original piece.”
“Our position, roughly speaking, could be summed up in three basic principles: 1. Avoid definitional essentialism. 2. Embrace clinical pragmatism. 3. Respect ordinary language.”
So they choose to avoid definitional essentialism and appear to regard this as a virtue/asset rather than a liability. But let’s look a little deeper.
An essential definition is one that names or reveals the essential nature of the object or entity under discussion, and in most scientific discussions is considered an essential facet of validity. So inflammation of the lungs, with congestion, usually due to infection with bacteria, viruses, or occasionally other pathogenic organisms, is the essential definition of pneumonia. Melanoma is defined essentially as “any of several types of skin tumors characterized by the malignant growth of melanocytes.” Peritonitis is defined essentially as “inflammation of the peritoneum.” All the above definitions are from my Random House dictionary referenced earlier, wherein can also be found essential definitions of almost all illnesses/diseases whose essential definitions are known. Note particularly that in each case cited above, the underlying biological pathology constitutes the core of the definition. This is because in all branches of medicine other than psychiatry, an understanding of the essential nature of the illness is and is considered to be the royal road to effective treatment and prevention.
There was a time when psychiatry also embraced this principle, and widely proclaimed that their so-called diagnoses referred to real illnesses, “just like diabetes”, whose precise underlying biological pathology would be discovered any year now. Indeed, Dr. Pies himself was at one time an enthusiastic supporter of this perspective. Here’s a quote from Psychiatry’s Crisis which he published in 1985:
“Perhaps the most invigorating trend in modern psychiatry is the thrust toward biological research and treatment. The neurochemical basis of depression is gradually unfolding , and its rigors yielding to somatic treatments. Those twin scourges, schizophrenia and Alzheimer’s Disease, are revealing more reluctantly their nature and causes, but progress is already evident.” [Emphasis added] [J Chron Dis, 1985: Vol 38: 6: 525-526]
But as the decades passed, and the spurious nature of the claims was routinely challenged by the anti-psychiatry movement, they began to back away from these contentions. Drs. Pies’ and Ruffalo’s efforts in these papers are just the latest chapter in the subsequent and futile attempt to legitimize psychiatry by other means.
The critical question at this point of the discussion, however, is why would Drs. Pies and Ruffalo choose to adopt – as a first principle, mind – to avoid definitional essentialism. Given the primary place of essential definitions in real medicine and in science generally, it’s difficult to avoid the conclusion, or at least the strong suspicion, that Drs. Pies’ and Ruffalo’s decision on this matter springs from a realization that their beloved psychiatry has no essential definitions and that, therefore, psychiatrists, quite literally, don’t know what they’re talking about. The notion that an individual’s anxiety, say, is caused by a putative, but wholly unexplained, indeed only vaguely described, “illness” called generalized anxiety disorder makes as much sense as the assertion that it is caused by a curse or incantation or, for that matter, excessive masturbation.
“2. Embrace clinical pragmatism.” Clinical pragmatism is one of those terms that can mean almost anything, and can be used to justify almost any type of intervention, including blatant torture!
“3. Respect ordinary language.” This is truly absurd. Drs. Pies and Ruffalo labor endlessly to promote the notion that disease should be conceptualized as a problem or entity that causes prolonged or severe distress and impairment, as opposed to a problem that stems from biological pathology.
But the ordinary language use of the term disease is: a condition that stems from a biological pathology, and diagnosis is the process of identifying this pathology. So, whatever facet of ordinary language they are respecting, they’re keeping it well hidden.
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“In turn, these principles lead us to three fundamental conclusions, which we flesh out in our original article and further elucidate here:
- There is no ‘essential definition’ (i.e., one specifying necessary and sufficient conditions) for terms like ‘disease’, though entities called by this name typically possess ‘family resemblances.'”
As mentioned previously in response to a similar contention in the earlier article, there are essential definitions for the term disease. They are to be found in dictionaries. Earlier I provided examples from the three dictionaries I keep on my desk.
Note, however, how Drs. Pies and Ruffalo have developed their position.
First, a false statement:
There is no ‘essential definition’ of disease.
then an irrelevancy:
Diseases typically have “family resemblances”. So what?
then sneaking in their long-standing attempt to justify psychiatry.
