Mapping Mental Disorder

A categorical mess

These posts explore the themes developed in my monograph, Narcisso-Fascism, which is itself a real-world test of the central concepts of the Biocognitive Model of Mind for psychiatry.

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Last week’s post provoked a couple of comments that raise important points:

The underlying problem can be put succinctly: to talk of mental disorders implies there is something wrong with the brain. This is purely speculative and arises because of failure to appreciate that mental symptoms (depression, anxiety, delusions, etc.) – even if extreme – don’t rise in a vacuum but are a reaction to life events.

The idea that to be biological, categories must map onto distinct causes with no crossover is patently untrue. Happens just as rarely in physical medicine as psychiatry. Never heard of the patient with obesity, sleep apnoea, hypertension, hyperlipidemia, diabetes, throw in CKD in a few years time....??? These are classic “syndromes” that rarely travel singularly... How many patients with T2DM “just” have diabetes??? Even more unlikely than that your patient with MDD “just” has depression. Comorbidity is not a feature of psychiatry that is absent in physical medicine … (from a medical student).

The point at issue is the vexing question of the nature of “mental disorder” itself. By that term, I mean broadly “complaints of disabling inner distress and/or manifestly disturbed or disorganised behaviour in the absence of demonstrated organic brain disease.” In trying to answer this question of the nature of abnormal mental life, psychiatry is off to a terrible start as it doesn’t have any sort of theory or model of what could be called “normal mental life.” Before you can answer the question of nature of mental disorder, you need to be able to talk meaningfully about mental order, aka theory of mind. To me, that’s elementary but to mainstream psychiatrists, it’s not, it’s a silly objection as they believe they have a formula that, in the fullness of time, will answer all questions regarding human mental life.

The term “disorder” was chosen for DSM-III in 1980 in order to get away from the assumptions implicit in their previous term, “reaction.” In DSM-II, everything was a reaction: Depressive reaction, schizophrenic reaction, phobic reaction, etc. This came from the rather eccentric but very influential Swiss-American psychiatrist, Adolf Meyer. Meyer’s record during his long life was too complicated to summarise here, he gets a fair bit of space in Andrew Scull’s history [1]. He didn’t like Freudian psychoanalysis as he had started his career as a neurologist (as did Freud) and although he kept a strong interest in the brain throughout his career, he saw life events as dominant, hence the idea of a “reaction.” DSM-III wanted to be atheoretical, to have no presuppositions, so they opted for “disorder,” allegedly on the basis it was so vague nobody could object. True or not, it’s close to neutral; all it says is something isn’t right. However, that doesn’t take any great insight: the whole point is that the community can see there’s something wrong. I’ve dealt with Aboriginal people and with peasant farmers deep in the mountains of far south Thailand who live fairly traditional lives, and they all understand “He ain’t right in the head.” The specialist’s role is to explain it and, ideally, to treat it without making it worse.

Enter psychiatry: Andrew Scull and Ann Harrington [2] show that as the idea of demonic possession was pushed out, medical people took over, but never as a united front. There was always a split between the tender-hearted and the firmly clear-sighted (as they like to see themselves). One side proposed that mental disorder was essentially a moral matter, partly in causation and partly in management. In the West, the idea goes back to Greek times at least, the notion that inherent personality flaws led to disaster which could be avoided if the person wasn’t so full of hubris, overweaning pride and conceit. Treatment therefore had to be directed at getting the person back on the strait and narrow, by moral suasion and good examples, e.g. the York Retreat run by the Quakers in the UK.

Opposed to them is the even more ancient idea that the root cause of any sort of disturbed behaviour is a physical affliction of the brain or other parts of the body. The Romans were strong on this idea [3] but it’s very widespread, often seen as the idea that there is something that can be added to or subtracted from the diet that will relieve all manner of woes. In the West by about 1800, that had hardened: mental disorder was increasingly seen as some sort of brain disease for which physical treatments were essential. These were many and varied and mostly cruel as it was widely held that terrifying the sufferer was an essential part of jolting the brain back to normality. During that century, the idea of hereditary degenerations of the brain gathered strength and fed into the eugenics movement, with catastrophic consequences in Nazi Germany. When the common and invariably fatal condition known as general paresis of the insane was found to be due to infection of the brain by syphilis, the idea of a “biological” psychiatry got a huge boost. But by that stage, Freud had burst on the scene with his notion that all mental problems are psychological in nature and could be treated with talking, so the split became permanent (as a former neurologist, Freud was sure the mind would turn out to be physical and, early in his career, wrote his Project for a Scientific Psychology, (1895) which wasn’t published during his life, for good reason).

