The science and pseudoscience of diagnosing mental illness

https://www.nybooks.com/articles/2021/01/14/changing-psychiatrys-mind/

by fortran77 • 6 years ago

38 51 6 years ago

graaben• 6 years ago

If anyone is interested in this topic, I'd highly recommend reading the Book of Woe [0]. Mental health diagnoses have been based on the DSM for nearly 75 years, however it's an extremely flawed book to say the least. The creation of each version has also been a very contentious and political process, leading to major influence from pharmaceutical companies and others with financial motives.

The problem with mental health diagnostics though is that there really is no good alternative yet, so for the foreseeable future we will be making huge, life altering decisions for people based on what is essentially a subjective judgement call.

[0]https://www.penguinrandomhouse.com/books/310517/the-book-of-...

shimonabi3• 6 years ago

Adam Curtis also explored this topic:

https://www.dailymotion.com/video/x6f1bj

It seems to me that what is "normal" is mostly defined by the political system.

Nav_Panel9• 6 years ago

Yeah, this was one of Foucault's major points, as well as several other "anti-psychiatry" thinkers in the 70s (most notably Thomas Szasz): "mental illness" is always a normative stance, and is incredibly useful politically.

kodachi• 6 years ago

There was a quote I couldn't find that said something like we are fortunate that millions of people share our same delusions/world-view that us and that kept us from the asylum.

zumu• 6 years ago

You should mention the DSM is purely an American text, while the ICD is what's used most everywhere else. This the DSM primarily captures the zeitgeist of American psychiatric opinion.

TheOperator• 6 years ago

My favourite part of psychiatry is that diagnosis never shrinks, it only grows, and this makes people healthier and the increase in mental illness is just us "discovering" that people were mentally ill all along.

The field is an endless dynamo of medicalization because they serve as a gatekeeper to funding, and if you throw enough money at anybody start to feel better, which creates an incentive for more and more to get diagnosed. For a broad swathe of new people to be diagnosed as mentally ill does not require biological evidence, or even proof that the classification improves patient outcomes, it just requires abusing the criteria used in broad all-encompassing intrinsically political typologies (Like DSM-V) until you can hammer most of the population into the mentally ill box. The diagnosis's aren't falsifiable and in multiple cases attempts to falsify a diagnosis proves the diagnosis.

There are also various absurdities with this status quo. The literal meaning of what a mental illness actually is in in flux and has literally changed multiple time over an older adults lifetime. If you meet 5 criteria you're healthy and get no assistance, if you meet 6 criteria you're definitely disabled. A bad reaction to an environment causing issues, the classic example being the child fidgeting after sitting in a desk for 8 hours being diagnosed with ADHD, leads to the child being blamed instead of the environment.

I don't think psychiatrists have no role in society I am just heavily sceptical that they're actually scientists, they seem like people using applied science like engineers.

DanBC• 6 years ago

Probably important to mention that this is strongly cultural and in many countries (eg, not the US) we don't see the massive over-pathologisation of normal ranges of human experience.

skoll43• 6 years ago

i recommend looking this video from the author of one of the books cited: https://www.youtube.com/watch?v=B3gitzyxBsg

ordu2• 6 years ago

It is a very interesting topic. Psychiatry was tried to be a branch of medicine, but it didn't work that way. Freud came as a kind of a doctor for mind, calling his clients 'patients' and mimicking "real" doctors in any way he could. It didn't work either. But while psychoanalysis and psychotherapy were a luxury for the rich, psychiatry often worked with people who didn't asked for a treatment or even resisted treatment.

I mean, the struggles of a psychiatry to become a science are shared by a psychology. A psychology mostly was nicer to people, because it was kept further from extreme cases, it had a freedom to keep an ethical stance by ignoring ethically difficult cases. I guess it is hard to remain human while forcefully treating a patient on the basis of some shitty theory of mind's diseases.

mrxd2• 6 years ago

Freud came as a kind of a doctor for mind, calling his clients 'patients' and mimicking "real" doctors in any way he could.

This is a popular misconception. In fact, Freud was a "real" doctor who studied neuroscience in medical school and had a career as a doctor working in hospitals. The most interesting thing about psychoanalysis is that it was invented by neurologists like Freud and his mentors Jean-Martin Charcot and Josef Breuer, not by psychologists. The "talking cure" was originally used to cure people who had been hospitalized with various physical symptoms and ailments.

The popular myth holds that psychoanalysis is a non-science trying to mimic science, but in reality it is the other direction. It was originally closer to biology and moved away from that.

Nav_Panel9• 6 years ago

YES! And Freud's early works are so interesting, particularly his model of the psyche in Studies on Hysteria (which I assume he elaborates more fully in "Project for a Scientific Psychology").

