個人擔任醫學系的教學推動人，每年近200位來精神科實習的醫學生，有直接或間接的接觸和指導，有些學生很有想法，對精神醫學的診斷和治療有深入的批判和挑戰。他們並不討人喜歡，有時還認同病人的病理狀態；各位知道他們的老師會如何因應？如何指導？他們離開精神科的時候有沒有帶著質疑或受傷的心態？他們未來會成為醫師後，會不會對精神醫學有偏見或負面的影響？
再看看專科醫師養成的訓練過程。如果精神診斷會談給人一種感受（錯覺），就是「汲汲於收集詢問症狀，來符合臨床診斷，忽略社會心理及精神病理學的探究」、「對藥物治療頭頭是道，心理社會問題不甚關心，甚至不屑一提…」，那麼我們的專科教育養成和評核的過程，是不是仍有討論的空間？如果「學術活動的內容，明顯的導向藥物的推銷和特定藥物治療成功的個別案例」，那麼我們在利益衝突的規範上，是否仍有加強的空間？
1.
質疑（是醫學進步的原動力）：
l 嚴格的人權檢驗：倫理及人權的考慮複雜且主觀。面對嚴重精神病人對個人或社會的危險、精神醫學治療上的強制保護、限制自主，無可避免要接受人權上的檢驗。
l 主觀成見：所有人不管是內行或外行，都自有一套對精神疾病的成因的看法，多數人心中對精神治療都有不同程度的懷疑（民眾在內外科疾病方面，比較不會有這類主觀的偏見）。
l 病人及家屬常缺乏病識感、承受貼標籤及病恥感的壓力。
l 醫學極限：儘管現代精神醫學突飛猛進，但在診斷、治療及預後的預測上仍有相當的不確定性；精神專科醫師的訓練，常缺乏對於科學文獻結果有深入的解讀，有時甚至受到藥廠的學術活動誤導；就連精神醫療專業人士，也多多少少對精神疾病的診斷和治療有不同程度的保留。
l 因應一：我們應思考：精神醫學的專科訓練內容，是否已經跟不上二十一世紀的腳步？精神醫學的訓練在醫學極限和人權檢驗的標準上，要如何更加「系統性地」在訓練計畫中強調「思辨」的過程？在診斷上如何強調「病理學的探索而非制式的DSM症狀會談」？在治療上如何強調整合性的全人治療？在實務上要如何避免「自陷於健保給付的規定或制式的治療準則」？
l 因應二：面對精神醫學本身局限的批判和質疑，精神醫學界要用謙卑的態度去接受並檢討改善（勿自我膨脹）。也應思考以積極的態度去改善；投入政治，協助學會善用政治的力量來導正政策和修法；此外，站在科學的立場，挑戰的力量愈大，進步的驅力也愈強，這是科學家所樂見挑戰，精神醫學的尊嚴，終究還是建立在紮實的臨床貢獻和嚴謹的研究實証。。
2.
反對：
l 反（精神）醫學人士有一部分是本人或親友就醫受過創傷者，即使他們的訴求並不一定理性，但他們的情緒強烈，且親身經驗常常具有說服力。
l 立法委員、明星、醫師、宗教、人道或人權狂熱份子對醫學的偏執或誤解。例如John Travolta及 Tom Cruise，利用其娛樂天分產生的高知名度，大談「反精神醫療」，造成民眾「拒醫、懼醫和仇醫」，影響之深，難以想像。
l 因應一：面對無知和偏見，精神醫學界應該站在保護病患及家屬的的立場，針對錯誤的精神醫學資訊和反精神醫學言論發表正式的澄清、聲明和譴責。為了讓力量集中起來，建議學會可以整理散發各處的相關的澄清、聲明和譴責，正式公告在「精神醫學會官網專區」，提供民眾、會員、團體和媒體，直接、方便地「引用或轉貼」來自官方的訊息，避免病患和家屬受到錯誤訊息的傷害。
l 因應二：為了減少過度診斷、執業不當、過度促銷特定治療、或違反利益衝突規範的不當行為，醫界要有自我監督的機轉，公開譴責或處罰執業不當及違反利益衝突規範的同僚。然而，面對界限模糊的議題，落實公開譴責或處罰的關鍵在於能不能推動「醫療除罪化」，讓醫師願意檢驗同儕或接受同儕的檢驗，以提早輔導專業技能不足或缺少畢業後訓練的醫師，以提升醫療品質並重視病患的福祉。
3.