“The most clinically relevant family resemblance among members of the class called ‘disease entities’ is the presence of prolonged or substantial suffering (or distress) and incapacity”
and finally, the rabbit comes out of the hat:
“these [suffering and incapacity] constitute the central focus of clinical care and treatment.”
So, voila; psychiatry isn’t a hoax after all. But note the very careful – and I would suggest – misleading wording. Drs. Pies and Ruffalo introduce the notion of suffering and incapacity not as the essential definition of disease, but rather as the central focus of clinical care and treatment. But care and treatment, important as they are in their own right, are not the critical issues in this discussion. The critical issue is that psychiatric “diagnoses”, in contrast to real illnesses, have no explanatory significance. They are just labels: rewordings of the presented problem. So why are Drs. Pies and Ruffalo harking back repeatedly to these properties of illness, if not to provide the impression of validity where none exists? It has become fashionable in certain political circles to imagine that the frequent repetition of a falsehood somehow makes it become true. It would be sad indeed if our esteemed champions of psychiatry and logic were to succumb to such influences.
DESCRIPTIVE VS. EXPLANATORY STATEMENTS
Here’s what Dr. Shedler wrote on this matter:
“Psychiatric diagnoses are categorically different [from medical diagnoses] because they are merely descriptive, not explanatory. They sound like medical diseases, especially with the ominously-appended disorder, but they aren’t. If we speak of generalized anxiety disorder and major depressive disorder as if they are equivalent to pneumonia or diabetes, we are committing a category error. A category error means ascribing a property to something that cannot possess it—like emotions to a rock.”
And Dr. Shedler is entirely correct. Let’s examine the DSM criteria for “major depressive disorder” to illustrate this. The “diagnostic” criteria are listed below:
- Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation).
- Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)
- Insomnia or hypersomnia nearly every day.
- Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).
- Fatigue or loss of energy nearly every day.
- Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick).
- Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
- Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. (DSM-5, pp 160-161)
All these items are descriptive. None have even the slightest explanatory significance.
It occurs to me here that Drs. Pies and Ruffalo don’t actually understand the difference between descriptive and explanatory statements, so let’s digress briefly to provide a simple elucidation of this most fundamental logical distinction.
Suppose a child were to ask his parent: How do car brakes cause the vehicle to stop? The knowledgeable parent might respond along the following lines:
Depressing the brake pedal pumps brake fluid from the master cylinder to the brake calipers. The calipers are wrapped around steel discs which are firmly attached to the wheels. The incoming fluid pushes the caliper pads against the disc, thereby causing the wheels to slow down and bring the car to a stop.
The careful reader will readily appreciate that the child’s question entails the descriptive statement that the car brakes cause the vehicle to stop. The three statements in the parent’s response constitute the explanation. If one understands the three statements, then one understands how car brakes work. My Random House dictionary gives the following for explain: “to make known the cause or reason of.”
Back to the Pies-Ruffalo document:
“3. The concept of ’cause’ and ‘causality’ is complex—and, like ‘disease’, admits of no essential definition.”
Actually, there is an essential definition of the word “cause”. It also can be found in dictionaries! Here’s what my three desk dictionaries say:
New World: “anything producing an effect or result…a person or thing acting voluntarily or involuntarily as the agent that brings about an effect or result”
Random House: “a person that acts or a thing that occurs so as to produce a specific result”
Merriam Webster: “something that brings about an effect or result.”
I realize that many readers may find this puzzling in that it’s obvious what the word cause means. Why do the eminent Drs. Pies and Ruffalo state that the word cause admits of no definition, when the definition is agreed by lexicographers, and accepted by the general population?
The issue arises because within the Empiricist philosophical tradition, concepts whose existence cannot be verified by the senses are generally excluded from consideration. Causes cannot be seen, therefore they are excluded from the discussion. The example of this that is frequently given is that of a billiard ball colliding with a second ball and causing the latter to move. Within the Empiricist tradition, we shouldn’t say that the former ball caused the second ball to move. We can only say that the first ball made contact with the second, and the second ball subsequently moved away. We don’t witness causality with our senses, so we shouldn’t allow it to contaminate our concepts.
The fatal flaw in all this, of course, is that with careful observation and the right equipment (fast cameras), we can witness the act of causality. At the point of contact, both balls become distorted – distortion that can be captured on film and measured. The distortions constitute tension in the two-ball system. (Think of a compressed spring). The tension is not contained mechanically, and so is promptly dissipated by transmitting some of the first ball’s energy to the second.
