“Brain disease”: the anti-psychiatrists respond

I don’t avoid reading opinions strongly critical of psychiatry. They help sharpen my reasoning skills. It’s always possible they might alter my views in some way.  And like most everyone, I consider myself openminded and receptive to criticism. However, after years of reading Thomas Szasz, Robert Whitaker, and the screeds of the less articulate, after perusing the leaflets and poster displays of the protesters at APA conferences, I’ve heard most of the arguments by now. I rarely engage with such harsh critics. As I’ve written elsewhere, there has to be a shared foundation, some agreed-upon axioms, for a dialog to take place. Otherwise it’s just a shouting match.

My own views are pretty stable at this point. I’m critical of many aspects of psychiatry: I blog about sloppy thinking in the field, the limitations of DSM nosology, the overuse of pharmaceuticals. I teach psychiatry residents to think psychologically and how to practice ethically. But unlike anti-psychiatrists, I don’t consider psychiatry a hoax or an evil injustice. If I did, I’d find another career. And while it isn’t hard to cite cases of psychiatric mismanagement, it’s a good deal easier to cite cases of psychiatric benefit. We help people far more than we harm them. Truth be told, I’m proud to be a psychiatrist.  If I wasn’t, I’d do something else.

Philip Hickey PhD is a retired psychologist who blogs on behaviorism and mental health. His articles are reposted on Mad in America, a popular website created by Whitaker that is highly critical of psychiatry. Dr. Hickey wrote a lengthy critique of my December 12 post on whether psychiatric disorders are brain diseases. I considered replying in the comments section on MIA, but the anti-psychiatric echo chamber there assures it would fall on deaf ears. So instead I’ll follow up here.

In composing my last post I was more concerned about slamming luminaries in my field than worrying about how anti-psychiatrists might react. The piece, after all, is critical of language by prominent psychiatrists. Consequently, I granted that schizophrenia and several other named disorders look primarily biological in nature, even though this hasn’t been proven. Dr. Hickey agrees with me on first impressions, which was all I was claiming. However, he then goes to great lengths to refute this rather trivial bone I threw to the biological psychiatrists.  I could now respond to each objection point by point — schizophrenia does affect a diverse array of mental functions, not merely the few in the DSM criteria; neuroanatomical changes go well beyond mere “brain shrinkage”.  But why bother?  I’m not here to argue for the biological foundations of schizophrenia.  Indeed, doing so too well weakens the main point of my prior post.  Note the insidious dynamic: confronted by someone so “anti” I’m called upon to be more “pro,” even though this serves neither of us.

I also predicted, without offering much in the way of argument, that a few severe psychiatric conditions will eventually be shown to have biological causes. Dr. Hickey vehemently disagrees, and holds that behaviorism and learning theory account for these conditions. That’s wildly implausible, but no matter. The truth is, no one really knows.

Dr. Hickey wanders into the weeds of DSM diagnosis and labeling, a topic I didn’t address at all, other than to use the common terms for psychiatric maladies.  I don’t object to cautious circumlocutions like “feelings and behaviors currently lumped under the controversial label ‘schizophrenia’.” It just takes longer to write. Whether schizophrenia is one disease or many (or not a disease at all), whether the DSM criteria are valid or way off-base, whether some of the features called schizophrenia are actually iatrogenic — none of this matters for my argument. The point remains that the clinical presentation we call schizophrenia looks like biological dysfunction even though its etiology remains unknown.

Dr. Hickey took pains to explain in great detail the limitations of reductionist thinking, how new properties emerge at higher levels of organization, and how it is a category error to refer, say, to psychology at a molecular level.  This is because I misspoke in trying to convey the reductionist viewpoint. I wrote that, in theory, “all psychopathology can be reduced to aberrant electrochemical events, i.e. brain disease.”  That’s not true; a learned phobia is a ready counterexample.  It’s particularly unfortunate that I made this mistake, as it confirms the worst fears of those who believe we psychiatrists are mired in primitive reductionism.  Actually, Dr. Hickey and I agree here.

