I Wonder if There is Some Axis II Going on Here? Further Thoughts on Muddled Thinking

Sandra Steingard, MD



1BoringOldMan invited me, after I commented on his site that I was uncomfortable – in a vague way – when he wrote about Schizophrenia, to elaborate.   In several posts (here and here), references were made to “A list” conditions – always including Schizophrenia – that correspond more directly to biomedical conditions than the vast majority of diagnoses in the DSM.  A number of years ago, if I had made a list like that, Schizophrenia would have been included.  But when I do that thought experiment now, my list remains blank.

When I finished my training in psychiatry, it was clear to me that the concept of depression was amorphous.  The kinds of people who would fall into the category of Major Depressive Disorder were so varied  as to make the term almost meaningless.  The various explanatory hypothesis for the causes of their troubles were broad, ranging from childhood trauma to unconscious conflicts to recent life stresses to abnormalities in their neurotransmitters.  I found it confusing and frustrating. Although some of these explanations may be valid, I did not have an accurate way to apply a particular explanation or set of explanations to any given individual.  In supervision and discussions with colleagues, everything was on the table; there seemed to be a problem with quality control.

At that time, I was not as confused when it came to the people I met who were experiencing problems that I label psychotic – hearing voices, having beliefs that did not appear to be true, having confused thoughts.  The conditions – as manifested in different individuals – did not appear to be as varied.  I was more comfortable with the categorizations of Schizophrenia and Bipolar Disorder. I was more comfortable using a disease model to understand their problems. 

Over time, my thinking on this has changed.  The easiest way to express this is that I am now as muddled in my thinking about the nature of psychosis as I am on just about everything else in psychiatry.  After a career of spending my days talking to people who hear voices or have beliefs that no one else shares or have a confused or disorganized manner of communicating, I see more variation among them than similarity.  People who “have schizophrenia” are asocial?  Well how does that comport with the vast social network so many of the people I work with have?  People diagnosed with Bipolar Disorder have episodes of illness interspersed with periods when they are symptom-free?  So how does that comport with the fact that so many of these people struggle to some extent in between their so-called episodes?   I have been told many times by colleagues something along the lines of  “Well I think he has Schizophrenia but he is so social.”  Or, with one of the worst phrases uttered in our field  when a person with, let’s say, psychosis remains troubled in some way after taking our drugs, “I wonder if there is some Axis II going on here?”

But equally important is the observation that the line that I thought demarcated psychosis from other states of consciousness is at best a big, blurry, and indistinct smudge.  This has been an area of curiosity and interest for me for many years.  What is the line between religious belief and religious delusion?  One person I know once said to me when I asked him about voices, “Well doc, I know you don’t believe this but I am not hearing voices anymore. But God is still talking to me.” 

What is the line between political delusion and fanaticism and passionate ideology?   Another person I knew initially thought that the government was communicating with him through the airwaves and he was a covert operative, paid monthly through what others thought were his Social Security checks.  As he “got better”, I found him one day reading a book about the JKF assassination.  It was a book suggesting some conspiracy theory.  Was he still ill?  Is everyone who believes there was a second shooter in the JFK assassination ill? He showed me a picture of  Howard Hunt taken in Dallas in 1963.  Hunt was one of the guys who broke into the Watergate complex during the Nixon administration.  I was obsessed with Watergate in 1973. Was I ill when I was so preoccupied with Nixon and Watergate?  Was I ill when I was convinced that Nixon was involved even before there was full disclosure and then recovered when the tapes were revealed? (Apologies to those of you too young to remember this time.)

Many of us look at the same political system and come away with deeply held but opposite formulations of the situation.  Am I mad when I read the psychiatric literature and come up a different  interpretation than many of my colleagues? I honestly do wonder, when I spend a quiet Saturday writing this, what keeps me so preoccupied while others can walk away and still feel good about their careers in psychiatry. I do not ignore or dismiss that some ideas are more  profoundly disturbing for the individual and those around him than others.  My only point is that I no longer see a line that clearly demarcates sanity from madness.

I used to think I could tell the difference between the voices experienced by someone labeled with schizophrenia and the voices of someone who is experiencing a dissociative episode.  The former, I thought, would be related to some distinct – probably fixed – altered brain state. The latter due to a more transient and reactive state.  The former would best be treated with drugs, the latter with psychotherapy. I even wrote a paper about this many years ago.  Although I still suspect that there are a variety of different kinds of conditions or states which might result in a person hallucinating, I no longer feel confident in being able to make that distinction. I am also not sure they are entirely distinct.  Maybe they are overlapping.  Remember; I admitted to being muddled on this.

