April 2013 Psychiatry & Philosophy Newsletter

jock_suit“Sometimes I wonder whether the world is being run by smart people who are putting us on, or by imbeciles who really mean it.” (Mark Twain).

The week got off to a good start when a paper on causes of mental disorder I had been hawking around since July last year was finally accepted. It was rejected in the usual week or two by two prestigious journals so I went down the food chain to a second tier journal. They promised a response in one week. Just over five months and several enquiries later, they rejected it with what I think would be the worst review I’ve ever seen. One of the reviewer’s complaints was that I hadn’t mentioned the biopsychosocial model as a valid explanation of mental disorder. I didn’t, because it isn’t: In 1998, I showed that it didn’t exist. It was never written and the whole “biopsychosocial industry” is now a gigantic fraud. Well, it would be apart from Twain’s pithy observation, above. So the question arises: how dumb does a psychiatrist have to be to believe that something exists when there is proof positive that it was never written? This is a grave worry, these are people have enormous power over people’s lives yet the level of explanation they use is about on the level of pixies and wood nymphs. There were about half a dozen more bloopers of a similar order of stupidity in that review so I sent the paper to a journal which still retains some critical reviewers on its list. In due course, back it came: “This is a very important paper…” Hey, glad to hear that, I think so too, that’s why I wrote it.

The paper looks at the reliability of the claim that mental disorder has a biological basis. There is no doubt that this is a major claim about the nature of something that affects about 25% of the population directly, and even more people indirectly. In the US alone, the mental health industry alone has a $100billion a year turnover (not including all the people who are in prison, on drugs or alcohol or homeless etc for reasons of mental disturbance). We are not talking chickenfeed. Therefore, in order to justify the claim by the director of NIMH, Dr Thomas Insel, that the correct way to approach mental disorder is through the neurosciences, there should be some fairly high-powered thinking on display, right? Er, sorry to say, wrong. There is, in fact, no thinking on display, and that’s what the paper is about.

I surveyed eleven of the most influential psychiatric journals over the eleven calendar years 2001-2011 to see if the claim that mental disorder is brain disorder has ever been proven. That yielded something like 19,500 original papers spread over about 150,000 pages. It would have been more but by that stage, I was absolutely sick to death of reading even the titles of the papers so I didn’t bother with either the Australian and New Zealand Journal of Psychiatry or the Canadian Journal of Psychiatry. I know full well that they have absolutely no idea that scientific claims need to be justified (believe it or not, the CJP still touts itself as advancing the biopsychosocial model) so I didn’t include them. There was nothing in any of those 150,000 pages that could possibly be taken as a justification of the claim that mental disorder is necessarily biological in nature. Nothing. Not a word.

Further, it would seem that there is not even an awareness that a claim of this nature needs justification. It is as though the most senior psychiatrists from all over the world don’t understand that the major claims underlying a scientific program actually have to be proven. I concluded that biological psychiatry is nothing but an ideology, i.e. “a set of beliefs that is false, misleading or held for the wrong reasons but is believed with such conviction as to be irrefutable.” Worse, the people who are pushing it “…use rhetorical language to present an excessively simplified and one-sided view of a complex question in such a manner as to induce people to think that the matter has been resolved when, in fact, it has not.” That is, while failing the criteria for scientific literature, they satisfy the definition of propaganda.

Hmm. This is a turn-up, isn’t it. It seems that our academic psychiatrists (“key opinion leaders”) are nothing but a bunch of propagandizing ideologues. No wonder they didn’t want to publish the paper. Well, you can see the whole thing in a few months in Ethical Human Psychology and Psychiatry and decide for yourself whether there is a science of biological psychiatry or whether it’s just a big con job. I think the answer is very clear.

Some of the papers I saw cited as their authority a book published in 1984 which I’d never read. “The Broken Brain: the biological revolution in psychiatry” was written by Nancy Andreasen, a very influential figure until she retired a few years ago. She was heavily involved in the DSM-III right from the beginning and was editor of the American Journal of Psychiatry from about 1992-2005. It seemed to me that if the argument in favour of biological psychiatry exists anywhere, it would be in this book. Wrong again. It’s not there. She simply states, over and over again: Mental disorder is biological, it has nothing to do with families or spouses, it isn’t your early life experiences, it’s your biology. She does not give any authorities for this but repeats it in dozens of different ways, probably several hundred times throughout the book. That’s nice for all the women who thought they were depressed because their drunk husbands were punching their heads in, or all the children who thought their brawling parents were getting them down. Nice for the drunks and brawlers, too, as she specifically says: No guilt.