抹黑
l 蓄意利用精神疾病預後的不確定性、以及精神病患和家屬的無助、無望和無知，藉由惡意抹黑精神醫學，他們最終的目的，就是要推銷販售沒有經過科學驗證過的產品或課程，用虛幻的希望去迷惑無助的病患和家屬，牟得私利。這類的抹黑，更容易造成民眾「拒醫、懼醫和仇醫」，直接對病患和家屬造成巨大傷害。
l 例如：「藥物治療控制大腦」、「治療是邪惡和陰謀」、「服用精神藥物導致自殺、暴力、殺人」、「精神科醫師發明診斷，和藥廠共謀大撈一筆」、「醫師為了賺錢才靠開藥害人」、不肖律師套上這種荒謬的「犯罪動機」來興訟。
l 利用「抹黑精神醫學」來牟利者很懂行銷，辦吸引人活動、正向的名稱和親民的宣傳，讓一般民眾先認同、讓衛生單位沒有戒心，再利用質疑及反對精神醫學的「立法委員、明星、醫師(含精神科)、宗教、人道或人權狂熱份子」，來進行抹黑和隱性推銷。
l 因應一：（一）對於不當執業或惡意抹黑的精神專科醫師，學會為了病患的權益，應加以制裁，惟介入應採嚴謹及「無罪認定」原則。「經會員提供証據並提案，由理監事（或專案委員會）討論後，確定不當執業事証屬實，顯見造成病患或家屬之傷害，學會透過官方途徑，「發新聞稿，註明不當執業者本名，說明不當執業之內容和本會停權的緣由」，以保護病人。（二）對於不當執業或惡意抹黑者不是精神專科醫師，學會並沒有警告、糾正或懲處的權責時，「為了保護患者，學會鼓勵會員提供証據並提案，由理監事（或專案委員會）討論後，確定不當執業及毀謗的事証屬實，顯見造成病患或家屬之傷害，學會透過官方途徑，發新聞稿、註明當事人本名，並說明不當執業和毀謗的內容，同時函請主管機關（例如衛福部及該員所屬之醫學會），於學會官網追蹤並公告主管機關的回覆和處置」。
l 因應二：（一）精神科專科醫師訓練必須跟上時代，了解「質疑、反對、抹黑精神醫學」者之動機，關於山達基教派及其分支（如無毒世界基金會或公民人權委員會）之反精神醫學影片，應列為專科訓練之必修課程（如附），了解病患可能獲得的錯誤資訊，減少這些反精神醫學言論、抹黑所造成的傷害。（二）山達基教派及其分支經常在校園或機關中舉辦反精神醫療之活動，精神醫學會站在保護病患及家屬的的立場，應針對其謬誤言論發表正式的澄清、聲明和譴責。「學會應透過官方途徑，發新聞稿、詳細說明山達基和其協會不當毀謗的內容及對病患或家屬之可能傷害，同時函請主管機關（例如衛福部、教育部及主辦之大專院校），並於學會官網追蹤並公告主管機關的處理和回應方式」。（三）對於尚未開展或舉辦之活動或展覽（例如他們「精神醫學是死亡工業」的活動都會先到校園去宣傳），網路已有這些一再重複的展覽的影片和手冊，學會可以事先整理，在該活動舉辦之前，函請主管機關（例如衛福部、教育部及主辦之大專院校）。主辦單位或因來自學會或教育部的壓力願意停辦，就能達到先行預防的效果；若主辦單位無所做為，亦可以在學會官網追蹤並公告主管機關和主辦單位的處理和回應（一但有制式的處理流程，祕書處直接就能處理，不至於太麻煩）。
結語：醫學有其極限，醫師根據目前最好的實証來照顧病患，視病猶親。換個角度想想，如果認為「癌症治療不夠有效、副作用太大、對治療有偏見」，經詳細說明後仍拒絕治療，個人的意願或許應該被尊重。然而，如果因個人偏見去抹黑所有腫瘤科醫師「發明疾病，和藥廠共謀大撈一筆」、「醫師為了賺錢才靠開有副作用的藥來害人」，造成癌症患者延誤治療、放棄治療、不敢治療，直接對病患和家屬造成巨大傷害，那麼醫學會就應該要提供民眾對等的訊息，導正謠言。更惡劣的是，抹黑的動機是出自「販賣未經過科學驗證過的抗癌產品來獲利」，那麼「政府和衛生單位」要有能力保護民眾，否則病患只能任人宰割。
參考資訊：