Now having said that, although some psychopathology arises solely psychologically, it’s also common for genetics or biochemistry to underlie aberrant psychological functioning.  This is the case for the many known diseases such as brain tumors, neurosyphilis, and lead poisoning that were once wrongly thought to be purely psychological (or demonic).  There is no reason to assume that all such discoveries are behind us.  Rather than digging one’s heels into radical behaviorism, radical neurobiology, or radical something-else, isn’t it more honest simply to say we don’t know what the future will reveal?

I’ll end by noting that anti-psychiatrists object to any pathologizing of behavior as stigmatizing and dehumanizing.  Unfortunately, it’s inevitable, and not just by psychiatrists. Paranoid psychosis — a behavioral description, not a diagnosis — may result from drugs, sleep deprivation, brain tumors, or extreme stress. Whatever the cause it’s still an unpleasant, dysfunctional state that differs markedly from the usual way human minds work. We can choose new, less stigmatizing names for such states, but we will never give up describing ourselves and others in value-laden terms. The conditions we call mental illnesses — and it’s interesting to ponder what exactly counts — are usually miserable for the sufferers, and arouse pity and fear in observers. It’s not realistic to imagine we’ll ever carefully tiptoe past naming such states.

I thank Dr. Hickey for his close reading of my article, and for calling it interesting and thought-provoking, probably the highest praise a psychiatrist can ever expect from such a critic.  I note that he calls me a typical psychiatrist when he disagrees with me, atypical and rare when we agree.  I would respectfully suggest that I’m not that rare.  Most of the psychiatrists I know have no rigid orthodoxy, no ideological axe to grind.  Most see only voluntary patients who come for relief of distress — and end up feeling relieved.  All value psychotherapy whether or not they provide it themselves, and all add a healthy dose of common sense to their specialized training. Psychiatry has much to improve, but that will only happen when supporters and critics engage in dialog, not a shouting match.

8 comments to “Brain disease”: the anti-psychiatrists respond

  • Philip Hickey is a fraud the way he is utilized at MIA. He has no credentials to write what tripe he gets away with per Whitaker and his crew.

    Nice post here though, you are too kind. Found it from your comment at http://www.1boringoldman yesterday, April 12 2016.

    Joel Hassman, MD

  • Jonathan Led Larsen

    Thanks for some eloquent posts, dr. Reidbord

    Having read your original post, about brain diseases, dr. Hickeys post and your response, I thought – having come thus far – I would leave my impression.

    I think you are right, that very little productive comes from shouting, and I also agree that dr. Hickey to a certain degree misrepresents or exaggerates your points from the first post. But – and this is perhaps the most interesting to concentrate on – there is also something about your original claim (that some mental issues ‘looks like biological dysfunction’) which really isn’t that apparent unless you implicitly assume this from the outset.

    A person in the grip of psychosis, for example, may say strange things, but if you meet such a person with an – for example – existential or phenomenological frame of reference it is not really apparent, that it looks like a biological dysfunction. Instead it may look like a fellow human being struggling to make sense of the world – in broad terms, of course, but no less broad than the term ‘biological dysfunction’.

    The following passage from your original post also – I think – uses the same way of making something seem obvious although it only is obvious if you agree from the outset:

    “Psychiatric “brain disease” is neither an exaggeration nor a lie. It does not require scientific proof — and brain imaging has neither strengthened nor weakened the case. For as long as one is not a philosophical dualist, it is surely true. In theory, all psychology can be reduced to electrochemical events in brain cells. All psychopathology can be reduced to aberrant electrochemical events, i.e., brain disease.”

    First and foremost this passage eludes the question of the environment. Is all psychology – even in theory – encapsulated in the brain? Mainstream assumptions probably supports this. But no brain has ever existed on its own. Ever. From the second of conception there exists an environment and it is unclear to what extent you can separate the brain from the environment and still talk of having a psychology or a functional brain. But in making the cut between brain and environment this is actually the assumption it implies: that it makes sense to talk of the brain in isolation.