The early versions of the DSM were heavily influenced by Meyer’s disciples but by the late 1960s, it was becoming clear that psychiatry was in a mess. There was too much intuition built into both the idea of a diagnosis and in treatment. As a patient, your diagnosis depended largely on who you saw but treatment depended on how much money you had. If you were rich, you could see a genteel psychiatrist in a comfortable office for long sessions of talking but if you were poor, you were shoved into a vast nuthouse full of seriously deranged people and you got what was on the treatment menu. If that meant having all your teeth extracted and half your large bowel removed, so be it; only the insightless would complain, and lack of insight meant psychosis which meant more treatment, not less. Grim days indeed.

Anyway, here we are in the 21^st Century and psychiatry’s historic split between mentalists and organicists has largely healed, but not by any advance in understanding. Biological psychiatry rules the roost, the notion that all mental disorder is due to a primary disorder of the brain. The idea that mental problems have mental causes has fallen away and gets very little airtime, as a glance at any major psychiatric journal shows. The reason for this neglect is perfectly clear: positivism. This is the philosophical doctrine underlying science as we know it today. I’ve covered this in more detail in [4] but very briefly, just about a hundred years ago, a group of physicists, mathematicians and logicians in Vienna, known to history as the Vienna Circle, turned science around. In a brief and punchy manifesto, published in 1929 [5], they announced that science, including maths and philosophy, could only be based in what we can prove. From this flowed a model of scientific explanation: every observation has to be explained in terms of what has been proven before. If we can’t prove it, it isn’t rational. Unprovable stuff may be pleasant or entertaining but that’s for poets and musicians; science itself had to stand or fall on what we can see, measure and duplicate. Explanation in science is reductive, every higher order observation must be fully explained in terms of lower orders, meaning no miracles and no skyhooks.

This is the doctrine of empiricism, that true knowledge comes to us via our senses, not by revelation, as in religion or charlatanry. By definition, and regardless of how real it feels, we can’t see or measure the mind; therefore, all talk of the mind is irrational and is not part of science. That put the early psychiatrists in a bind: their business was the mind, so how could they talk about it and still remain within the bounds of valid science? The Freudians ignored it and gradually drifted off into ever-wider circles of speculation that eventually split apart acrimoniously [6]. Biologically-inclined psychiatrists, however, were in a much stronger position. They didn’t want to talk about “The Mind” as a thing sui generis, a thing in its own right, they saw mental life as simply a step on the path down to the brain. It’s a bit like pain for a surgeon: a complaint of pain in the right iliac fossa is just a sign post on the way to a diagnosis of appendicitis, and then directly to an operation which cures it. All very mechanical, no room for whimsy. Same for psychiatry: under the new positivist regime, the complaint “I feel sad” is simply a signpost to low serotonin (5HT) for which a particular drug is de rigueur. Nothing whimsical, nothing fanciful, in either the psychiatrist or the patient.

So what about the mind? How does that fit in with the new “biomedical model” of psychiatry? It doesn’t. Your life experiences, your hopes, fears and ambitions don’t get a look in. It’s all brain, and the brain is all genetics. In fact, that hasn’t worked out very well so there’s now room for inflammatory chemicals floating around in the blood stream, epigenetics, diet, environmental chemicals (one of RFK Jr’s pet obsessions), bowel flora and so on. In fact, these are all more or less closely related but that’s another story. As far as “The Mind” goes, that too is a matter of biology. To complete the story, which almost never happens, it’s expected that all mental life will eventually be explained as a matter of biology, as in “One fine day, ordinary laboratory science will tell us all we need to know about the mind with no questions unanswered.” How will this come about? “Oh, don’t worry about that, science will ride to the rescue.” This is called promissory materialism, clearly expressed by the historian and materialist philosopher, Richard Carrier:

…everything can be reduced to matter and energy in space and time: quarks and other sub-atomic particles and their behaviors are all that there is, out of which everything without exception is made. And this fits with the fact that society can be reduced to humans, and humans can be reduced to cells, and cells can be reduced to chemical systems, which can be reduced in turn to sub-atomic particles. So therefore societies can be reduced to sub-atomic particles. The natural corollary of this view is that the sciences follow the same pattern: sociology can be reduced to psychology, psychology to biology, biology to chemistry, and chemistry to physics. So, theoretically, all of sociology and psychology can be described entirely by physics [7, S.III.5.5].

That’s optimism for you. I believe he’s wrong, my case is set out in [4, Chap. 14]. Nonetheless, that opinion underpins the biomedical model psychiatrists talk about (the one they have never written, see Chap 2 in [4]). They’re thinking in terms of linear causation, that event A leads to event B and thence to C, etc, when the reality of mind and much biology is non-linear.