- Wikipedia：http://zh.wikipedia.org/wiki/山達基
- HBO紀錄片：Going Clear: Scientology and the Prison of Belief (By Owen Gleiberman) https://youtu.be/kL2Tn-2qANU
- HBO紀錄片：揭露山達基控制名人內幕 http://www.cw.com.tw/article/article.action?id=5066390
- 山達基信仰之牢籠 http://scientology-chinese.com/blog/post/30778015
- 山達基抹黑精神醫學影片：精神科藥物未公開過的真相 - 紀錄片（全）https://www.youtube.com/watch?v=X2haip0_y34
- 山達基抹黑精神醫學影片：精神醫學：致命工業 - 紀錄片（全）https://www.youtube.com/watch?v=LDnbvurw7Ws
- BBC報導原文：http://www.bbc.com/culture/story/20150320-a-scary-must-see-scientology-doc
- Fox News Video about HBO's 'Going Clear' exposes secrets of Scientology https://www.youtube.com/watch?v=gMGT7Y1Z0zw
- The APA president and Chairman of Psychiatry at the Columbia University, Dr Jeffrey Lieberman, comments on “Should Celebrities Speak Out About Illness?” http://www.medscape.com/viewarticle/841049
- http://ccascientology.blogspot.tw/2009/08/blog-post_2039.html
- https://www.youtube.com/watch?v=suTFsLF-wxY
HBO紀錄片 揭露山達基控制名人內幕
ReplyDelete精華簡文HBO紀錄片 揭露山達基控制名人內幕
天下編輯部 2015-04-01
https://www.cw.com.tw/article/article.action?id=5066390
https://youtu.be/kL2Tn-2qANU
HBO29日晚上播出的一部紀錄片，指稱山達基控制阿湯哥和約翰屈服塔，包括逼迫阿湯哥和妮可基曼離婚、約翰屈伏塔擔心事業下滑，不敢離開山達基等等，宛如電影情節。
這部紀錄片讓人一窺神秘的山達基教派，但也對擁有不少山達基名人信徒的好萊塢投下威力十足的震撼彈。
山達基*已經全面發動宣傳反擊這部紀錄片已，而HBO則雇用160名律師嚴陣以待。
HBO在29日晚間在美國首播的記錄片「揭開山達基教和信仰監獄」(Going Clear: Scientology and the Prison of Belief)，這部紀錄片是奧斯卡獎得主吉布尼（Alex Gibney），依據普立茲獎得主萊特（LawrenceWright）的著作所拍攝。
紀錄片訪問成功脫離山達基的教友和幹部，透露這個組織的神祕內幕，包括顧私家偵探調查呢可基嫚，竊聽她的電話，逼迫阿湯哥和妮可離婚，因為妮可的父親是山達基痛恨的心理學家。山達基並有專人負責離間妮可和阿湯哥的孩子與妮可的關係。
