I’d like to start with a few disclaimers. This is not an anti-psychiatry post. This is also not the place to ask or receive advice about your mental health, or what nowadays is called “mental health”.
For some time now I’ve been feeling like I live in a different world than most people I know. It has come to a point where I have to face an awkward alternative: Either most people I know are wrong (including learned men and experts) or I am insane. As I don’t believe I have lost my sanity, and as I believe that I have very strong arguments to hold my ideas against all reasonable counterarguments; I think it’s about time I sit down and share my ideas more or less publicly. This is one of such ideas. What follows is the summary of my academic studies, my professional experience working in the field of mental health, my own personal thoughts, and the influence of several authors, chiefly Georges Canguilhem and Jacques Lacan.
The APA defines psychopathology as “the scientific study of mental disorders, including their theoretical underpinnings, etiology, progression, symptomatology, diagnosis, and treatment”. It is a jurisdiction of medicine, although that does not exclude other disciplines from delving into it as well. It is intrinsically linked to psychiatry, to the point where one cannot exist without the other. But psychiatry itself is a rather contradictory branch of medicine, because while every other specialization of medicine has built its own object of study by exploring a specific organ or function from the body, psychiatry exists only by virtue of that which it ignores. In its origins, psychiatry was born to deal with what has been classically classified as insanity, those people described by Descartes who believed they were made of glass or who fancied themselves to be pitches of water. These outlandish delusions have always caused turmoil in society because nobody really knows where they come from, what they mean and, most importantly, what to do with them. Insane people clearly need help but they do not want it, or what help they are willing to receive it’s impossible for other people to give. They break the law but they are not criminals, or at least they are bening. They behave like savages but are human beings and deserve to be treated as such.
Now enter the Enlightenment: Lady Reason triumphs all over the Western world, everything now has or will have a place and an explanation in the encyclopedia of universal knowledge. And what we understand we control. There are now a bunch of physicians who have little evidence but little doubt that these people are sick and that it is their task to heal them. And that they’ll try with all their available resources, but with little success. So while neurology developed from the study of the brain, cardiology from that of the heart and so on, psychiatry was born out of sheer embarrassment. It is the branch of medicine that studies mental disorders. However, being a part of modern scientific medicine, it cannot but assert that mental disorders can be explained by studying the body, the contradiction being that the day psychiatry discovers the bodily cause of mental disorders will be the day that it ceases to exist as a specialization of medicine, for said cause would fall under the jurisdiction of another specialization: If it’s in the brain then it would be neurology, if it’s in the genes it would be medical genetics, and if we were to discover a new organ in the body then a new specialization will be born to study it, leaving psychiatry in the past.
Therefore, psychiatry exists only because we do not know what mental disorders are. In fact, we don’t even know if the mind is real or not, much less whether it can get sick. What do we actually know then? We know that 1. there are people who need help, and 2. that there are means to help them. So it becomes a matter of administering a scarce resource. This is what psychopathology really is: It is not a science of mental pathology, it is the art of distributing psychiatric drugs and psychological treatments.
There used to be psychopathology. Classic psychiatrists wrote impressive treaties on the subject, with thousands of pages explaining in detail and classifying the behavior of their patients. The mountains really were in labour, alas, only a mouse was born: No progress was made regarding the causes, and most importantly the treatment of such behaviors. This last problem was drastically improved by the invention of psychopharmacology. Suddenly psychiatrists had a powerful tool to treat the symptoms of insanity, so even though they weren’t any close to understanding these symptoms, they changed their ideas on the subject to reflect the influence of psychiatric drugs. These influences can be accurately gauged by the changes on the DSM. The first DSMs included theories about the origin and nature of mental disorders, the last DSMs only mention the clinical symptoms necessary to prescribe a treatment. When a patient is diagnosed with depression the only relevant information that is learned is that said patient will start a treatment for depression.
So are mental disorders real? Of course they are. Whether they are mental or disorders, that’s another question. They are real because they are a set of behaviors that have been observed to occur together: Feelings of sadness, self-harming ideas or behaviors, inability to feel pleasure, these are all things that are real, observable, measurable, and treatable. But are these symptoms a mental problem? Are they a medical problem, or a problem at all? This is highly debatable, and in any case, not a solid foundation for a science.
If a person feels sad all the time, it is only natural for them to think that this life is not worth living. But the opposite is also true: If a person is convinced that there is nothing good in this world, then they will feel sad and hopeless all the time. So what comes first? Should we treat the sadness or the thoughts? And what if the person likes to feel sad, if they don’t want any help? Should we force them? And to make matters worse, it turns out that both psychiatric drugs and psychotherapy are effective*. And this is only to talk about those treatments that have empiric evidence to back them up and are approved by psychiatry, because, under the right circumstances, literally everything can be therapeutic: There’s horse therapy, art therapy, music therapy, dog therapy, video-game therapy, you name it.