I am not someone who finds it useful to make a distinction between the mind and the brain.   In my view, we are talking about the same thing but at different levels of abstraction. What we think, feel, hear, and see is all processed through the brain.  Some of this is easier to  parse out. In my college neurobiology class, I learned from the Nobel Prize winning scientist David Hubel how the brain “sees” moving objects. We saw neurons “react” to the alterations in light.  Of course that is a long way from understanding why we think a particular painting is beautiful but it is a start.  Even before I moved to Vermont, I knew of one of our most famous citizens, Phineas Gage, whose personality changed after a tamping iron was lodged in his brain’s frontal lobe.  This was an early confirmation that things as complex as social comportment and motivation were related to brain function.

I also understand that in all of medicine, the concepts of illness and disease are increasingly amorphous. We tend to think about the clearly defined entities – a strep infection that clears with a 10 day course of penicillin – and forget the many shades of grey.  Many of us harbor pathogens that do not make us sick. There is an increasing focus on the microbiome – the many bacteria that live on and within our body.  Most of them not only do not make us ill but may promote our health.  Even cancer is defined more on a gradient than in a categorical way.  There are many lesions in the body that are not clearly cancerous but are also not clearly normal. The notion that there is a clear line between health and illness in this realm is fuzzy – we all have cells that have a malignant potential but our body polices and eradicates them most of the time.  Yet, to tell someone who is dying of cancer that she does not have an illness or that the condition that is killing her is a construct begs absurdity.

Does this inform us about how we think about psychosis?  Does the problem just lie in a popularly held but antiquated notion of what an illness is?  Is it possible that a complex array of events – genetic vulnerability, nutritional deficiencies, life stress – can culminate in one person experiencing some passing phase of mild altered thinking that will resolve with sleep and support from friends while in another person lead to a sustained state that holds on for months if not years?   Is a state induced by heavy drug use similar to or different from a state that appears to be induced by intense emotional or physical abuse?  Do we really need to understand the workings of the brain to help a person who suffers in this way?  Does our message – that this is a disease – relieve guilt and shame or exacerbate it?  Is it helpful to have psychiatrists? Are we doctors of the brain or of the mind? Do we just confound and confuse?

Although I end up with more questions than answers, there are people who have helped me gain some clarity.  One of them is the British psychiatrist, Joanna Moncrieff. In her books, “The Myth of the Chemical Cure” and “The Bitterest Pills” she makes the distinction between a drug centered and a disease centered approach to thinking about psychoactive drugs.  She has written about this on MIA, where there is also a critique of her recent book.  The disease-centered approach is predicated on the notion that a) we have identified the specific disease or pathophysiology that underlies a particular symptom or syndrome and b) the drug targets that particular abnormality. The drug-centered approach takes into account that a drug has psychoactive effects. Some of those effects may be useful for some people but, if so, it is not because it is correcting a specific underlying problem.  An important advantage of the drug-centered approach is that it is more intellectually honest since we have yet to define any particular diseases or brain abnormalities associated with the various mental states that we label as disorders.  It can also help to protect us from minimizing the problems these drugs cause.  In the disease-centered model, these problems are considered side effects that need to be tolerated in order the treat the disease. In the drug-centered model, we are more likely to consider all of the effects of a drug and then determine with our patient whether these effects  yield more benefit than harm.  The disease-centered model has resulted in our forming the premature conclusion that we understand these altered states, and it has contributed to some of us  being more sanguine about forced treatment because it allows us to think that – rather than just tranquilizing people to contain problematic behavior – we are treating a disease.

Another blogger whose work I admire is Nev Jones who writes at her site Phenomenology of Madness.  Nev and her colleague, Layasha Ostrow started LERN.   Nev writes about her own and her family experiences with – to use her term – madness. One of her more poignant posts is here.  She is so articulate and careful with her language (among other things, she is philosophically trained) that I hesitate to say more and risk misrepresenting her.  She is an activist and a scholar and I find her courageous in her willingness and ability to articulate difficult and sometimes unpopular positions.  But if I were to encapsulate the one point Nev has so clearly articulated for me, it is the concept of heterogeneity.  Any attempt to label just stomps upon the rather vast conditions or states or experiences – words just plain fail me here – that I observe almost every day.  

