When is a Science?

The Swedish botanist Carl Linnaeus (1707-1778) was one of the most influential scientists who ever lived, but Anglophone countries give him practically no credit. Working largely alone, he devised the binomial system used to assign a name to every living thing. For example, prior to his time, whales were considered fish because they lived in water. This could not be sorted out until Linnaeus showed how the relations between different species formed pathways, so that for fish, having scales and gills was the critical equipment that allowed them to live in water. For whales, having a uterus and breasts took priority, shifting them from the class of “fish with hair but no scales or gills” to “mammals that live in the ocean.” This was the foundation that allowed advances such as Darwin’s theory of evolution, Mendel’s genetics and so on. Without an adequate system of classification, science as we know it could not develop. What is not generally known is that classification is not science in itself, it is a preliminary to science. This point is of paramount importance for psychiatry. Following last week’s post, a (very experienced) reader asked:

How scientific is the DSM?

How do we judge whether a system is scientifically sound?

These questions underpin the entire critical psychiatry movement. We can answer the first one straight away: It’s not. A system of classification, or nosology, as it is known in medicine, is not itself scientific. It is the first step toward building a valid knowledge of a field, for example, classifying different types of rocks in geology. If they can’t be named so that everybody knows what is meant by “a granite outcrop” or “a breccia intrusion,” then there will be no progress. This happened in psychiatry. Psychiatrists threw around lots of big words which sounded very impressive but a study which began in 1966, the International Pilot Study of Schizophrenia, showed they were using the terms more or less randomly. There was no discipline. It was like one group calling whales fish, another correctly saying they’re mammals and a third saying they’re actually water dragons.

In 1973, to great fanfare, a group of psychiatrists in St Louis, Missouri, published a set of diagnostic criteria to be used in research [1]. Called the “research diagnostic criteria” (RDC), they were intended to select “pure” cases for research projects. That way, when somebody used the term “schizophrenia” in a paper, everybody would know just what it meant. Originally, these were not intended for clinical use as they were incomplete and selected only the clearest cases, leaving the bulk of less tidy cases unnamed. Of course, nobody took any notice of that and immediately began trying to apply them in daily practice so, in 1980, the diagnostic manual was rewritten in the same style.

Very deliberately, the new DSM-III did not make any claims about the nature or origin of mental disorder. All it said was a diagnosis of, say, depression can only be made when the patient shows just these features and not others. It nominates depression as “any condition that satisfies just these criteria.” It doesn’t say anything about causes but it opened an ancient trap for psychiatry, one that depends on the difference between naming something and explaining it. Knowing something’s name doesn’t tell us anything interesting about what it is, how it came to be or, most importantly, what it’s for. Physicist and Nobel laureate Richard Feynman (1918-1988) made this point at different times in his lectures:

See that bird? It’s a brown-throated thrush, but in Germany it’s called a Halzenfugel, and in Chinese they call it a Chung Ling and even if you know all those names for it, you still know nothing about the bird. You only know something about people; what they call the bird.

The point is that you cannot name something and explain it in the same speech act. Except in medicine. If I say to you “You have a carbuncle,” I have named it for you so you can tell your relatives but they’ll be none the wiser. Medically, however, I’ve gone a lot further. I’ve named it, described it and explained it (a single infection deep under the skin, usually Staph aureus, with pus pointing at several heads) because a large part of medical school is learning a million new names and what they mean. When talking to patients, I have to explain what a name means, but in talking to other physicians, I can leave that bit out because, by virtue of their training, they already know. Strictly speaking, this is an enthymeme, meaning an essential step in the argument has been left out. It’s only by exploring all the hidden premises that you can work out whether somebody is trying to pull the wool over your eyes.