It's only just now, 100 years later, that we're starting to develop the neuroscience to ground these theories more definitively (thanks to Karl Friston), and what Friston's seeing is quite close to what Freud posited back then. See research like: https://pubmed.ncbi.nlm.nih.gov/27471478/

beagle3• 6 years ago

Freud’s work wasn’t science or resembling it. It was a mix of observations and thoughts. Biology at the tine was way closer to modern science.

In fact, Karl Popper’s seminal work that characterized science and is essentially used to define science today, was motivated in no small part by trying to formalize Alfred Adler’s claims in a rigorous consistent verifiable and falsifiable manner - and realizing that was impossible.

ordu2• 6 years ago

The popular myth holds that psychoanalysis is a non-science trying to mimic science, but in reality it is the other direction. It was originally closer to biology and moved away from that.

At the time biology itself was not a very scientific discipline. Biology became a real science when chemistry caught up with biology and biochemistry was born. Before that biology was mostly like a psychology: a lot of vague words, theories telling us things about something that cannot be seen or measured, and so on.

Though I can agree, that with the time psychoanalysis moved even further from science than it's starting point.

kafkabot992• 6 years ago

There was a brief stint in college when I thought I wanted to be a psychiatrist. I think in retrospect it was an attempt to turn my philosophical inclinations to a practical purpose. But it quickly became clear, in my opinion, that the field does not fully understand itself; it is based on more unproven premises than probably any other field of science, or even 'social science'. With the exception of some kinds of disease (possibly schizophrenia), a psychiatrist's ability seems to vary independently of his education. Success comes from being wise and understanding human nature, knowing how to talk to people.

Psychiatry doesn't understand that people have been caring about mental health for millennia, even if it wasn't called mental health, and so the field is not lindy at all. This sounds crazy but they should really be looking back to the roles/practices of priests, even shamans, just to try and get some semblance of an idea of what works and what doesn't...because they currently have absolutely no idea.

I would except CBT from this critique...it does actually seem to be a remarkable treatment (it is also lindy).

Nav_Panel9• 6 years ago

the field does not fully understand itself
This sounds crazy but they should really be looking back to the roles/practices of priests, even shamans, just to try and get some semblance of an idea of what works and what doesn't

These things are exactly what psychoanalysis did and has always done. That kind of historical and reflexive investigation appears in plenty of Freud's writings (as well as later theorists, like Lacan, who drew heavily on Levi-Strauss's anthropological work).

Too bad that psychoanalysis takes shit for being "unverifiable" and "unfalsifiable" (as if what we currently have doesn't suffer from the exact same flaws, which I believe are inherent to any study of mental phenomena).

watwut5• 6 years ago

Freud is not taken seriously anymore and for good reasons. I mean, his historical contribution was good, but it is outdated and basically bunch of nonsense as far as we know now.

kafkabot992• 6 years ago

These are good points, but I think they are more applicable to clinical psychology, at least in US and today. Psychiatry as a science and a field of medicine is committed to a certain view of mental illness as disease that precludes this kind of theorizing. Imo.

markdown• 6 years ago

it is also lindy

You keep using that word. I do not think we know what it means like you think we do.

Bodell• 6 years ago

You’ve never done the Lindy? Maybe you’ve done the mashed potato?

throw18376• 6 years ago

psychiatrists, as in MDs, in the US used to study psychoanalysis until about the 80s/90s.

i think one factor that discredited it is that psychoanalysis does not have an adequate theory or treatment for diseases like schizophrenia and bipolar disorder. these both seem to be mostly biological, are attested throughout history and nobody had any way of really dealing with them before lithium and antipsychotics.

(some would say that people with these disorders used to become shamans or priests, but I think that this is somewhat disputed these days.)

anyway, as far as I know no amount of wisdom, compassion, or even complex theories of mind will treat psychosis, although they certainly all can help get somebody to stay on their medication.

and i don't think it's a minor thing -- seems to me like the core problem a psychiatrist ought to be able to treat, even if in numbers depression and anxiety are way larger.

nvrspyx2• 6 years ago

Since the full article is behind a paywall, I cannot see the details that the author goes into. However, I will say that psychiatry has a long way to go. One major issue is that there's no commonly agreed upon methods of diagnoses. There's a wide range of inventories, surveys, structured clinical interviews, etc., and every psychiatrist has their preferred sets of those. It doesn't help that the questions asked are often easily interpreted different from patient to patient and that some questions are quite literal, while others are somewhat vague probes into emotion. With that said, the issue is ultimately the reliance solely on the word of the patients, whom are often lacking a degree of insight due to their mental illness (e.g. brain fog, deficient expression, cognitive dissonance, emotional suppression, etc.).

It doesn't help that mental illness has some inherent difficulties compared to other areas of medicine:

* Prevalently comorbid with some illnesses being symptoms of something else (e.g. anxiety and depression being symptoms of bipolar disorder)

* Distinctions between illnesses being blurry and those illnesses overlapping in symptoms (e.g. General Anxiety Disorder and Major Depression Disorder, Psychosis and Mania, Panic Disorders and PTSD, etc.)