    The second point, I would like to make, is that the monist (physicalist) assumption does not necessarily support that all psychology in theory can be reduced to brain configurations. A monist perspective can also hold that something is irreducible. Examples can fx be found with some thinkers within systems theory, which holds that mind is immanent not in som part of the system but in the system as a whole, including parts of the environment (e.g. Searle, Bateson).

    I hope I have managed to convey my thoughts in a constructive tone – and I commend you for being fair in your ripost to dr. Hickey. It is very valuable to be civil and calm as it also enables more clear-headed thinking on ones own part. And I very much agree with your critique of the tendency to use brain disease-terminology in order to frame psychiatry better. It is a sad and intellectually sloppy tendency.

    Best

    Jonathan
    Psychologist, ph.d.-student

    • Hi Jonathan,

      A claim that someone’s problem “looks like” biological dysfunction requires taking the presentation as a whole, i.e., not focusing on one or two symptoms in isolation. While it is certainly true that a person “saying strange things” may do so for non-biological reasons, that’s not our topic. Schizophrenia is much more: most presentations are largely similar across cultures, usually strike individuals at a characteristic time in life and have a typical time course, include changes in the form of thought as well as its content, have a number of associated neuroanatomical changes, and seem to have partial genetic heritability. Given all this circumstantial evidence, the likelihood that schizophrenia is largely accounted for by biological mechanisms is very high.

      A claim that something “looks like” biological dysfunction also relies on substantial exposure to clear-cut examples (and non-examples) of biological dysfunction. This is an argument from experience, and as such, may feel unfair to you. However, it is my observation that very few people with lots of first-hand exposure to serious mental disorders raise these questions. A priori reasoning only goes so far.

      “Is all psychology – even in theory – encapsulated in the brain?” Psychology is the study of behavior, thoughts, and emotions in a person. Since environment, including other people, greatly influence these things, they are essential factors in psychological study. But the field is about the individual. So yes, in a sense, it’s all in the brain — and even more specifically, in those parts of the brain devoted to behavior, thoughts, and emotions. By analogy, consider pain. The environment may trigger it, but the pain is in the experiencer, not the environment.

      Which brings us to your last point. My own view is epiphenomenalist. I see mind as an emergent property of matter. In that sense it may be a property of “the system as a whole,” but that still leaves open the question of what system. Personally, I do not believe mind exists partly in the environment; the “system,” as I see it, are those parts of the brain where mind and consciousness arise. We may both take comfort in the fact that such questions are safely within the realm of philosophy, and as such we have no means of judging their rightness or wrongness. Best to you as well.

  • Jonathan Led Larsen

    Hi Steven,

    Thanks for your reply 🙂

    Of course you are right, that there is more to schizophrenia than ‘saying strange things’. But I think you beg the question. The research, you indirectly mention, to a large degree also presupposes both that there is a homogenous disease called schizophrenia, it supposes that neuroanatomical changes are the causal root of the disease and it supposes heritability based on research which isn’t really that solid (which usually mentions 80 percent heritability – findings which are definitely not backed up by genetic research on identifiable mechanisms).

    From the WHO research on prevalence in different parts of the world you can either conclude it must be biological (because it looks the same) or that it must be culture-dependent (because the prevalence and severity varies with primarily socioeconomic status). In my opinion it doesn’t make sense to claim it is either-or – or that biology can be reduced to sociology or psychology or any other way around.

    I’m not sure I can follow what you are writing about experience. My 10 years working with patients on the schizophrenia spectrum haven’t left me with that impression. On the other hand, actually, it has left me with the impression, that mental health professionals, doctors, nurses, social workers, psychologists, move in and out of different interpretative positions – and that – often – the less they know an individual the more they fluctuate towards biological reductionism. Perhaps this is what you mean: That the more ‘alien’ something seems, the more we tend to reach for a biological frame of reference?

    With regards to psychology as an individual science this is surely one very narrow interpretation. Most interesting psychology I know of, recognizes that psychology is at its base interpersonal. Interpersonal factors – to follow your example of pain – can through culture change the very meaning of basic biological functions. In rituals, for example, pain is sometimes sought out for its spiritual connotations, and have probably played a significant role in the survival of our species through the ages.To what degree you can talk of a ritual as residing in one skull… well I’m doubtful it would catch all the nuances.

