Logical Errors in Mental Health

Rob Ryley

 

Not a day goes by without some magazine, newspaper, or TV program reciting some common claims of mental health professionals. Unfortunately, some of these claims are plainly illogical or scientifically dubious, once you do a bit of reading and thinking. Others are not explicit statements. Rather, they are either assumptions presented as observations, or value judgments stated as facts. Either way, they prevent the listener from reasonably assessing the validity of the argument and making their own conclusion. Here are some pertinent examples.

Mental diseases are brain diseases.

This is a common claim made today, with the "re-medicalization" of psychiatry. Unfortunately, this statement has more to do with politics than scientific facts. There are a few flaws to this:

1. " Mental disease" (the term mental disorder is more modern) encompasses vaguely defined area of behavior. Diverse phenomena, such as Alzheimer's disease, alcoholism, schizophrenia, and conduct disorder are all referred to as "mental disorders." But are all of them necessarily brain diseases? Is there anything that they have in common? Not really, other than the fact that doctors define them as "mental disorders". In obvious brain disease, there are frequently (but not always) verifiable signs of neurological disorder, such as unsteady gait, impaired consciousness, or obviously impaired cognition and memory. It is also possible to test for most types of brain diseases with laboratory techniques (either while alive or at autopsy). Groups of people considered "mentally ill" do not routinely exhibit any of these signs reliably, nor are there any objective laboratory tests to aid in diagnosis (Kaplan and Saddock, 1996, p. 12). Indeed, the first step in the diagnosis of mental disorder is to rule out any general medical condition.

With other medical conditions, it is possible for a disease to be present, yet the doctor is unable to detect it, since no signs or symptoms indicate any problem (HIV infection is a good example). Yet, does it make sense to call someone a "latent schizophrenic", meaning they "have schizophrenia" yet do not show symptoms? How would you separate the merely odd from the psychotic? While the term disease refers to biological events, the term "mental illness" refers to interpretations of behavior. Analogies comparing the two are flawed because they neglect this.

2. Mental illness is often used as an ad homenim to discredit the individual. This has been a common use of psychiatric diagnosis in psychiatry in Russia. " ...there are two main groups [of schizophrenia patients] ...1) people admitted to the mental hospital long before they had been political dissenters ...2. others who... have put forward complex social and economic theories as alternatives to orthodox Marxism..." (Wing, cited in Szasz, 1994, p. 126).

A similar situation has happened in America. Veterans who described the horrors of Vietnam were originally said to be schizophrenic and suffering from "long-term psychiatric disorders that induced delusional thinking about the war." There must be a lot of "crazy" people because the U.S. Army used tough screening procedures to keep such people out of service. During World War I, more than one million draftees were considered emotionally unfit for service. (Kutchins and Kirk, 1997, p. 105-108). Rather than realizing that war is hell, the Veterans Administration chose to use psychiatry to discredit the soldiers' stories, and failed to assume responsibility for helping these troubled men adapt to civilian life. This sad situation changed when veterans organized, and with some political pressure, got a diagnosis (now known as Post Traumatic Stress Disorder) in the DSM. (Unfortunately, the only way to help someone today is to give them a DSM label).

3. All of those fancy brain scans, showing major differences in the brains of mental patients and normals fail to take one thing into account: few of the studies have been replicated successfully. In peopled labeled with schizophrenia, there is a tendency for some to have enlarged ventricles, signifying brain matter loss. Yet, this phenomena is common in other conditions that do not resemble schizophrenic behavior, and it is quite likely that a person will have enlarged ventricles, yet not have a diagnosis of schizophrenia. It is also possible for a person to be "schizophrenic" and yet have a normal brain. In short, the differences are not statistically, nor scientifically, significant. (Ross and Pam, 1995, p. 55-57)

Those who consider mental illness a synonym for brain disease fail to take into account the difference in social roles of brain damaged and mental patients. A brain damaged person is presumed competent, unless there is sufficient reason to view him or her as incompetent. A mentally ill person, however, is by definition incompetent. Even when a brain damaged person is considered incompetent, they are treated differently than a mental patient. All analogies between psychological "illnesses" and physical illnesses are faulty, since they neglect how the diagnosis affects a persons social status.

"It is conceivable, of course, that significant physico-chemical disturbances will be found in some 'mental patients" and some "conditions" called 'mental illness". But this does not mean that all so called mental illness have biological causes, simply because it has become customary to use the tel111 'mental illness" to stigmatize, or to control--the person whose behavior offends society.." (Szasz, 1974, p. 101-102)


Schizophrenia is a genetic neurobiological disorder.