* Symptoms being inherently unstable because of the number of uncontrollable internal and external variables that influence them

* Medications affect every person differently to the point where medications in the same classification (e.g. SSRI) will have vastly different effects to the same patient (e.g. one SSRI alleviates symptoms, while another doesn't or even exacerbates symptoms)

* Those medications having difficult onboarding effects or side effects (e.g. SSRIs typically making depressive symptoms worse for the first 3-6 weeks before symptoms improve)

* Lack of physical testing methods like blood tests, biopsies, etc.

* The many complexities and unknowns of the brain that we have still yet to understand compared to other organs

* Diagnoses and treatments need to be personalized, but no easy, economic, objective way to do so. For example, brain activity and functional networks vary from person to person, effective stimulation treatments require personalized neurophysiological targeting derived from functional connectivity analysis, illness can derive from a wide range of causes or combination of causes like brain networks, neurotransmitter imbalance, hormone imbalance, etc. You even need to consider those with more detail, like are the involved brain networks too strong or too weak, is the neurotransmitter imbalance from deficient production or deficient uptake, etc.?

---

TL;DR: It's no wonder that diagnosis of mental illness is so inconsistent across psychiatry because our current methods are almost entirely qualitative, mental illness is relatively poorly understood compared to other areas of medicine, mental illness is inherently comorbid and overlapping, and diagnosis/treatment requires a deeply personalized approach with no good way to do so (yet).

watwut5• 6 years ago

Add to it pretty often incooperation od patient. Where with broken hand you are bound to cooperate, with psychiatric care of it is bigger issue.

nvrspyx2• 6 years ago

I'd file that as either symptomatic of their illness or cultural stigmatization (which I forgot to mention). The latter doesn't just influence patients, but also how other areas of medicine sometimes view psychiatry.

fortran772• 6 years ago

It's actually not behind a paywall--it's behind a "register" wall. If you register for a free account you can read this entire article.

apsec112• 6 years ago

Is there a paywall workaround? Articles are off-topic for HN if they are paywalled with no workaround.

fortran772• 6 years ago

Yes. If you register for a free account, you can read this entire article.

LatteLazy2• 6 years ago

Mental health is a very very undeveloped field. We don't have good treatments for most illnesses. We don't even really know which illnesses are which (take a look at how the DSM changes over relatively short time periods).

This is the real reason people are hesitant to admit having or discuss others illnesses.

Full disclosure, I'm one of those people. I have what has been variously called Severe Depression, Treatment Resistant Depression, Major Mood Disorder and is now called Major Depressive Disorder. My symptoms haven't changed and its only been a decade. So you can see how ephemeral diseases are in this field. Until we can reliably classify diseases, we can't even look for causes. Until we have causes, treatments are no better than herbal medicine.

cmehdy2• 6 years ago

The DSM is a guide on average, not a book of truth. For one, it offers SOMETHING to discuss in the first place.

The names change, there are sometimes huge mistakes in those books, etc.. That's absolutely true. It doesn't mean that there is no progress to the process, even if admittedly it's all pretty slow (for reasons that everyone will have their own opinion about).

I've lived my life since early childhood with various major issues, of which only recently Major depressive disorder and Generalized anxiety disorder were the primary diagnoses (but there are other major things that I'd prefer keeping to myself).

Putting some name, ANY name, on those issues, allowed me to look for what is usually brought up to improve things. Doing that allowed me to apply certain tools to my situation which have been incredibly helpful, and those tools include both therapy and medical treatment. Doing THAT allowed me to stop digging a deeper grave. I'm not cured from depression, suicidal ideation, cognitive distortions, etc.. much in the same way a burn victim isn't cured from it when they're still in the medical ward working at their rehabilitation. It's not a reason to say that the medical ward is useless.

So even if you are not satisfied with the state of things (and I'm not either btw), at least you can concede that having people trying to apply scientific processes to the issues AND having a world-spanning effort in significant numbers will do more to help figure things out than any localized shamanism effort.

LatteLazy2• 6 years ago

I don't want to run down the process completely. You're right that some level of classification is necessary to access services in the current system. That's fine as long as people realise that that is all a "diagnosis" is in this field. Too often people think a diagnosis means there is a tried and tested correct treatment...

lend0002• 6 years ago

A bit off-topic but I'm sure there are some experts perusing this thread:

What are some examples of mental illnesses that would result in someone making up or hallucinating an extraordinary, single, formative event in their life, and sticking to that story indefinitely while not inventing others?

derbOac• 6 years ago

I am an expert, I guess.

Delusions of pregnancy are a classic example of this, and are fascinating to observe, and also deeply saddening for several reasons.