There are some who believe in the demon deceptor, a person, or a group of people, who control our reality and make lies pass for truth, usually with malicious intent. These people believe that the pharmaceutical industry has created mental disorders only to sell drugs, and that psychologists and psychiatrists are their accomplices. For my part, I think it is overly optimistic to believe that someone has such a degree of control over the situation as to make it bend to their will. I believe that people are just confused, and with good reason, because being human is quite a bizarre experience. There are of course those who profit from the confusion of their fellow man, and prey on their ignorance. But even evil has its limits, and nobody can summon such perfect wickedness that no good may come of it. The truth is that for all the confusion that our idea of psychopathology entails, the treatment and the care for people with mental disorders has progressed a great deal in the last decades.
On the other hand there are the encyclopedists, who will argue that the fact that we haven’t discovered the bodily sources of mental disorders does not mean that we won’t succeed in the future. We have certainly made discoveries in this direction: Not only do we know now that it is impossible to be sad or mad without a brain, but we also know what specific brain part or substance is required. But even after all the advances in neurology, still no neurologic exam is indicated for the diagnoses of mental disorders, and for good reason. Because ultimately, what decides if someone has a mental disorder or not are arbitrary criteria. The fact that homosexuality is no longer a mental illness is only because of the fact that society has shifted its values towards the acceptance of diverse sexual orientations, were it not for that fact we would speak about the “homosexual brain” just as we know speak about “the depressed brain”. We could also speak about “the carpenter brain” or “the the writer’s brain”, and treat all of those conditions as illnesses.
In conclusion, I believe that contemporary psychopathology is a case of finding a hammer and suddenly realizing we are surrounded by nails. If something can be treated as an illness it will be treated as an illness, because that is l’esprit de l’époque. Classifying something as an illness, assigning it a part of the brain, and prescribing it a drug as treatment makes it real and important, so politicians, scientists, and the general public are aware of its existence and direct resources its way. This is why everyday we “discover” that there are more things linked to mental health: Poor housing, poor nourishment, the weather, sexual orientation, racial discrimination, political ideologies… and as there is no psychopathology there’s no limit to psychic pathologies. There’s a drug for everything or a therapy for everything. It’s no coincidence that we now have the most effective treatments in history and the highest rate of accessibility to mental health services ever, but the rates of mental disorders are soaring well. And despite all the advances in psychotherapy and psychopharmacology, no breakthroughs have been made in psychopathology.
I’m convinced that in the future people will look at our ideas on psychopathology as we now look at humorism.
Sources:
APA Definition of Psychopathology: https://dictionary.apa.org/psychopathology
*Psychotherapy just as effective as pharmacotherapy: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244449/
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Aight, I'm here to pitch. I might not be a psychiatrist, yet, but it's that or die trying so I'll try and defend the much maligned field.
On an object level. You're mostly right. Psychiatry is largely pre-paradigmatic. We only have very vague ideas about the underlying underpinnings of many of the most common diseases.
We can find pretty reliable correlates in some cases, such as subtle differences in neuronal wiring or the activity of larger regions that associate with mental illnesses like depression, autism, OCD and so on. Unfortunately, much like the discovery of Tau proteins in Alzheimers, just because we have a marker for the illness does not mean that reversing the marker will reliably reverse the disease. All the drugs that claimed to reduce neurofibrillary plaques did jack-shit for actually curing Alzheimers.
Oh boy.
For example, autism
Yay! We have a neurological, albeit still rough, understanding of what's going on here.
And yet, pray tell what a neurologist is going to do about it? Take an autistic child to a neurologist or neurosurgeon and ask for them to be cured. I'm sure they're too kind (for all their ego), to laugh you out of the room, but all they can offer is pity and a referral to a shrink or SALT.
Similarly, depression is primarily a disease of the brain (leaving aside conjectures about the gut brain axis, general inflammation and so on). Can a neurologist do anything about it?
Well, nothing a psychiatrist doesn't already do. In other words, therapy, meds and more aggressive interventions like electroconvulsive therapy (and ketamine, LSD and so on).
What have you achieved, barring a rebranding?
Even as we begin to understand some of the underlying processes of pathophysiology in depression, such as why rebooting the brain with induced seizures works when meds fail, it does not change the fact that ECT works beyond reasonable doubt.
In a world where we suddenly discovered, with perfect accuracy, the exact neurological underpinnings of mental illnesses (and didn't just cure them in the womb or immediately developed miraculous treatments), you know what would happen?
Specialization of labor. In other words "neurologists" doing the same shit as psychiatrists do today.
You're falling prey to semantics and fuzziness of definitions.