This statement is based on a very superficial reading of the scientific literature. This is understandable, as most psychiatry journals won't publish anything that criticizes biological psychiatry. Consider these facts:

1. The pairwise concordance rate (the proportion in which twins share a diagnosis) for ill twins ranges from 15%-71%, depending on the investigator and time period. (Boyle, 1990, p. 119). Early studies often had very high rates because of poor research design and investigator bias. The later studies often vary because of differences in diagnostic criteria and research design. (Generally, only significant differences are found with very liberal and vague criteria). Given that the rates are far from reliable, this should increase suspicion of their validity.

2. Most of the cited twin studies used subjective impressions based on the appearance of individuals to determine whether a person was an identical or fraternal twin. Unfortunately, similarity of appearance is not a reliable indicator of identity. It is quite possible that the diagnosis of a subject influenced whether a researcher considered them an identical or fraternal twin. "In MZ [monozygotic or identical twin] pairs where one had been hospitalized, the appearance of the pair may have become dissimilar. Thus, the disconcordant MZ pairs might have been judged to be DZ [fraternal twins], and the MZ concordance rate inflated" (Boyle, 1990, p. 122). In addition, it is likely that identical twins have much more similar environments then fraternal. This is avoided with the "equal-environments assumption" which allows hereditarians to avoid any talk about environmental factors without citing evidence.

3. Much genetic research is based on the concept of a "schizophrenia spectrum". Although it may be acceptable for categories with proven validity, this cool trick enables researchers to manufacture statistically significant differences out of nothing. According to this theory, if a person is related to a schizophrenic, and (in the eyes of the researchers) appears to behave in a similarly strange way, even if he or she does notqualify for a diagnosis of schizophrenia, they are considered "inside the spectrum." and counted as a match. In one widely cited adoption study by Kety and his associates, the spectrum was so wide it included patients originally diagnosed as "manic depressive" by the hospital doctors who actually saw the patient. (Boyle, 1990, p. 148)

There are other flaws to these studies, which are too numerous to detail here. I suggest you check out the sources at the end of this document and respond to all claims of genetic influence on some behavior with a good degree of skepticism.

Family inheritance of a disorder indicates genetic influence.

This is a common fallacy when interpreting identical twin studies. Strictly speaking, the presence of a relative does not indicate whether a particular disorder is inherited or environmentally induced. The only time a conclusion can be made is when a person has a disorder, and there is no family pattern. Only then is it safe to rule out genetics as a cause.

I believe the main reason this faith in genetics exists is because of the misconception we have about genes and it such explanations appear to absolve people of responsibility. We assume that if it is genetic, it is unchangeable. Furthermore, if a person's mental disorder is biological, we can't hold them accountable for the behavior. Unfortunately, those premises are flawed. It is not at all clear what role genetics has on our behavior. Even if something is genetic, it doesn't mean environmental modifications are useless. Diabetes (a favorite example of psychiatry) is partly genetic. Yet, if a person eats a healthy diet, they may never develop symptoms of diabetes. The role of genetics is grossly oversimplified in social sciences. This is not done in other areas of medicine.

Schizophrenia is a disorder because we can treat it with drugs

This claim fails for a few reasons. First, simply because a person sees a doctor, complains of some problem, and then takes a pill for it, does not necessarily mean that there is necessarily some biological malfunction. This confuses the patient role with the condition of the person's body. If we want to use language precisely, scientists should use terms like "disease", and "disorder" to mean verifiable and measurable biological abnormalities. To do otherwise is unscientific.

Second, rather than clarifying what they mean by a "mental disorder", psychiatrists describe what they do to someone who they consider "sick." If a psychiatrist considered theft a disease and chopping of the hand effectively deterred this behavior, would it be considered a surgical treatment? If not, why?

Convincing the public that mental disorders are biological will reduce the stigma.

Only a blatantly ahistorical person would believe this remark. One need not have a Ph.D in history to recall how the ancient Jews ostracized lepers. More recently, consider how persons suffering from tuberculosis were quarantined. Finally, HIV infected patients also come to mind. They suffer a tremendous stigma on top of the strain from their disease. Few doubt the biological reality of AIDS, yet people avoid them just the same. Why would psychiatrists think people will treat mental patients with dignity simply because doctors consider them "sick"?

Chemical imbalances cause severe mental disorders (e.g. schizophrenia), just like a lack of insulin results in diabetes.

This claim is similar to the idea that drugs used to control behavior proves the condition is biologically caused. On the face, it appears sound. But, considering that there is no laboratory test to measure these hypothetical "chemical imbalances". Just where does this idea come from?

Psychiatrists accidentally discovered neuroleptics could control the behavior of psychiatric inmates considered psychotic. Later on, it was found out that these drugs inhibited the action of the neurotransmitter dopamine. Psychiatrists inferred that schizophrenics had a chemical excess of dopamine (or too many dopamine receptors).