片中指稱，阿湯哥與妮可離婚的新女友，也是山達基安排的，這位名叫波尼亞迪(Nazanin Boniadi)的電視女星在成功擄獲阿湯哥的心之後，又因為阿湯哥認為她不夠尊敬山達基領袖，被阿湯哥趕走，結果被山達基處罰用牙刷洗廁所。
片中也指約翰屈伏塔因為事業不順接觸山達基，結果入會之後事業一帆風順，因為擔心退出會導致事業受挫，同時山達基握有他一些不可告人的秘密，因此屈伏塔始終不敢退出。
*山達基（英語：Scientology）：
此教派是由L·羅恩·賀伯特(L. Ron Hubbard)所創立，作風神秘，又有不少好萊塢名人教友，因此備受矚目。但這個教派經常引起爭議，因為退出它的教友都將它描述為邪教，並指稱身心受到虐待，而且靈性服務收費極高。對於這類的指控，山達基一向毫不留情，一定告上法院。
山達基資產和收入雄厚，美國國稅局與其纏鬥數年，最後決定放棄，在1993年把它列為免稅的非營利宗教組織。
以「校園無毒活動」為例子，老實說中醫大中醫學院也辦過幾次，即使在我擔任醫學院副院長時也無權干涉其他學院辦活動 (更惶論我已卸任)。唯有學會函請主管機關（例如衛福部、教育部及主辦之大專院校），以不同程度表達相關的澄清、聲明和譴責，教育部或校方有警力，由上而下或能制止。
ReplyDeleteThis comment has been removed by the author.
ReplyDelete學會去函教育部、衛福部或大學的說明可以如下：「關於山達基教派及其分支（無毒世界基金會或公民人權委員會）在XXX大學主辦的YYY活動，根據過去類似活動之內容，該團體將強烈主張「反醫療」及「反精神醫學」(如附件)，舉例而言，該團隊倡議「藥物治療控制大腦」、「治療是邪惡和陰謀」、「服用精神藥物導致自殺、暴力、殺人」、「精神科醫師發明診斷，和藥廠共謀大撈一筆」、「醫師為了賺錢才靠開藥害人」等，蓄意利用精神疾病預後的不確定性、以及精神病患和家屬的無助、無望和無知，藉由惡意抹黑精神醫學，造成民眾「拒醫、懼醫和仇醫」，直接對病患和家屬造成巨大傷害。
ReplyDelete本會強烈建議主管機關（例如衛福部、教育部及主辦之大專院校）慎重評估，舉辦該活動所造成之嚴重傷害。」
附件：
1. http://zh.wikipedia.org/wiki/山達基
2. 公民人權委員會：https://www.cchr.tw/cchr-reports/citizen-commission-on-human-rights/introduction.html
3. 公民人權委員會反醫療及反精神醫學文宣：
https://www.cchr.tw/videos.html
https://www.cchr.tw/cchr-reports/overview.html
4. 無毒世界基金會：https://www.notodrugs.org.tw
5. 無毒世界基金會反精神醫學醫療文宣：https://www.notodrugs.org.tw/drugfacts-booklets.html
Four Dogmas of Antipsychiatry
ReplyDeleteMay 6, 2022 Ronald W. Pies, MD
https://www.psychiatrictimes.com/view/four-dogmas-of-antipsychiatry
These persistent fallacies have misled the public and undermined treatment of those with psychiatric illnesses.
