Conceptual understanding of psychiatric diagnosis

As I said in my last post, a paper that has been influencing the Future DSM Strategic Committee has been Hyman (2021). The abstract concludes that "scientific results demonstrate that psychiatric disorders cannot reasonably be understood as discrete categories—and certainly not as natural kinds".

Hyman reaches conclusions with strong implications for current psychiatric diagnostic systems, such as DSM. For example, he states that "The currently predominant categorical nosologies are fundamentally in error and are damaging to science". He sees psychiatric and neurological disorders as "groupings of disorders that exhibit some internal scientific and clinical coherence, but also have changing and permeable boundaries that are negotiated by interested professional groups". His argument is primarily against seeing any distinctions between disorders and non-disorders and between disorders as categorical in nature. To summarise in another quote:-

If by natural kinds we mean categories of things existing in nature that are well bounded and have stable, cohesive causal structures, as is the case for chemical elements, then the poorly bounded, etiologically and pathophysiologically complex psychiatric disorders are something else entirely. 

For me, Hyman, and the Future DSM Strategic Committee in general, could go further in their conceptual understanding of psychiatric diagnosis. They still seem to be too enamoured of the possibilities for "localising the mind" in the brain. Despite the lack of evidence for biomedical markers of mental illness, psychiatry remains paradigmatically committed to the idea that mental functions must be localised in the brain in some way (see eg. previous post). Of course the brain is the vehicle for meaningful experiences, such as functional mental illness. But the brain does not create meaning; it is people as a whole that do that. 

In particular, a new DSM needs to re-create the distinction between functional and organic psychosis, which was present in DSM-I, and was abolished by DSM-IV (see previous post). I am not arguing for Cartesian dualism, splitting the mind from the brain (see eg. another previous post). Mind and body are integrated in the organism. People are animate, embodied beings. But what needs to be made clear is that naturalistic explanations of primary mental illness are inadequate because of the need to take a holistic personalistic perspective of mental health problems. The evidence for the abolition of the distinction between organic and functional mental illness does not exist and the argument for doing so by DSM-IV was flawed (see yet another previous post).

Related to this, I suspect Hyman still wants to hold on to the idea that primary mental illness will be shown to have biological aspects to its causation. Of course there's a tautological sense in which this is true, because the brain is necessary to mediate mental illness. But in the same way as we can't, or at least shouldn't, talk about our 'normal' thoughts, emotions and behaviour as being caused by the brain as such, nor should functional mental illness be described in those terms. The whole organism is the condition of its parts, and is in turn realised by them. We may be able to understand some of the reasons for functional mental illness, but these cannot be proven in a natural scientific way (see eg. previous post). We can only hope to understand formative causal influences, not efficient causes (see eg. another previous post). By contrast, brain pathology is a necessary cause of organic mental illness, such as dementia or delirium.

It's unclear to be what the next stage of the DSM review process will be, but as I've always said, proper conceptual foundations for understanding psychiatric diagnosis are needed before progress can be made.

Whither DSM?

Scientific American reports that the American Psychiatric Association (APA) is optimistic that “DSM [Diagnostic and Statistical Manual] can be retooled to become more scientific” (see article). Maybe because of the current DSM-5, people may assume that APA means ‘scientific’ in the sense of natural scientific, implying that a biological cause of primary mental illness will be found. But the press release comes across as, at least potentially, more open-minded. And ‘scientific’ can be defined more in terms of the application of rigour to analysing data (see eg. previous post) than implying a positivistic understanding of mental illness. Science doesn’t have to be reduced to physics and chemistry or mere empiricism. It can make sense to say that psychiatry should be more scientific (see eg. another previous post). There is, in fact, a need to move away from so much of the pseudoscience of biomedical psychiatry (see eg. yet another previous post). A key paper influencing the Future DSM Strategic Committee is by Steven Hyman (2021), a former National Institute of Mental Health (NIMH) director and DSM-5 Task Force member, which makes the case that psychiatric disorders are not natural kinds (see eg. previous post).

DSM-5 failed because of its misdirected aspirations (see eg. previous post). The current DSM review committee has to accommodate a range of different views. But there are some hopeful signs in its paper on the ‘Initial strategy for the Future of DSM’. One of its four subcommittees is the Socioeconomic, Cultural, and Environmental Determinants of Mental Health Subcommittee, which the paper admits 

fills a gap in DSM given that despite the influence of socioeconomic, cultural, and environmental determinants of mental health on the development, progression, and treatment of mental disorders, they are not adequately addressed in DSM or in other psychiatric nosologies.

The overall committee also wants to avoid the problem of reification of psychiatric disorders (see eg. previous post). The idea of embracing “biology and environment and their interactions as key determinants of mental disorders” is said to be under consideration. The committee wants to find a pragmatic solution to psychiatric diagnosis “without abandoning the whole effort or eschewing improving current nosology”. Let’s see how this process develops.