Naming, describing and explaining are different speech acts. A coherent system of names is a precursor of science but it is not science itself as it has no explanatory or predictive value. Psychiatrists, however, misunderstand that bit. For the great majority who think only in biological terms, simply naming something also serves to explain it, just because they believe there is nothing else. They may be a bit fuzzy on the details (like, hopelessly fuzzy) but they assume that the act of giving a name to a condition also locates it in the biological framework, and thus serves to explain it. That assumption, however, is discreetly left out, making their argument an enthymeme. The correct response is to insist that they prove that all mental disorder is necessarily biological which, of course, they can’t do and their argument is therefore invalid [2, Chap. 2].

Another terribly important point the reader raised is this: If psychiatry can talk about mental abnormality, doesn’t that imply they have a clear understanding of mental normality, of where normal stops and abnormal takes over? This is another enthymeme: if we talk about abnormality, there is an unspoken assumption that we have a clear idea of normality. Which, in human terms, we don’t. People even refer to bad or depraved behaviour as “sick” but there’s nothing sick about it at all. There are wicked people, they exist and they are definitely not “sick.” I don’t mean there is some supernatural force called “evil” that takes control of people’s minds and makes them do bad things, I mean there are people who get a kick out of hurting or crushing or even killing other people. They know perfectly well that society prohibits it but as long as they can get away with it, they’ll do it. Trump showed this in his Access Hollywood tape: “I don’t even wait. And when you’re a star, (women) let you do it. You can do anything ... Grab ‘em by the pussy. You can do anything.” That’s not sick, it’s evil, as he knows because if somebody did it to him, he’d fall in a screaming heap and call the cops.

The problem of normal vs. abnormal is that, for two reasons, psychiatry doesn’t want to to deal with concepts of good and evil. First, it messes with their neat biological project which says: “If it’s not normal, it’s brain disease and therefore our baby.” Second, it implies that mental factors such as personality are both real and important and they have real moral values. Once that door is opened, psychiatrists have no way of limiting how much undesirable behaviour is actually psychological, not biological. In other words, they’d lose customers to, quel horreur, psychologists.

On their part, psychologists have spent a lot of time defining normal mental function. They have very elegant questionnaires that ask about your personality, and lots of tests that show how intelligent you are and where you stand in relation to everybody else. These show two critically important points that psychiatry doesn’t want to know about. First, they all show that normality is a broad range, not a point on a graph or a number on a scale. Normality and social desirability are two distinct concepts. A rowdy, impulsive person is just as abnormal as a tightly organised and super-responsible person.

Second, every measurable parameter of mental life has a dimensional distribution, i.e. normal blurs smoothly across to abnormal with no cut-off point. The idea that abnormal is a separate and distinct category from normal is simply false. But psychiatry is built on the notion of categories of abnormality, which leads to the absurd position where people end up with half a dozen or more separate diagnoses. So why bother? The answer is another unstated premise: that the ultimate goal for biological psychiatry is for each surface syndrome (depression, panic disorder, OCD, ADHD etc) to map down to a specific defect on the genome. Then pharmacologists will be able to devise a new drug for each defect and Bob’s your uncle, mental disorder is brought under control. Do they say this? No, it’s another hidden premise but the biological project in psychiatry doesn’t make sense without that one.

For these reasons, the DSM system is not in itself scientific. At best, it’s prescientific, awaiting proof of the biology. Note that after 75 years of intense biological research in psychiatry, there’s still no evidence that any true mental disorder has a biological cause. There are plenty of physical conditions that have mental complications, e.g. Alzheimer’s, epilepsy, even a broken leg, but the cause is physical. If, however, somebody were to show that some mental disorders are wholly caused by mental events in a healthy brain, then we would be forced to relabel the current DSM system as “pseudoscience.”