But the critical point is that there is an essential definition of the word cause.
. . . . . . . . . . . . . . . .
“Nevertheless, it is quite consistent with ordinary language to say that at least some psychiatric disorders—denoted by their respective DSM diagnostic categories—represent causes of a patient’s suffering and incapacity in the mental, psychological, and behavioral realm.”
Let’s put this matter in context. For the last four decades or so, research psychiatrists have labored strenuously in their respective areas to uncover the biological pathologies that would validate their various diagnoses, i.e. would prove that they are real illnesses. This has been the holy grail of psychiatric research, and despite the routine issuing of press releases proclaiming successful finds in this or that area, the researchers are still empty-handed. There isn’t a shred of proof that any of psychiatry’s functional “disorders” are caused by a biological pathology. Nevertheless, since at least the 80’s, psychiatrists have been routinely claiming that their “diagnoses” are real illnesses – “just like diabetes”. At the present time, having been outed on this matter by the anti-psychiatry movement, most are actively disassociating themselves from this theory (using the word, theory, of course, in the dictionary-endorsed sense of guess or conjecture).
Drs. Pies and Ruffalo wade into this mish-mash of deception and confusion, and proclaim that biological pathology is not the defining feature of disease after all. The critical features of disease, according to them, are distress and incapacity, even though every dictionary I’ve been able to consult confirms the biological pathology requirement. Incidentally, in addition to my desk dictionaries, I also consulted some online dictionaries on this point. Here’s a summary of my findings:
Disease: a disordered or incorrectly functioning organ, part, structure, or system of the body resulting from the effect of genetic or developmental errors, infection, poisons, nutritional deficiency or imbalance, toxicity, or unfavorable environmental factors; illness; sickness; ailment.
Disease: a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms : SICKNESS, MALADY
Disease: a disorder of structure or function in a human, animal, or plant, especially one that produces specific signs or symptoms or that affects a specific location and is not simply a direct result of physical injury.
Disease: a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not due to any immediate external injury.
Webster’s New World College Dictionary, Fifth Edition, 2014
Disease: a particular destructive process in an organ or organism, with a specific cause and characteristic symptoms; specif., an illness; ailment
The American Heritage Dictionary of the English Language, Fifth Edition 2016
Disease: An abnormal condition of a part, organ, or system of an organism resulting from various causes, such as infection, inflammation, environmental factors, or genetic defect, and characterized by an identifiable group of signs, symptoms, or both.
The American heritage Dictionary of Medicine, 2018
Disease: An abnormal condition of a part, organ, or system of an organism resulting from various causes, such as infection, inflammation, environmental factors, or genetic defect, and characterized by an identifiable group of signs, symptoms, or both.
The eminent doctors then point out that distress and incapacity are present in all the “diagnoses” listed in the DSM. This is not surprising, since the presence of distress and incapacity are routinely included in the DSM’s definition of each “diagnosis”.
And so, Drs. Pies and Ruffalo are able to proclaim without a shadow of doubt that all psychiatric diagnoses do in fact describe valid disease entities and can correctly be considered causative of the various “signs and symptoms”. Three cheers for the great doctors. Nobel Committee, take note!
So the search for the holy grail can be called off. All that’s needed is some verbal legerdemain. It’s called the fallacy of building the conclusion into the premises.
Incidentally, the absurdity of this particular contention can be illustrated with an example. Suppose that we wish to produce a definition of strenuous physical exercise. We might come up with something like this:
- Vigorous and prolonged use of various muscle sets to achieve physical fitness, strength, and endurance.
- The exercises caused significant pain and distress.
- The exercises entail a disabling level of pain and discomfort.
The careful reader will readily discern that according to the principles endorsed by Dr. Pies and Dr. Ruffalo, we have proven that strenuous physical exercise is a disease! Homework assignment: prove that long-distance bike riding is a disease.
The learned doctors continue along the same spurious vein for five more pages. Here are some of their contentions:
“Following the lead of the late psychiatrist Robert Kendell (1975), we believe that suffering and incapacity are the main elements of the disease concept. The physician (and non-medical psychotherapist) are thus most concerned with the alleviation of suffering and incapacity, regardless of whether we classify the patient’s presenting problem as a disease, a disorder, or an illness.”