The position at present is that the idea of a reductionist biological psychiatry dominates the field but it is based in an old and, I have argued [4, Chap 2; 8], outdated concept of science. Vast investment of time and money in biological psychiatry has failed to reveal anything of even remote interest; it survives on promise alone. Strictly speaking, as per the dictates of a valid philosophy of science, biological psychiatrists should set a date or an event that would force them to give up but they never have, mainly because their egos get in the way. After all this time, they just can’t admit they could have been wrong all along.

So back to the comments from last week. The term “mental disorder” itself says only that people assume something in the mental realm is wrong and must be explained. It wasn’t intended to imply a biological cause but it’s ended up that way, just because establishment psychiatry doesn’t pay more than lip service to the idea of researching psychological matters in psychiatry. They can study social factors, such as the relationship between alcholism and depression, because that evades the rule against mental factors but that’s all. As the reader says, the belief that all mental disorder will reduce to a special case of brain disorder is purely speculative, it has never been justified. However, if you say that out loud, you’ll wear a torrent of abuse from the mainstream, as in “The lady doth protest too much, methinks.”

Comment No. 2 comes from a medical student, starting with: “The idea that to be biological, categories must map onto distinct causes with no crossover is patently untrue.” What I said was:

The categorical approach in DSM only makes sense if we assume that all mental disorder is biological in nature, that each distinct surface syndrome will map down to a specific disorder on the genome with no cross-over.

The context was that Blind Freddy can see that all measurable parameters in mental life distribute dimensionally, not categorically, so why did the DSM-III committee build their system on such an obvious error? It has to be that they were preparing the ground for a full-blown reductionist biological psychiatry. If they had another reason, I’d love to hear it but I’ve never seen anything that would qualify as a justification. He continues: “Happens just as rarely in physical medicine as psychiatry,” and suggested Type II diabetes (obese type) as an exemplar. Before we start on that, what about Huntington’s Disease? Kartagener’s syndrome? Type I diabetes? Every known infection and so on? Here, the surface manifestation maps down to a very specific and unique biological cause.

The example he uses, generally known by the dopey expression “Metabolic syndrome,” is in fact a good example of the very complex feedback systems in the body, but they start with a psychological fact: the person eats too much and doesn’t exercise enough (to digress: Wikipedia: “In the U.S., about 25% of the adult population has metabolic syndrome, a proportion increasing with age…” In the 1950s, it was practically unknown, especially in countries that still had rationing from the 1940s. Look at this photo of the early Rolling Stones: they were NORMAL. In my high school of 1100 kids in the early 1960s, there was one child who would qualify as obese. He was a pom and had arrived here seriously overweight. He died years ago. These days, I can go to the shops and half the kids waddling past are as fat as he was). A high fat, high calory diet causes obesity and changes in the bowel flora which increases bowel wall permeability to chemicals with kinin-like activity and contribute to insulin resistance. One physical state leads on to another, with each biochemical step along the way carefully charted. How does that relate to depression as a unique, stand-alone biological disease of the brain? It doesn’t. Despite spending untold billions on basic research, biological psychiatry can’t offer any potential pathways by which brain states influence mental states. It’s all promissory materialism.

I’ve made the case that the most common cause of recurrent or persistent depression is an unsuspected anxiety state [9]. Anxiety is to be seen as purely psychological with no significant genetic component, while depression follows it as a realistic mental reaction to a troubled life. One mental state causes another, then the impairment of depression feeds back to intensify the anxiety, wholly as a psychological phenomenon. That’s not too complicated: mental disorders have mental causes. Mainstream psychiatry refuses to consider this (the local journals wouldn’t even review my book, that’s how hostile they are, but they wouldn’t give reasons).

What is called “comorbidity” in psychiatry is a perversion of the medical term. It is taken to mean “co-occuring but causally independent conditions.” A person can therefore have half a dozen or more diagnoses: Major depression, generalised anxiety, obsessive-compulsive disorder; social phobia, ASD, borderline personality disorder, avoidant PD, sleep disorder, tic disorder and so on. I’ve seen people who have been given up to a dozen separate diagnoses and a drug or two for each one, e.g. an 18yo woman who (from memory) had had eleven diagnoses and 32 different drugs plus ECT in three years. It’s crap. They were all seriously anxious; when the “comorbid anxiety” was managed effectively, all the other stuff disappeared, like when the over-eating and lack of exercise is managed, all the other components of the so-called metabolic syndrome disappear. Psychiatry refuses to believe that mental problems have mental causes. That’s because reductive biological psychiatry is an ideology of mental disorder, not a rational science [8, Chap 2].