The book itself is written in the breathless prose beloved of the medical writers in the Sunday papers who are trying to get their bored readers excited over yet another dramatic “breakthrough.” From beginning to end, page after dreary page, it is stuffed full of errors, innuendos, misleading associations, deceptive claims and outright nonsense. It was all I could do to dredge on and not hurl it out the window. But, from the historical point of view, it is interesting because it shows a number of points about the propaganda war being waged by the NIMH and their friends in the drug industry. On p36, she says: “Manic disorder… that may alternate with depression, is relatively rare and affects only 0.5 to 1% of the population.”

That’s interesting, because in the thirty years since she wrote this book, the incidence of this allegedly genetic disorder has exploded to something like 6% of the population [1], 600-1200% increase in one generation. Wow, something’s happening there. You’d think all those biological psychiatrists and geneticists would be frothing at the mouth to research this epidemic and come up with the “cause.” Surely that would be worth a Nobel Prize or two? Apparently not. Robert Whitaker has set out his case in Anatomy of an Epidemic: a sizable proportion of this rise is caused by the drugs used to treat bipolar and other psychiatric disorders (mainly stimulants and antidepressants). When coupled with loosening diagnostic boundaries and clinical ignorance of the definition of “manic” the effects and side effects of these medications are being misconstrued for bipolar disorder. Somehow, I don’t think that’s the answer they want, so he may not get an invitation to Stockholm this year.

Next question: Why are so many people getting these drugs? Well, that’s what I focus on. My answer is that, because psychiatry doesn’t have a model of mental disorder, its diagnostic standards are so sloppy you could diagnose your dog with a mental disorder. As soon as the diagnosis is made, out come the prescription pads and doggie is on drugs for life. Doesn’t matter whether you have been treating her like a dog, as they say, doesn’t matter whether she was growled at in the kennel when she was little or whether she was bullied at obedience school, mental symptoms = biological disorder = drugs.

Andreasen’s book is strange because some of the little case histories she gives are anything but biological. For example, on p65, she gives the story of Greg, an IT programmer with agoraphobia. My reading of it is that is one of the clearest examples of a psychologically-caused phobia you could ever see, I only wish my patients had such clear histories because it would make treatment much easier. Bizarrely, Dr Andreasen doesn’t even see it; his condition is biological and that’s all there is to it. Clearly, her belief preceded the evidence and therefore blinds her to the obvious facts.

We could go on but it’s not worth it. At this stage, the claim that mental disorder derives wholly (or even mostly) from abnormal biology in the brain has no more scientific support than it did a generation ago, meaning practically none. There are mountains of papers claiming to establish this link but the proof is in the details, and the details show that while these findings are not due to chance (ie p<0.05) the magnitude (relative risk, odds ratio, effect size) of these associations is so extremely small they’re useless (see Ioannidis, Why Most Published Research Findings are False PLOS 2005). As Prof. Andreasen, holder of the National Medal of Science for services to medicine, falls for the mistake of thinking that truth can be established by dint of repetition of a falsehood. The so-called biological basis of mental disorder is an ideological claim kept alive only by a constant deluge of propaganda from people who stand to gain most from it. Have a look at the quote from Mark Twain again, and finish with one from Upton Sinclair: “It’s difficult to get a man to understand something when his salary depends on his not understanding it.”

1 Merikangas et al Arch Gen Psychiatry. 2007;64(5):543-552. doi:10.1001/archpsyc.64.5.543

I will may begin answering one or more questions per month in each newsletter given I get some questions. Send your questions to jockmclaren2@gmail.com with the word ‘question’ in the title. Start submitting now for next month!

Highlighted Books and

Talking of books, anybody who hasn’t read this should do so:

Horwitz AV, Wakefield JC. The Loss of Sadness: how psychiatry transformed normal sorrow into Depressive Disorder. New York: Oxford University Press, 2007. ISBN 978 0 19 531304 8.