Geriatrics is a perfectly respectable specialization in medicine despite, last time I checked, there being no "old age organ" (well, maybe the thymus). Huh. Why hasn't their lunch been taken by all the cardiologists, oncologists, neurologists and other people with well-defined magisteria?
Specialization.
It is convenient.
It works.
You poor man. You've been beaten to the punch by Dr. Scott Alexander Sisskind on several occasions, though I'm too lazy to link more than one, but which handily contains links to yet more ink spilled on the topic. Worry not, it happens to the best of us.
My answer is a resounding mu that brings all the local cattle to the yard.
None of this matters. Not that I really see any reason to call it "highly debatable".
You mistake medicine as practised as "science" whereas what doctors outside research settings do is closer to engineering.
I don't particular care that we don't know the exact cause of depression. I know of multiple batteries of tests that, with reasonable accuracy, tells me whether or not a given patient will benefit from counseling, medication, and other interventions, and which, when measured serially over time, tells me if it's working. And vice versa, if you take someone who doesn't have the markers of depression and feed them SSRIs, it doesn't make them happier. So what if it isn't actually a deficiency of serotonin that causes depression? The drugs, while less effective than desirable, are not useless.
I really don't see any reason to twist yourself into knots about whether depression is "mental", as opposed to what, neurological? Biochemical? All of the above in same capacity, depending on your appetite for abstraction?
"Medical"? Come on dude.
To draw an analogy, let's say you have a malfunctioning PC, or maybe a server rack in an AI datacenter. A vascular surgeon notices the water cooling is leaking and bills you $70000. A cardiologist checks the PSU. The neurologist makes sure the RAM is seated tightly or otherwise asks their neurosurgery buddies to bend some socket pins and reapply the thermal paste.
Whereas what psychiatrists are doing is both a combination of relatively simple things like
giving drugsdusting the fans, as well as the equivalent of prompt-engineering an LLM. The brain, despite operating according to the same physical laws as an H100 loaded with GPT-4, is just as nigh impossible to understand from first principles, and some higher order discrepancies difficult to treat by looking at bare meat/metal. That does not mean we exist in utter epistemic helplessness. What we do works. It is not perfect. It is not complete. It is, however, not useless or a waste of time. What is is semantic arguments and forcing allied specialists to do jobs that they're no better equipped to do than we are, simply because that sounds neater and more scientific. Categories and doctors were both made for Man, and not the other way around.Complex systems that aren't amenable to direct analysis at the elementary level are still amenable to modification and control. That is what psychiatrists do. If we were folded into neurology, then congratulations, all you would achieve is neurologists performing the same tasks a psychiatrist does, and likely end up creating a new subspeciality which is all but psychiatry in name (and we already have the opposite approach with some of the nerdier shrinks becoming neuropsychiatrists) .
This is the same line of thinking that would assume that, if one day we replaced the Standard Model with a Grand Unified Theory of Everything, then we no longer need those overly abstracted biologists, and those fussy chemists. Why, just model everything at the level of fundamental quantum mechanics? What do you mean the computer caught fire when I tried to diagnose ADHD using Feynman path integrals?
None of what you say is forbidden knowledge tacitly swept under the rug by psychiatrists, the witch doctors. The typical reaction, from anyone who has acquaintance with a textbook written after that fraud, Freud, would be the same long-suffering sigh as if you accosted an economist and told them that their models are flawed because they assume rational actors acting in enlightened self interest. They know that's not how it works. They're more than happy to fudge their idealized calculations or look for deeper trends. It's not an easy task, and in many ways, the interaction of many minds operating under relatively well-defined incentives is easier to model than a single one which is a fractal, sweltering, wet and buzzing ball of noise on the verge of criticality .
It's all rather moot at that point.
I appreciate your reply quite a bit. I’d like to ask you, in earnest, if psychiatry is legitimate, why is the problem only getting worse with increasing application? Has “mental health” ever been worse than now? I don’t actually know the answer, but it sure doesn’t seem so.
It's a long story, but if I had to sum it up: Legitimate/well-intended awareness campaigns can cause mass psychogenic illness, social media fads and the fetishization of therapy culture doing the same, previously under-diagnosed conditions being actually noticed and diagnosed, the drug epidemic, and a reaction to social atomization and the fraying of familial bonds that contributed a great deal to people keeping their shit together in the past when they lived in objectively shit conditions.
It seems to me that it's both true that conditions like ADHD and autism that were once missed because of ignorance are now being diagnosed far earlier and there's a lot of fad chasing and social contagion. Do enough hard drugs and you'll break something up there too, and said drugs have never been more common or tacitly tolerated.
(The actual incidence of "real" autism has likely increased significantly since the previous century, potentially due to increasing parental age, but it's all very confused and I'm only conveying my best understanding of the situation in the West.)
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