Later on, scientists found a synthetic drug named L-Dopa induced bizarre hallucinations and psychotic symptoms in Parkinson's patients. It was later found out that L-Dopa increases the action of the neurotransmitter dopamine in the section of the brain called the substansia nigra. By analogy, psychiatrists declared schizophrenics suffering from a "chemical imbalance" of dopamine, simply because their psychosis resembled the drug induced symptoms of Parkinson's patients. This is the primary support for the much touted "dopamine theory" of schizophrenia.

First, the doctor has no reason to believe there is actually a "chemical imbalance" in the brain of a psychiatric patient. A person may have a perfectly normal brain, yet still exhibit the behaviors in question. Without any tools that measure the chemical levels, the claim that there are imbalances is premature. Just as medicine rejects theories that postulate "energy imbalances" as causes of disease because it isn't measurable, likewise the "chemical imbalance" model should not be accepted until psychiatrists 1) define what a "chemical balance" is, and 2) specify at what level are the chemicals out of balance. Then, the "chemical imbalance" theory would be testable.

As for the resemblance between drug induced psychosis and schizophrenia, it is not as simple as it appears. It takes a large logical leap to suggest simply because two groups look the similar, they have the same cause. Both a flu virus and an allergic reaction can cause a runny nose. Yet, these are two very different situations, requiring different treatments. Appearances can, and often are, misleading.

The DSM is a scientific manual and accurately classifies mental disorders.

In the obsession to appear scientific, psychiatry and mental health practitioners are increasingly interested in diagnostic reliability and the use of psychiatric labels. Proponents of classification claim that one essential function of science is to group things together in a sensible system. What they fail to see is that classification presently used in psychiatry is often counter-productive, arbitrary, and politically motivated. It also blurs the distinction between disease and diagnosis.

Many professionals fail to understand the distinction between diagnosis and disease. If you really think carefully about how the words are used, you will understand they are not entirely the same thing. Historically, disease originally meant some physical alteration or deviation of the body. "It was not until Virchow delivered his famous twenty lectures ...that that the model of disease as cellular pathology was firmly established" (Szasz, 1988, p. 8).

Diagnosis refers to a physician's judgment, based on current medical knowledge, of what ails a person. It is quite possible for a person to suffer from a disease, but not have a diagnosis. While disease entities and patterns exist in nature, diagnosis is the social identification of a person as "sick" and entitled to the benefits of the "sick role." Diagnosis is what entitles a person to health care, whether they are "really sick" or not. In other areas of health care, diagnosis is usually based on scientific knowledge. In mental health, political considerations take over.

Consider the case of homosexuality. Did scientific factors lead psychiatry to eliminate it as a label in the DSM? Hardly. According to Kutchins and Kirk (1997) radical gay rights protesters lit the fuse that eventually blew the diagnosis of homosexuality out of the manual. " The impact of outsiders is worth noting... Even though gay psychiatrists were far more prominent and better organized as time went on, their efforts were ineffective when compared with the impact of outside agitation" (p. 65-66).

Although many believe the DSM is a scientific document, its most important function is insurance reimbursement. Drug companies playa particularly important role in the development of diagnostic categories. As Ketcham and Kirk (1997) explain: "Drug companies have a direct financial interest in expanding the number of people who can be defined as having a mental disorder and who then might be treated with chemical products" (p. 13). Might this explain the dramatic increase of diagnoses in DSM?

Given the significant economic and political factors influencing psychiatric diagnosis, the DSM is given much more authority and credence than it deserves. Until people recognize this, we will never come any closer to dealing with the troubling problems the "mental health bible" tries to label.

References

Boyle, Mary (1990) Schizophrenia: A ScientificDelusion? New York, NY: Routledge

Caplan, Paula J. (1994) They Say You're Crazy: How the World's Most Powerful Psychiatrists Decide Who's Normal. New York, NY: Addison-Wesley Publishing Company

Kaplan, Harold I., Saddok, Benjamin J. (1996) Concise Textbook of Clinical Psychiatry. Baltimore, MD: Williams & Williams.

Kutchins, Herb & Kirk, Sturart A,. Making Us Crazy: The Psychiatric Bible and the Creation of Mental Disorders New York, NY: Free Press

Ross, Colin; Pam, Alvin. (1995) Pseudoscience in Biological Psychiatry: Blaming the Body. New York, NY: John Wiley & Sons Inc.

Szasz, Thomas (1974) The Myth of Mental Illness: Foundations of a Theory of Personal Conduct. New York, NY: Harper and Row Publishers.

Szasz, Thomas. ( 1988) Schizophrenia: The Sacred Symbol of Psychiatry. Syracuse, NY: Syracuse University Press

 

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