I may be being overoptimistic about the initial publication of the Future DSM Strategic Committee. DSM may never properly incorporate the uncertainty of psychiatry. It may find it difficult to accommodate the inevitable unreliability of psychiatric diagnosis, considering the historical motivation of DSM-III to increase reliability (see eg. previous post). Psychiatric assessment has always been about differential diagnosis and aetiology, rather than a single diagnosis, often seen as having implied biological causes. I’ve never been one for wanting to completely abandon psychiatric diagnosis but modern psychiatry does overvalue it, particularly when it takes a biomedical approach (see eg. previous post and my 2002 article).

Is critical psychiatry creating its own myths?

I’ve just watched Joanna Moncrieff being interviewed on It’s your life with James “JC” Cooley” (see video), one of several video podcasts to which she has contributed. She says that antidepressants numb people, which may initially be helpful, but cannot be a long term solution because they may prevent people being “tuned into what they need to do to feel better”. She talks as if the numbing is a physiological effect, but I think it is more likely to be the result of a placebo reaction (see eg. previous post). Any apparent benefit of antidepressants because of a placebo reaction may not last, or may diminish over time, and/or cause a nocebo effect, such as emotional numbing because people do not think their psychosocial problems have really been dealt with. 

I’ve expressed concern before about how social media can misrepresent the truth about psychiatry (see eg. previous post). Video podcasts may be helpful in promoting personal perspectives, such as Jo’s, but there are not necessarily the same checks on transmitted information as more traditional forms of communication. As far as I know, Jo cannot point to any academic reference to support SSRI antidepressants being pharmacologically emotionally numbing, In fact SSRIs were introduced partly because they tended to be less sedative than tricyclics, the previous generation of antidepressants. I’m not of course saying that patients do not complain of emotional numbing with antidepressants, particularly over the longer term; the argument is about the mechanism of this effect. There does seem to be a need for discussion on this issue in the academic medical press.

As I’ve also said several times before, although ideologically I am close to Jo, I do worry about her niggling overstatement (see eg. previous post). She makes very clear in the interview on the JC Cooley show that her motivation for change is not necessarily to stop people using antidepressants, but more to ensure they are properly informed to be able to make a decision about them. She also says she’s always had a “rebellious streak”. Misplaced authority should be challenged but the rebel within Jo may need to be tempered by accuracy and truth. It’s important critical/relational psychiatry does not merely replace the myths of biomedical psychiatry with its own myths.

Changing the way the facts of mental health and illness are seen

As I wrote in my book chapter (see extract), "From the beginning, the aim of the Philadelphia Association (PA) was to "change the way the 'facts' of 'mental health' and 'mental illness' are seen" (R. Cooper, 1994). Current activities of PA include the support of their two community houses, a low-cost psychotherapy service and a training programme in psychotherapy and other study programmes and events.

Despite PA’s intentions for change, psychiatry still clings to what is really an outdated view of mental health and illness (see eg. last post). Psychiatry has always hoped that a biological understanding of mental illness as brain abnormality is just round the corner. It does now tend to accept that the pharmacological and neuroscientific emphases of the last 50 or so years has not really progressed practice, but nonetheless refuses to acknowledge that the flaw is its own conceptual foundations.

People have been so indoctrinated into believing that they are their brains that they cannot see the conceptual fallacy in doing so. People’s brains are only part of them, like their other bodily parts. Most mental illness is not caused by faulty brains; it relates more to them as a person as a whole. By thinking of ourselves as machines, we fail to recognise the purposiveness of life.

Will psychiatry ever change?

As Diana and Nikolas Rose wrote in their 2023 Psychological Medicine article (see previous post), psychiatrists tend to see themselves as 

exponents of highly effective, neurobiological based, targeted treatment of brain disorders, like their peers in other biomedical specialities. The leaders of the psychiatric establishment are likely to resist … a reconfiguration of their profession [by giving up such a claim].

This is despite the fact that psychiatric disorders are not dependent on biological pathology, whereas physical diseases are. A purely biological account of primary mental disorder is not possible, but psychiatrists keep hoping one will be found.

It’s depressing to see how much psychiatry is prepared to cling to its outdated understanding of mental illness, which it actually promotes as a major advance, misleading people that there has been real progress (see eg. recent post). As I’ve commonly said (see eg. my editorial), the essential position of critical/relational psychiatry is that functional mental illness should not be reduced to brain disease. Although, of course, all mental disorders involve cerebral processes, despite what psychiatry says, neuroscience is not moving us towards having a biological and genetic understanding of primary mental disorders (see eg. previous post).