COMMENTARY
Dedicated to the memory of W.V.O Quine (1908-2000)
In many ways, this is a particularly exciting and fruitful time for psychiatry. In the past decade, psychiatrists have developed 2 new forms of psychotherapy: dynamic deconstructive psychotherapy (DDP), an evidence-based therapy for borderline personality disorder1; and complicated grief therapy (CGT) for patients whose grieving process has become dysfunctional and “derailed.”2 In the somatic treatment realm, recent evidence suggests that ketamine—an N-methyl-D-aspartate (NMDA) receptor blocker—is effective in reducing acute suicidal ideation, perhaps pointing to new molecular mechanisms in antidepressant treatment.3 Meanwhile, data on psychiatry residency matching shows that an increasing number of medical school graduates are being drawn to psychiatry.4
All this is good news. The not-so-good news is that psychiatry continues to be attacked and disparaged by a loosely organized movement usually referred to as “antipsychiatry,” comprehensively reviewed by Rob Whitley, PhD.5 In addition, the movement known as “critical psychiatry” has emerged over the past 2 decades, and—in principle, if not in practice—is distinct from antipsychiatry. As psychiatrist D.B. Double, MD, has noted, critical psychiatry encourages the integration of mind and body, and argues that “minds are enabled but not reducible to brains” and that “mental disorders show through the brain but not necessarily in the brain.”6 More broadly, there are many responsible critics of psychiatry—both within and outside the profession—whose aim is, so to speak, to “build a better psychiatry” rather than to disparage, undermine, and ultimately destroy it. The latter is arguably the main goal of antipsychiatry.
Many of the guests interviewed on these pages in Awais Aftab, MD’s, excellent column7 could be considered exemplars of “critical psychiatry.” As my Tufts colleague, Daniel Morehead, MD, has argued, our aim as a profession should not be to “squelch” responsible critics of psychiatry, but rather “…to defend and affirm the ethical, practical, and scientific legitimacy of what we do as psychiatrists.”8
One component of defending psychiatry involves clearing away the acres of conceptual underbrush that have fueled so many of antipsychiatry’s rhetorical fires. This has been a central preoccupation of mine since at least 1979, when I was still a resident and engaged in a polite but impassioned debate with the late Thomas Szasz, MD—perhaps the world’s most famous critic of psychiatry and a teacher of mine at SUNY Upstate Medical University.9 Since then, along with my Tufts colleagues—Morehead and Mark Ruffalo, MSW, DPsa—I have tried to debunk a number of fallacious arguments and claims proffered by various antipsychiatry clinicians, groups, and bloggers.10-13 (Some of these claims overlap with those of critical psychiatry, but, in my view, they stem from quite different motivations.) The remainder of this article is aimed at debunking 4 “dogmas” of antipsychiatry, with a respectful nod to the analytic philosopher W.V.O. Quine, author of the groundbreaking essay Two Dogmas of Empiricism.14
Four Dogmas of Antipsychiatry
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Four Dogmas of Antipsychiatry
1. The essential definition dogma (“narrow materialism”)
A bit of background is needed to understand this dogma. In the philosophy of language, an essential definition is one that specifies the necessary and sufficient conditions for a particular idea or entity—in other words, the “essence” of the thing. So, an essential definition of a triangle would be “a 3-sided geometrical figure.” It is obviously much harder to come up with an essential definition of, say, justice or liberty. Indeed, the philosopher Ludwig Wittgenstein (1889-1951) famously argued that most words in common use do not have essential definitions; rather, the meaning of a word depends on its use in various contexts or “language games.” Moreover, “…things which could be thought to be connected by 1 essential common feature may in fact be connected by a series of overlapping similarities, where no 1 feature is common to all of the things. He [termed] this concept family resemblance.”15
Now, what does all this have to do with disease and antipsychiatry? Simply put, the Szaszian strain of antipsychiatry implicitly asserts that there is an essential definition of disease (or illness—Szasz uses the terms more or less synonymously). For Szasz, the necessary and sufficient (essential) condition for the ascription of disease is the demonstrable presence of some bodily abnormality, either anatomical or physiological. As he put it in a recent update of The Myth of Mental Illness, we are obliged to accept “…the pathologist’s materialist-scientific definition of illness as the structural or functional alteration of cells, tissues, and organs.”16 It follows, of course, that for Szasz, there could be no “mental” illness, which he regarded as merely a metaphor or a myth.