    My point isn’t that biology does not play a role in mental suffering/disorder/diseases/experience – of course it does. What I’m advocating is that it is much more complex than biology and that questions of causality and etiology are still very much unanswered.

    It still seems unwarranted to claim biological reductionism as self-evident – although it probably would be preferable if it where that simple. Instead we are stuck with figuring out an extremely complex web of interacting systems and levels which – not least – involves a lot of futile infight between far too compartmentalized scientific fields.

    Best 🙂
    Jonathan

    • In my original post I said the evidence suggests that schizophrenia is fundamentally biological. The whole point was to set up a straw man, which I immediately attacked as mere appearance, not proof. Yet you (and Dr. Hickey) endeavor to disprove something I wasn’t trying to prove in the first place. I gave my reasons for thinking as I do — natural history, heritability, etc. Naturally, you’re free to look at the same evidence and come to another impression. However, please note that “prevalence and severity varies with primarily socioeconomic status” applies very well to tuberculosis (TB) too.

      Is it meaningful to talk about biological disease when environment nearly always factors in? To paraphrase, it isn’t that Mycobacterium tuberculosis doesn’t play a role — of course it does. However, TB is much more complex than biology: public health and sociological factors are relevant too. Even as I take your point, I submit that the study of TB as a biological disease is not a fallacy or malignant reductionism. It’s just one lens that enjoys prominence thanks to its usefulness. TB can also be studied sociologically without ever mentioning the microorganism. Likewise, if we discover that schizophrenia arises in the presence of a particular set of genes (or intrauterine toxins, or whatever), we’ll presumably grant it the same ontological status as tuberculosis. Why wouldn’t we?

      I’m genuinely surprised that your ten years of working with patients on the schizophrenia spectrum gives you the impression that a biological frame of reference fades with familiarity. (Of course, I won’t say biological reductionism, as that’s your gloss, not mine). Perhaps this has to do with the word “spectrum” and that you are apparently commenting from Denmark. Historically, diagnosis of schizophrenia has varied from country to country, the definition being looser in the USSR than the US, for instance. In any case, that has not been my personal experience, nor that of other psychiatrists or psychologists I know. While it’s true that the most severe, “medical-appearing” presentations are in emergency departments and acute inpatient units, i.e., short-term stays, I have also worked long-term with such patients in my office. I get to know them as people with unique histories and life stories. In doing so, both they and I see that they are not their diagnosis. Time differentiates the person from the disease, so to speak. It’s much the same as in the rest of medicine.

      Psychology studies individuals. I disagree that this is a “very narrow interpretation,” it’s what the word means. Of course psychology includes interpersonal factors; we are fundamentally social creatures. Yet it can be contrasted with sociology, which studies the emergent properties of groups, not individuals. E.g., rituals and culture are usually viewed sociologically or anthropologically, i.e., at the group level — unless we are talking about idiosyncratic rituals limited to one person, in which case we are back to psychology.

      You seem to have fallen into calling my viewpoint biological reductionism. I wish you wouldn’t, since that’s a clear mischaracterization. As I’ve said all along, new properties emerge at higher levels of systemic organization; there is no psychology at the cellular level. There is likewise no sociology at the individual level, so in a way I think I’m being less reductionistic than you are. Cheers.

  • Matty H.

    Have you heard of this interesting research:

    http://news.stanford.edu/2014/07/16/voices-culture-luhrmann-071614/

    ‘Stanford anthropologist Tanya Luhrmann found that voice-hearing experiences of people with serious psychotic disorders are shaped by local culture – in the United States, the voices are harsh and threatening; in Africa and India, they are more benign and playful. This may have clinical implications for how to treat people with schizophrenia, she suggests.’

  • Just stumbled across this article and am very impressed. I have bipolar disorder and don’t care WHY I have a serious mental illness – I only care about how I can minimize the damage. I’m a member of the MIA community and a fan of Phil Hickey (and Joel Hassman). You won’t get any shouting match from me.

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