It is a remarkably incisive and insightful demolition job on orthodox psychiatry’s attempt to turn ordinary downers into formal illnesses that require treatment, meaning drugs. So I jumped when their new book came out:All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders New York: Oxford University Press, 2012. ISBN 978 0 19 979375 4.

It follows the same approach, looking closely at the history of anxiety and how psychiatry saw it before DSM-III came along. It then shows how the incidence of diagnosed anxiety disorders rocketed as more and more of what were once considered pretty normal fears were converted into illnesses. They show how the DSM committees have twisted and turned in their goal to see everything as evidence of brain disorders and they look at the damage it has done to the community. Their approach is that fear is not just a normal part of life, it’s a very important factor in our survival. Fear has intense evolutionary significance as it is one of the most powerful factors that kept our protohuman ancestors alive rather than ending up as some bigger animal’s breakfast. All moving creatures have an internal warning system that alerts them to danger and gets them ready to deal with it, either by slugging it out or by nicking off.

Horwitz and Wakefield, who are sociologists, argue that many cases of what biological psychiatry sees as illnesses are just examples of the brain doing what it has been programmed to do by millions of years of evolution. I think their case is extremely powerful. However, it suffers from one crucial point: unlike their first book, they don’t actually have a model of anxiety disorders in mind. They are unable to say where normal anxiety stops and mental disorder takes over so they end up in the same position as the biological psychiatrists, saying “Well, this is what we believe, so you better believe it too.” Regrettably, even sadly, it just doesn’t quite work. Parts of the book are very good, but parts of it read like a Me Too book, as in, “We’ve done depression, why don’t we do anxiety as well? OK, so where do we start?”

There are two models of anxiety conditions they should have included. The first is the acute anxiety state, where a person becomes so agitated that he just cannot function. He is shaking and sweating, his heart is thumping, he is about to vomit, he can’t breathe or string two words together and so on. Yes, this is the body doing exactly what it was programmed to do by evolution but no, it isn’t helping him function, especially if it was brought on by a frog or by needing to give a speech at his brother’s wedding. The correct model here is the Yerkes-Dodson curve of acute arousal. Damaging over-arousal may be brought on by a fire, or by seeing his children in danger, but it is still physiologically normal. That’s the first point.

The second is where a person develops disabling fear just by some trivial matter. Horwitz and Wakefield try to hammer these into their evolutionary model but it doesn’t work: the vast majority of panic states have no evolutionary significance at all. They didn’t allow for these problems being a product of a normal brain (i.e. no chemical imbalance whatsoever) caught in a self-reinforcing loop of fear leading to further fear. They wanted to show that anxiety should properly be seen as a natural function but couldn’t allow for the fact that humans aren’t just baboons on the veldt reacting to the sight of a leopard. We have cognitive capacities that baboons don’t have, and we can therefore tangle ourselves in self-fulfilling prophecies that amount to a “disease” state (dis-ease) but are not thereby biochemical diseases of the brain.

The problem for anybody reading their new book is that, by refusing to admit there may be something else beside brain disease and evolutionary arguments, they had to push the evidence in directions it really shouldn’t have gone. I would think that anybody who isn’t already familiar with the manifestations of anxiety may get a bit lost in this book, unlike their first, which was outstanding in its clarity. However, it is still in a league of its own when compared with the usual tripe out of APA Publishing, which tries to say that every twinge of fear is a biochemical disorder of the brain. No it’s not, but nor is it necessarily just a matter of evolution. There is a lot of room between these two extremes, and it’s where most anxious people find themselves.

For details of the Yerkes-Dodson curve and of anxiety as a recursive problem, see Chap. 14 in my 2007 book, Humanizing Madness and also take a look at Diamond et al, The Temporal Dynamics Model of Emotional Memory Processing (FREE!!!), 2007, Neural Plasticity. The section in my book is more tailored to the arguments above but the Diamond paper provides the best overall review of the Yerkes-Dodson curve I’ve seen and should definitely accompany my chapter. Their paper is quite a marvel with a massive total of ~450 references (13 out of 33 pages are references)!

If anybody has a book they wish to recommend, let me know (better still, write a hundred words on why you liked it and I’ll post it).

Cheers,
Jock
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