The problem with this vaunted “materialist-scientific definition of illness” is that it must compete with many other conceptions and definitions of illness and disease, including ones based on the presence of substantial suffering and incapacity—the “overlapping similarity” that connects many, if not most, conditions we call serious diseases or illnesses.9 In contrast, as Morehead pointed out to me (email communication, April 23, 2022), Szasz’s definition of disease could be considered a “narrow materialist” position—what I call the “lumps and bumps” model of disease.
And yet, as I noted 40 years ago, “There has never been a single set of criteria for the ascription of disease,”9 and the definition remains ambiguous and contested to this day. This was vividly demonstrated when the American Medical Association, in its deliberations on obesity, requested an advisory opinion from its Council on Science and Public Health. The question before the council was, “Is obesity a disease?” The council’s considered response was a lesson in both the limits of language and the merits of humility: “Without a single, clear, authoritative, and widely accepted definition of disease, it is difficult to determine conclusively whether or not obesity is a medical disease state.”17,18 Finally, consider this remarkably expansive concept of disease in no less a source than Harrison’s Principles of Internal Medicine (8th ed.)19:
“The clinical method has as its object the collection of accurate data concerning all the diseases to which human beings are subject; namely, all conditions that limit life in its powers, enjoyment, and duration.”
Four Dogmas of Antipsychiatry
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2. The diagnostic causality dogma (“self-validating diagnosis”)
This antipsychiatry dogma seems to be quite fashionable in recent years, both as a criticism of the DSM disorder categories and of psychiatry in general. In brief, this dogma holds that any legitimate, scientifically based set of disease criteria must be grounded in causation or etiology—and not consist merely of signs or symptoms that both define the disorder and purport to explain it. Critics allege that the current mode of (DSM) psychiatric classification amounts to a kind of circular argument or self-validating claim (eg, “We know this patient’s hallucinations are due to schizophrenia, and we know she has schizophrenia because she fulfills the DSM’s symptomatic criteria for schizophrenia”). In effect, the critics’ claim is that psychiatric diagnoses, unlike medical diagnoses, are merely descriptive, not explanatory.20
Put another way, this dogma holds that (1) if the DSM diagnostic criteria for disorder X do not address the cause or etiology of disorder X; then, perforce (2) condition X cannot justifiably be considered a cause of the patient’s problem.20 Ruffalo and I have dissected this fallacious argument in detail,20 and I will merely summarize our analysis here. In brief, disease categories—more accurately, the real-world conditions to which they point—can have causal efficacy (be the cause of something) without themselves having a known cause. And, no—this does not amount to a circular argument.
Here is a rough analogy. Suppose we have devised a list of signs that compose our criteria for an earthquake—for example, “ground trembling,” “buildings shaking,” “loud rumbling,” etc. We need not know the actual cause of earthquakes (such as shifting of tectonic plates) to make the claim, “The apartment building collapsed because of the earthquake.” By the same token, we are justified in saying, for example, “John’s command auditory hallucinations are caused by his having schizophrenia” (per DSM-5 criteria) without knowing the underlying cause(s) of schizophrenia—provided we can tether the term schizophrenia to external validators, like course of illness, predictive validity, response to treatment, neuroimaging studies, etc.
Of course, this is only a provisional claim, subject to empirical falsification. We may find, for example, that John’s hallucinations are actually caused by a traumatic experience or by complex partial seizures. Similarly, we may not know the cause of schizophrenia, but we can still say provisionally—and without courting circularity—that schizophrenia is the cause of John’s suffering and incapacity.