There is an important principle in philosophy generally known as Occam’s Razor, or the principle of parsimony. It says that the number of explanatory entities must not expand beyond the minimum required to do the job: “Of two theories competing to account for an observation, the simpler explanation is to be preferred.” Psychiatry has two theories competing to account for the observation of mental disorder, the reductive biological account and the psychological. The biological says: mental disorders have biological causes, i.e. it is a branch of the ontological position known as physicalism (previously materialism). Jeremy Stoljar at ANU, probably the preeminent authority on physicalism, says it won’t work [10]. He says that the notion that knowledge of the brain will fully explain mind is either a boring truth that doesn’t advance our knowledge, or an interesting idea that just happens to be wrong. It is not and never can be both true and interesting.

If we look at Richard Carrier’s brave reductionism (“So, theoretically, all of sociology and psychology can be described entirely by physics…”), it reaches the point where he has to explain how a fundamental particle can have a sense of humour. It can’t be done. There’s another old idea called panpsychism, the notion that all elementary particles are endowed with a tiny quantity of mentality. When enough particles come together to form a brain, a mind ensues and takes control. I’ve always thought this was a bloody stupid idea but it’s had a second coming recently based on the notion that the non-physical cannot arise from the physical. I have a paper due for publication soon, building on the biocognitive model [9], that shows exactly why it’s a bloody stupid idea because the non-physical can definitely arise from the physical. It’s called information. So back to Bro. Carrier: stepwise reductionism as per his plan is exactly what biological psychiatry needs to write their phantom biomedical model. In their naivete, they think it provides a resolution of the mind-body problem but it doesn’t, because they still have to admit that mental matters are real, that simply wanting to move a pile of bricks will eventually move the bricks. The argument is more complex than we can cover here but it leaves them no wriggle room: intellectually speaking, reductionist biological psychiatry is flogging a dead horse.

The alternative is the psychological account: the mind is a real thing arising from the brain’s computational capacity by rational processes, and mental disorders have mental causes. That’s pretty simple: depression is a reaction to life events. I have outlined [9] how this can come about, essentially a form of paralysis, as it were, of the brain’s real but poorly-understood reward system. Just as the perception of a threat activates the sympathetic nervous system, producing among others a rapid heart rate, so too the perception of a major loss deactivates the brain’s “pleasure centres.” This produces a picture of apathy and detachment which, if it goes on long enough, results in a sense that life is pointless so it may as well end. This is not a complicated notion. The only thing that stops mainstream psychiatry adopting it is their adamantine refusal to look at anything that says mind is a real thing, i.e. any theory that says they could be wrong. That, of course, is the antithesis of the scientific attitude but we won’t start on that now (see [11] for some details of the mind-numbing recalcitrance of the RANZCP).

The biocognitive model [9] offers a resolution of the mind-body problem specifically for psychiatry but, in doing so, it consigns biological psychiatry to the history books. A corollary of that model is that animals have minds but don’t tell that to psychiatrists, you’ll get a diagnosis of schizophrenia.

References:

1. Scull A (2022) Desperate Remedies: Psychiatry and the mysteries of mental illness. London: Penguin.

2. Harrington A (2020). Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness. New York: Norton.

3. Robinson DN (1996). Wild Beasts and Idle Humours: The insanity defence from antiquity to the present. University Press: Harvard.

4. McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon.

5. Hahn H, Neurath O, Carnap R (1929). The Scientific Conception of the World: The Vienna Circle. Ernst Mach Society, University of Vienna.

6. Masson JM (1984). The Assault on Truth: Freud’s suppression of the seduction theory. New York: Simon and Schuster.

7. Carrier, R. (2005). Sense and Goodness Without a God: a defence of metaphysical naturalism. Bloomington, IN: AuthorHouse. (Kindle version)

8. McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London: Routledge. Amazon

9. McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. Amazon.

10. Stoljar D (2010). Physicalism. Oxford: Routledge.

11. McLaren N (2023). The Biopsychosocial Model and Scientific Deception. Ethical Human Psychology and Psychiatry, 25: 106-118.doi:10.1891/EHPP-2023-0008.

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My critical works are best approached in this order:

The case against mainstream psychiatry:

McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry. Ann Arbor, MI: Future Psychiatry Press. Amazon (this also covers a range of modern philosophers, showing that their work cannot be extended to account for mental disorder).

Development and justification of the biocognitive model:

McLaren N (2021): Natural Dualism and Mental Disorder: The biocognitive model for psychiatry. London, Routledge. At Amazon.

Clinical application of the biocognitive model:

McLaren N (2018). Anxiety: The Inside Story. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

Testing the biocognitive model in an unrelated field:

McLaren N (2023): Narcisso-Fascism: The psychopathology of right wing extremism. Ann Arbor, MI: Future Psychiatry Press. At Amazon.

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