Again, note the psychiatric arrogance: “we believe [and the late Robert Kendell, MD also believed] …” followed in the next sentence by “thus” (i.e. therefore). In other words, Drs. Pies and Ruffalo are presenting their belief (backed by the belief of Robert Kendell, MD) as evidence for their spurious notions. I wonder if this transmutation of beliefs to fact applies to everybody, or is it a gift given only to psychiatrists and their acolytes?
Suffering and incapacity are not the main elements of disease. The main element (the very essence) of disease is the presence of biological pathology. The problem with the approach advocated by Drs. Pies and Ruffalo, apart from its logical absurdity, is that the “treatment” required to treat real diseases is not the same as, and is often incompatible with, the “treatment” required to alleviate non-disease problems. Confronted with a severely depressed person, a psychiatrist tends to reach for the prescription pad. But non-medical workers will seek to identify the psycho-socio-cultural-economic sources of the depression. In other words, they seek real explanations for the depression, and help the client find a way out. The social worker who successfully gets a homeless family into a publicly-subsidized apartment does more to relieve depression than any number of prescription-writing psychiatrists. Nevertheless, it is extremely rare to find a psychiatrist who will even entertain the possibility that such an approach has any validity or efficacy in the alleviation of depression and despondency. One occasionally encounters a psychiatrist who concedes the value of counseling, but the emphasis is almost always on persuading the client that he/she is ill and should take the pills, as prescribed.
. . . . . . . . . . . . . . . .
Back to the learned doctors.
“So, when we ask, ‘What was the cause of Smith’s panic attack?’ it is perfectly understandable to reply, in ordinary language, ‘It turns out Smith has panic disorder.’ This claim, of course, doesn’t address the etiopathology of panic disorder. Nor does it imply that other, perhaps subsidiary or contributing causes can’t be posited or discerned; e.g., ‘Smith was under a lot of pressure at work,’ or ‘Smith had just been evicted from his apartment.’ We may even go so far as to posit unconscious causes that would lend themselves to a psychoanalytic understanding of panic disorder.”
But the phrase “Smith has panic disorder” is simply another way of saying that Smith meets the DSM criteria for this “disorder”. And none of these criteria provide the slightest help in understanding the origin or maintenance of Smith’s problem.
In addition, there is a clear implication here that being under a lot of pressure at work or a recent eviction could not be the primary cause of Smith’s panic attack. These psychosocial problems are relegated to subsidiary or contributing status, which of course is exactly what happens within the psychiatric realm every single day. The truly galling aspect of this is that if one were to ask Smith why he is experiencing panic attacks, he will almost certainly provide a psycho-social-economic type of explanation, e.g., “My wife and son and I are living in our car!” But he’s just a “patient”. What does he know?
. . . . . . . . . . . . . . . . .
“We maintain that it is both philosophically and scientifically valid to state, for instance, that a patient’s persistent worry, indecisiveness, and insomnia are caused by their generalized anxiety disorder; and that a diagnosis of generalized anxiety disorder (or major depressive disorder, bipolar disorder, etc.) does not merely re-package and re-state the patient’s symptoms; but rather, points to a ‘real-world’ disease entity. Many theories may be posited about what causes the disorder, but we can reasonably say that it is the disorder itself that causes the patient’s signs, symptoms, suffering, and incapacity.”
In fact, as I think I’ve demonstrated adequately, it is emphatically not valid, either philosophically or scientifically, to posit as causes loose collections of vaguely-defined thoughts, feelings, and behaviors that actually have no causal significance. It may well be that all the DSM criterion items including the ever-present requirement of distress or incapacity spring from psycho-socio-cultural-economic causes. If this is so, and the two learned doctors, by their own admission, cannot rule this out, why is it that psychiatrists confine their treatments almost universally to the prescribing of dangerous drugs or the administration of high-voltage, intra-cranial electric shocks?
And the answer, of course, is: because these are their only stock in trade. When one sells one’s soul to the devil, there’s no backsies. Psychiatrists consciously and self-servingly gambled their professional futures on the promise of neurological pathologies just around the proverbial corner. These were easy beds to make, especially with the massive influx of pharma money; but they are not comfortable to lie on, and might even induce a person to seek honest work!