The reader’s next question leads to a much broader matter: “How do we judge whether a system is scientifically sound?” That’s called philosophy of science and is a very large subject in its own right. Large, fascinating and hotly contested but psychiatry quietly ignores some important rules, such as: No hidden premises. Everything has to be out in the open. There is another we’ve mentioned which psychiatry conceals: the ancient debate over good, bad and socially undesirable, i.e. morality. Psychiatrists will very quickly tell you: “We’re not in the business of making moral judgements. If you want morality, go and see a priest.” This rule comes from positivism, the philosophy that says science concerns itself only with things that can be seen and measured, not with metaphysical questions such as the meaning of life and all that [3]. Psychiatrists have to be as dispassionate as a surgeon deciding whether to operate on a convicted embezzler or child rapist. The proper attitude is objective and distant, with no emotional involvement as that is likely to bias proper diagnosis and treatment.

The problem is that that attitude itself produces bias, but hides it under “professional detachment.” Amanda A is aged 23 and is unable to work due to constantly arguing with people. From about age 5, she was fostered as her father went to prison while her mother was a drug user working as a prostitute. Through no fault of her own, Amanda was bounced between one foster setting and another, back and forth between distant relatives and strangers, losing contact with her various half-siblings and steadily becoming more and more anxious. From about 14, she began to conceal her anxiety under querulous suspicion. She sees a psychiatrist who diagnoses social phobia, panic disorder, borderline personality disorder, ADHD and type II bipolar disorder. She is told her problems are clearly genetic as a quick look at her entire family reveals unremitting disturbance. She is prescribed a range of drugs but there is never any discussion of her deep sense of loss and her fear of attachment in case she is again abandoned.

Brian B is 21 and, as he says, a total failure and oxygen thief. He has failed his university course twice and now can’t reapply but he has no work experience and doesn’t know what to do. He still lives with his parents but has few friends and says the thought of suicide is never far away. He has very little social life as he spends his nights playing games and sleeps all day. He first saw psychiatrists at age 10 when he was diagnosed with ADHD, inattentive type. Over the years, he has had various stimulant drugs but admits he never took them consistently as he sold them to buy computer games. This assessment was forced by his parents who were concerned he was actually autistic and should be granted some sort of pension and treatment rights. Slowly, reluctantly, he revealed a history of quite grotesque, non-violent sexual abuse by a neighbouring couple which started at about age 8 and continued for about five years. Apart from that, he said his home life was good but he never told anybody as he felt too guilty. The psychiatrist confirmed the diagnoses of ASD, ADHD, MDD and unspecified personality disorder. He was not referred for any sort of talk therapy.

Absolutely typical cases, we see them every day. The irremediable bias is the psychiatrist’s opinion that mental disorder is genetically determined, that psychological matters cannot influence genes, so that whatever the patient feels about his or her life amounts to nothing. This is the very antithesis of the scientific attitude, as it assumes humans are just lumps of chemicals whose course in life is not influenced by mental matters such as beliefs, emotions, hopes and so on. There is no proof of this. Instead, psychiatrists have convinced themselves they’re right and can’t possibly be wrong, that lay people are wrong and can’t possibly be right, and that any criticism is bad faith antipsychiatry, etc. Criticism of the status quo is the engine of scientific progress; without criticism, nothing changes and science degenerates into cultish or political dogma. This has happened many, many times in the past but it’s also happening now, all day, every day, in psychiatry. Their pseudo-objectivity conceals from psychiatrists themselves the fact that whatever they’re doing, it ain’t science.

References:

1. Feighner JP, Robins E, Guze SB, Woodruff RA, Winokur G, Munoz R (1972) Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry. 26: 57-63

2. McLaren N (2024). Theories in Psychiatry: building a post-positivist psychiatry.

3. Hahn H, Neurath O, Carnap R (1929). The Scientific Conception of the World: The Vienna Circle. Ernst Mach Society, University of Vienna. ). Reprinted in: Robert Scharf and Val Dusek (Eds.) Philosophy of Technology: The Technological Condition: An Anthology, Second Edition. (New York: J Wiley, 2014):101-110. http://rreece.github.io/philosophy-reading-list/docs/the-scientific-conception-of-the-world-the-vienna-circle.pdf

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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.

The whole of this work is copyright but may be copied or retransmitted provided the author is acknowledged.