That said, as Aftab has pointed out to me (email communication, April 24, 2022), there is a risk of “reifying” our diagnostic categories and imputing more causal explanatory power to them than they merit. This is certainly true of very heterogeneous and nebulous diagnoses, such as major depressive disorder. And, of course, ideally, all medical diagnostic categories would be based on causal explanations—that, after all, is the royal road to successful treatment. But the history of medical practice is replete with examples of syndromes the precise causes of which have remained a mystery for decades, even to the present day (eg, incapacitating headaches known as trigeminal autonomic cephalalgias).13 As Morehead has rightly observed, “We can know that an illness is medically and biologically real without knowing the specific cause or pathophysiology of that illness.”21
Four Dogmas of Antipsychiatry
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3. The “social construction” dogma
The notion that psychiatric disease categories are merely “socially constructed” has become a widely disseminated claim in antipsychiatry circles, although the idea is not confined to antipsychiatry. By “socially constructed,” some critics of psychiatry want to claim that psychiatric disorders have no independent reality, apart from the subjective musings of psychiatrists—in contrast, say, to cancer and tertiary syphilis, which are held to be real diseases.
To back up a bit: The concept of social construction dates back to the 1960s and is described by social scientist Chitvan Trivedi as follows: “We do not find or discover knowledge or reality so much as we construct it. For example, we invent concepts, schemes, models, etc, to make sense of our experiences and we keep refining them as we gain more experience.”22
Now, there is a limited sense in which psychiatry’s critics are right. If they want to claim that psychiatric disease categories are created through a process of consensual human decision-making—and are not preexisting, physical structures in the natural world—I have no quarrel with that. But the same can be said for literally all medical disease categories. Hence, the social constructionist critique of psychiatry has very little cash value (to use William James’s term) as critiques go.
Take the example of cancer: It might be argued that when a pathologist looks through a microscope and identifies cancer cells, he or she is identifying a natural kind that exists in nature, independent of human cognition, opinion, and social construction. But this is simply wrong. The designation cancer cell is the socially constructed product of intense human discussion, debate, and medical conventions. Indeed, there is often intense disagreement among oncologists and pathologists regarding what should or should not count as cancer. For example, ductal carcinoma in situ (DCIS) is regarded as cancer by some but not all oncologists, with the result that “…women with DCIS are labelled as ‘cancer patients,’ with concomitant anxiety and negative impact on their lives, despite the fact that most DCIS lesions will probably never progress to invasive breast cancer.”23
But there is a more crucial point to make regarding social construction and psychiatric disease. As clinical psychologist Hew Green, PhD, has put it24:
“…although we can still say that schizophrenia is socially constructed, we remain nonetheless able to entertain the possibility that there is a distinct neurocognitive ‘disorder’ in the organism towards which this construct is legitimately trying to point. The definition given in the DSM, which has changed in various ways over the years, is very obviously constructed; a definition after all is just a verbal attempt to capture some state of affairs in the world. Meanwhile, the reality (the ‘state of affairs’ itself) is something ‘out there’ beyond language and is not ‘constructed’ in the sense we are interested in here.”
Another way of putting the matter: The DSM diagnostic criteria for schizophrenia—like all medical categories—are indeed socially constructed. But the immense suffering and incapacity caused by the disease of schizophrenia is very, very real.
Four Dogmas of Antipsychiatry
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4. The “objectivity” dogma
In a sense, this dogma is another way of framing the social construction claim. The traditional position of antipsychiatry is that, unlike “real” medical specialties that have objective criteria for their disease categories, psychiatry is based solely on the subjective reports (ie, symptoms) of its patients and the equally subjective judgments of psychiatrists. As 1 psychiatrist known for strong criticism of psychiatric diagnosis has put it, “…the criteria for [psychiatric] diagnoses are arrived at by subjective judgments rather than objective evidence…” Specifically,25
“The diagnoses listed in the major psychiatric diagnostic manuals have not yet been linked with any sort of physical test or other biological marker (apart from the dementias), and so, unlike the rest of medicine, psychiatric diagnoses do not have pathophysiological correlates and no independent data is available to the diagnostician to support their subjective assessment of diagnosis…”
There are several fallacies and confusions in this line of argument. In brief: (1) The term objective is never defined in the article; (2) the term objective evidence is falsely conflated and identified with physical test[s] or other biological marker[s] that represent only 1 type of objective evidence; (3) the claim that “no independent data is available” to the psychiatric diagnostician is patently false; and (4) there are many well-established pathophysiological correlates linked with the most serious psychiatric disorders, such as schizophrenia and bipolar disorder (correlation, of course, is not causation).