A friend who has been a helpful editor has commented that I sometimes end rather abruptly.  I fear I have done it again.  As I said, I am pretty muddled.  But this is already pretty long so I hope anyone who has made it this far is not too disappointed.


  1. I appreciate how this post breaks down the difference between the disease centered approach and the drug centered approach. It’s always seemed to me, from my earliest moments researching drugs for my own experimentation, that it makes sense to consider the person holistically, the drug holistically, and all the interactions between the two. To say that any psych drug treats a specific disorder and everything else is a “side effect” seems to ignore the vast majority of what’s happening when I take a drug.

  2. Thank you for this clarity (ironically). After having spent the last 30 years of my life living, studying, experiencing, suffering through, medicated for, and eventually finding my way off meds and healing from all this mess, I agree completely and resonate whole-heartedly with the muddled-ness of it all. This alone, drove me crazy, in a painful and disorienting way, as I tried to make sense of my experience.

    I think a big part of it, of course, is all the deceit, mythology and general lack of understanding of the human spirit which exists in this field. Attempts at practicing the healing arts and sciences from a place of integrity and self-awareness are grossly overshadowed by all the now well-publicized fiascos of psychiatric treatment and the mental health system, in general.

    This one question stood out to me when I read your article–

    “Do we really need to understand the workings of the brain to help a person who suffers in this way?”

    I’m feeling bold, so I will disclose my own personal response to this, because I feel strongly about it. From my experience of mental health, my unequivocal belief is that no, we do not need to understand how the brain works in order to relieve a person suffering from this kind of chronic pain, whether mental, emotional, physical or spiritual. I believe that trying to understand the brain overcomplicates the actual healing, and that, perhaps, it is this pursuit of understanding how the brain functions in order to resolve these issues of mental health, is what contributes to a lot of the muddled-ness. In my journey, I found this knowledge, while interesting, relatively inconsequential to healing—both, for myself, and for the clients which I now support.

    For me–and I do wonder to what extent this could be generalized, I don’t want to ever make that assumption when I write or talk about my healing—what worked was to understand how my heart had been wounded and spirit broken, and then I focused on healing these in present time. That’s a process that benefits greatly from having safe and trustworthy support.

    Then, I learned my spirit, which is not only more practical, but much easier to learn than the brain. How we learn our spirit is not a universal process, this is where our individual paths lead us to know ourselves. That is our own creativity.

    In the course of all this, my energy calmed down a great deal, and I learned how to become grounded. I learned to quiet my mind—which was a miracle, in and of itself—in order to feel life in a way I never had. As a result of grounding and learning self-compassion, my brain healed from the damage of emotional trauma and medication trauma. With patience and a dedicated desire to focus, my neurons followed suit.

    So that was the shift in focus that lead to clarity and healing–from brain to spirit, via the heart. It’s a whole new world, in that shift.

    Thank you again for this enlightening article. I really enjoyed reading it, rang so true.

  3. How many people have been diagnosed “psychotic”, and therefore “ill”, for believing that the US government was spying on them? In the aftermath of the Snowden revelations about the scope of the NSA operations, I think that many American psychiatrists should ask themselves how many lives they have ruined by labeling “psychotic” many such individuals. Not to mention that some do see psychiatry as a way to impose political ideology http://washington.cbslocal.com/2013/10/29/sean-penn-tea-party-ted-cruz-should-be-committed-by-executive-order/ .

    Sandra says that in his opinion “mind” and “brain” are the same thing. I beg to differ strongly. And I think that this “belief” that mind and brain are the same thing is the prime reason psychiatry has caused, and continues to cause, so much pain to so many people. The best way to understand this difference is to consider “software” and “hardware” in a computer. In a computer, “hardware runs software”, but software is not the computer running it, even though when a computer runs software, you can certainly see correlates between hardware activity (like billions of transistors of a CPU switching) and software.
    In fact, staying with the NSA story, such correlates are one of the most sophisticated ways to break otherwise theoretically correct cryptosystems https://en.wikipedia.org/wiki/Side_channel_attack .