There are many delusions, although they usually have certain themes (e.g., of reference, jealousy, persecution). Delusional disorder ala the DSM is defined by delusions per se but not hallucinations (not saying this is a "real category" as opposed to a coincidence of phenomena or lack thereof, but it is the diagnosis). So individuals who meet criteria for this seem very normal -- they're lucid, coherent, and so forth -- until you get them on a certain topic.

With delusions of pregnancy it is that they are pregnant. They have tests that are negative from multiple places (over the counter, in the clinic etc.) and often a few friends, family, and partners have counseled them about it to no avail. The general explanation is that they're all in on a conspiracy to thwart the pregnancy, because they're jealous, or don't trust their ability to be a parent, or whatever the case may be.

I've seen cases where the delusional pregnancy goes on for years. This is biologically implausible. Some individuals just sort of avoid this topic; others will assert that there have been multiple pregnancies, usually aborted by those who are trying to sabotage the pregnancy (e.g., secret medicines to induce abortion, etc.).

All mental illness is sad at some level (well, nearly all), but the delusions of pregnancy are as well. It's clear someone desperately wants to be a mother, and genuinely believes people are aborting their pregnancy, or attempting to, or otherwise is unable to have the child.

I'm sure I could think of many other delusional examples involving significant formative events but outside of broad themes they're often idiosyncratic.

lend0002• 6 years ago

That's fascinating. It sounds like there is some overlap with hypochondria.

I am especially interested in the hallucinatory angle, which seems to be outside the scope of DSM. Is there a mental illness that might explain someone having something akin to a one time religious experience, too real for them to dismiss? If certain drugs can do this, is there any reasonable evidence to demonstrate that such substances can spontaneously be created in sufficient quantity under the right circumstances?

pessimizer• 6 years ago

You don't have to be mentally ill to do that. I think most people remember something happening to them that didn't, but that they heard about happening to someone else, or saw in a movie.

https://en.wikipedia.org/wiki/Elizabeth_Loftus

rebelos• 6 years ago

Many of these cases may be due to sleep-disordered breathing, which is massively under-diagnosed because of a little known controversy within the sleep medicine field involving the scoring of sleep polysomnographies.

The American Academy of Sleep Medicine (AASM) admitted to a horrible mistake in their original scoring guidelines [1], but sleep physicians and labs are still way behind on catching up to this. The usual scoring methodology will only detect people with traditional obstructive sleep apnea, because it looks exclusively for long pauses in breathing and significant drops in oxygen saturation. By contrast, there are many people experiencing heavily fragmented sleep because of micro-arousals that will not meet those criteria. Here are some quotes from the AASM on this:

Respiratory events associated with arousals, even without oxygen desaturation, cause significant, and potentially dangerous, sleep apnea symptoms. During PSG, arousal-based respiratory scoring should be performed in the clinical evaluation of patients with suspected OSA, especially in those patients with symptoms of excessive daytime sleepiness, fatigue, insomnia, or other neurocognitive symptoms.
Studies have shown that not utilizing arousal-based scoring may lead to a missed diagnosis in up to 30% to 40% of patients with OSA, especially in patients who are younger and non-obese.
Not including arousal-based respiratory events of any form when scoring a PSG may lead to either lack of proper diagnosis of OSA, misclassification of OSA severity, or misidentification of another sleep disorder or medical disorder (eg, idiopathic hypersomnia, chronic fatigue syndrome). These patients may remain improperly treated, leading to persistent sleep symptoms, worsened work performance, decreased neurocognitive function, and poor clinical outcomes.

This is a massive, stupefying failure in medical ethics that has persisted for unclear reasons (though likely having to do with insurance). Undiagnosed sleep-disordered breathing is probably at fault for a substantial share of seemingly treatment-resistent mood disorders.

Here's a quite informative talk that goes into some of the relevant details: https://www.youtube.com/watch?v=tV4NBugGSnQ.

If you think you may have a sleep disorder, the best thing you can do is get a proper sleep study that uses arousal-based scoring. If you can't find a physician or a sleep lab that does this, then the WatchPAT is a cutting edge and affordable OTC option that will also work well: https://www.amazon.com/Home-Sleep-Study-Apnea-Test/dp/B07XKW....

[1] https://jcsm.aasm.org/doi/10.5664/jcsm.7234

frongpik• 6 years ago

Psychiatry exercises what we'd call strategic incompetence: it doesn't really want to know, for the knowledge would be a liability.

The bridge to the scientific foundation of psychiatry is hypnotic induction. Find out what it really is and the rest of the puzzle will be easy to assemble. That induction is related to magnetic induction and is similar to how a solenoid induces current in another solenoid.

But as we know, studying that effect is a big no no, and the treat of being called a heretic (or crackpot) is how scientists are kept away from psychiatry.

The science and pseudoscience of diagnosing mental illness

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