Each of these rejoinders would take a good deal of space to unpack, but the key points are as follows:
1. The definition of objective is itself contested—arguably, even socially constructed—and is the focus of considerable debate among philosophers of science. Indeed, “The prospects for a science providing a non-perspectival ‘view from nowhere’ or for proceeding in a way uninformed by human goals and values are fairly slim…”26
2. To the limited extent we can define objective, 1 measure of objectivity is interrater reliability, termed kappa. The higher the kappa, the more reliable the observation. The kappa for several major psychiatric disorders (though not all) compares favorably with kappas in several other medical specialties (eg, 0.53 for ischemic stroke versus 0.76 for bipolar disorder, depending on which DSM criteria are used).27
3. By most definitions, objective evidence is not limited to lab tests and biomarkers. As psychiatrists, we carry out detailed mental status exams; perform limited neurological exams; interview family members; evaluate school records; and order a variety of ancillary studies, such as neuropsychological testing. All these modalities can provide objective evidence of disease, as can the vegetative signs we look for, such as weight loss and early morning awakening.
4. In performing a differential diagnosis, psychiatrists routinely obtain laboratory studies, brain imaging, and other independent data. As psychiatrist Nathaniel P. Morris, MD, notes, “We use objective tests all the time to evaluate patients with mental illness… we use blood work and imaging every day to evaluate patients with symptoms of mental illness. A vegan suffering from crippling depression might have B12 deficiency, while a patient who abuses IV drugs with progressive delusions and aggression could have HIV encephalopathy.”28
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5. There are literally hundreds of studies demonstrating pathophysiological correlates of schizophrenia, bipolar disorder, obsessive-compulsive disorder, and other psychiatric diseases. Although these findings may not point to causation, they are comparable to correlates in other areas of medicine. For example, enlargement of brain ventricles represents one of the most robust and consistent findings in schizophrenia and is likely related to neurodevelopmental and/or neurodegenerative causes.29
But to be clear: The finding of a specific biological abnormality is neither necessary nor sufficient for a condition validly to be deemed a disease. A putative disease’s validity is established through a painstaking, iterative process that compiles data on familial/genetic pattern; stability of diagnosis over time; course of illness; response to treatment; and many other validators.30,31 As the late Bernard J. Carroll, MD, observed, “…biomarkers are not an automatic gold standard of evidence for diagnostic validity…Laboratory measures are the servants of clinical science, not the other way around.”31
Concluding Thoughts
The medical discipline of psychiatry is still a work in progress. Despite many advances in the past 50 years, we continue to rely on a diagnostic framework that lacks a comprehensive, biopsychosocial foundation, and clear implications for treatment. Criticisms of psychiatry aimed at ameliorating these shortcomings should be met with open-minded appreciation. But antipsychiatry’s fallacious and baseless attacks are aimed at delegitimizing and ultimately destroying psychiatry. We need to push back forcefully against the 4 dogmas discussed in this article, while also attending closely to psychiatry’s responsible critics—and most of all, attending to the urgent needs of our patients.
Dr Pies is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of Psychiatric Times™ (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on Amazon.
Acknowledgement: The author wishes to thank Drs Mark Ruffalo, Daniel Morehead, and Awais Aftab for their thoughtful comments and careful reading of an earlier draft of this article. For more on the complexities of “causality” in psychiatry, please see these 2 blogs from Dr Aftab:
Can Symptoms Be Caused by Descriptive Syndromes? An Analysis
An Exchange with Ruffalo & Pies: More on Diagnosis & Diagnostic Explanation
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Four Dogmas of Antipsychiatry
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https://www.psychiatrictimes.com/view/four-dogmas-of-antipsychiatry
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Four Dogmas of Antipsychiatry
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