    But software is not the computer. If you burn a computer that runs Windows, Windows still exists. Even if you were to burn all the computers that run Windows, and burn all the media, like DVDs, that store a copy of Windows, you could still reconstruct it, at least theoretically speaking, from the minds of the people who coded Windows. And even if you were to eliminate these people as well, Windows as an abstract concept would still exist and some other people could in theory reconstruct it. If you eliminate a brain, that brain is gone forever. The majority of people in the world -ie, religious people- believe that the mind continues to live after the death of the brain. I have come to think of government sponsored psychiatry as a violation of the “establishment clause” of the first amendment of the US constitution. The claim that mind = brains, that many psychiatrist believe, is the best example of this violation.

    • I agree 100% with your comments. No society in the history of the world that I am aware of, other than our own, has ever entertained the idea that humans are just bodies and that there is no spiritual reality or entity involved. What that entity might be is and will probably remain a mystery, but that doesn’t mean it doesn’t exist. Your hardware/software analogy is excellent, but I’d add also that there needs to be someone operating the software, someone who decides which programs to run and what data to enter and what a desirable outcome is. None of this is addressed by the “human as brain” viewpoint.

      Science is in truth a sub-study of philosophy. That’s why people get a “Ph.D.” even if they’re studying science. Psychiatry is based on some hard philosophical assumptions, such as “brain=Mind,” but tries to pretend that they are “obvious” or “unavoidable conclusions,” which is one of the classic sophistries used to slip unverified assumptions into an argument. In essence, they assume a conclusion and then reason from that assumption as if it is fact. And that, specifically, is what leads to the muddled confusion described in the article. Real science clarifies things. “Science” that creates more confusion is false science that rests on an incorrect assumption that the “scientist” is unwilling to let go of. That describes psychiatry to a tee!

      — Steve

  4. This is a great article, Sandra, but I part company with you on these two points:

    (1) “I am not someone who finds it useful to make a distinction between the mind and the brain. In my view, we are talking about the same thing but at different levels of abstraction”

    (2) “Phineas Gage, whose personality changed after a tamping iron was lodged in his brain’s frontal lobe. This was an early confirmation that things as complex as social comportment and motivation were related to brain function.”

    With respect to (1), I have found mind vs. brain to be absolutely critically when debating psychiatry. Breggin’s analogy of the crappy television show (the mind) not being the fault of the cable connection (the brain) is perfect. Rather than saying the mind and the brain are the same, I think it’s more accurate to say that the mind is “reflected” in the brain.

    And regarding (2), certainly Gage’s experience (and strangely we’re just covering that now in my introductory psych course) confirms that the mind can be changed by changing the brain. It’s a very far cry from that, though, to suggest that all trouble with the mind originates in the brain (which I’m not suggesting for a moment is the position that you take).

    I think it’s very telling that for all psychiatry’s bluster, they are still forced to stick with the term “mental illness” rather than “neurological disease,” at least when they’re talking to their patients or to the media.

  5. Curious question: what would happen if muddled thinking was an observed “symptom” in a person (aka patient) and how would that person be treated? Please consider both meanings of the word treat.

    treat (trt)
    v. treat·ed, treat·ing, treats
    1. To act or behave in a specified manner toward.
    2. To regard and handle in a certain way.

    a. To give medical aid to (someone): treated many patients in the emergency room.
    b. To give medical aid to counteract (a disease or condition): treated malaria with quinine.


    Are we doctors of the brain or of the mind? An unbalanced and imperfect combination.

    Do we just confound and confuse? In the worst cases, I think psychiatry / psychiatrists / the “mental” system effectively sabotages and destroys not only a person’s life, but the person themselves.

    I completely agree with Alex.

    I appreciate and admire you Dr. Steingard, and I enjoy reading your entries.

  6. I think that the only utility in having the labels is to differentiate those to whom the society should give a pass. In the US, everyone works. I think it is helpful to distinguish those who won’t work from those who can’t work. The latter should receive SSI or SSDI. Unlike Szaz, I do want to reserve the death penality for those who were capable of making another choice. If someone commits a crime while laboring under false assumptions, they should be judged by another standard. For purposes of working with people, labels are superfluous. You contract around where they view the problem or need for change. The label adds nothing.

  7. Thank you Sandra for this post. I have spent most of the last four years trying to understand my son’s condition. Is he bi-polar? schizophrenic? just sad and confused? born this way? Does he need drugs or better nutrition? Will he ever get better? After four years I still have more questions than answers. It is so good to hear a professional who admits to being confused as well. Thank you for your honesty!