Nassir Ghaemi and The Psychological Fallacy

On August 8, 2013, the eminent psychiatrist Nassir Ghaemi, MD, MPH, published an article on Medscape. The title of the piece is “The Psychological Fallacy in Psychiatry.” The article is almost four years old. Ordinarily I don’t discuss material this dated, but the content of this article is particularly important, and worthy of discussion, belated as it is.

NASSIR GHAEMI’S BIO

According to his bio, Dr. Ghaemi:

“…is an academic psychiatrist specializing in mood illnesses, depression and bipolar illness, and Editor of a monthly newsletter, The Psychiatry Letter (www.psychiatryletter.org).

He is Professor of Psychiatry at Tufts Medical Center in Boston, where he directs the Mood Disorders Program. He is a also a Clinical Lecturer at Harvard Medical School, and teaches at the Cambridge Health Alliance.

In the past, he trained and worked mostly in the Boston area, mainly in Harvard-affiliated hospitals (McLean Hospital, Massachusetts General Hospital, and Cambridge Hospital). He has also worked at George Washington University, and Emory University. His medical degree is from the Medical College of Virginia/​Virginia Commonwealth University.

His clinical work and research has focused on depression and manic-depressive illness. In this work, he has published over 200 scientific articles, over 50 scientific book chapters, and he has written or edited over half a dozen books. He is an Associate Editor of Acta Psychiatrica Scandinavica, and is a Distinguished Fellow of the American Psychiatric Association.

After his medical training, he obtained an MA in philosophy from Tufts University in 2001, and a MPH from the Harvard School of Public Health in 2004.”

So by any standard, Dr. Ghaemi is a highly educated, distinguished, and eminent psychiatrist.

THE PSYCHOLOGICAL FALLACY

Here’s the opening to Dr. Ghaemi’s Medscape article:

“How many times has a patient told me, when I asked about depressive or manic symptoms: ‘Yes, but I was depressed because of x, y, and z’? Or ‘I get manic when I get really interested in things’?

How many times have I seen psychiatrists downplay a mood illness diagnosis because they were associated with many psychosocial stressors?”

This is a little tangled, but let’s see if we can unravel it. The issue here is the obvious fact that people who are despondent can usually articulate, with a reasonable degree of conviction, why they are feeling down. And their explanations are generally credible. In other words, their sadness, far from being any kind of pathology, is actually the natural, understandable, and incidentally adaptive, reaction to adverse events or adverse life circumstances.

The great majority of psychiatrists reject this concept out of hand, and in his second paragraph quoted above, Dr. Ghaemi is castigating those psychiatrists who are deviating from the party line.

The party line is that once sadness crosses arbitrary and vaguely defined thresholds of severity, frequency, duration, and impact, it ceases to be ordinary sadness, resulting from loss or adverse circumstances, and becomes, by some miracle only understood by psychiatrists, a neurobiological illness — a real illness just like diabetes, that needs to be “treated” with neurotoxic chemicals and/or neuro-destructive electric shocks.

So these rogue psychiatrists are straying from the orthodoxy by expressing the belief that people who are burdened by excessive loss or difficulties are understandably depressed, and therefore not “diagnosable,” but Dr. Ghaemi is bringing them back to the fold in the fine tradition of psychiatric pedagogy.

Let’s address this issue by way of an example. Consider the cases of two people, Peter and Paul, who come within the orbit of psychiatry. Both have had recent losses and both are living in difficult circumstances, and both are despondent. The examining psychiatrist, Dr. Checkem, runs them both through the APA’s facile and unvalidatable checklist for major depressive disorder. He finds that Peter meets the first five of the nine checklist items:

“1. Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful). (Note: In children and adolescents, can be irritable mood.)

2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation.)

3. Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. (Note: In children, consider failure to make expected weight gain.)

4. Insomnia or hypersomnia nearly every day.

5. Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down).” (DSM-5, pp 160-161)

but Paul meets only four of the nine. Dr. Checkem works hard to “pin” a fifth item on Paul to clinch the “diagnosis,” but it just won’t fly, and he’s an honest doctor, so he notes “no diagnosis” in his assessment, and sends Paul home with advice to start a hobby, or have more sex, or take long walks, or whatever. But Peter gets a “diagnosis” of “major depressive disorder,” is enrolled as a “patient,” and given a prescription for a so-called antidepressant.

And incidentally, the only difference between the two men on the checklist items was that Peter reported a decrease in appetite and a 7% weight loss (from 150 to 140 pounds); but Paul reported no change in appetite and no loss of weight in the same time frame.

Now in fairness to psychiatry, it could be argued that arbitrary cutoffs are used in many areas of life, and although inevitably artificial, they are not intrinsically flawed in matters of enrollment, allocation, etc.

But that’s not the issue here. The issue is not that Peter gets enrolled and Paul doesn’t. The issue is that Peter, according to psychiatrists, has a biological brain illness to which his various psychosocio-economic stressors are merely triggers, while in Paul’s case, these similar triggers are the legitimate and proximate causes of his depression.

And to add to the inanity, if Paul goes on to experience a decrease in appetite and lose a few pounds in the next week or so, and returns to the righteous Dr. Checkem, he will also be found to be the victim of a depression-causing brain illness. And the despondency, which a few days earlier was the normal reflection of adversity, is now the product of a full-blown biological brain illness for which, like Peter, he has to take poison pills for life. And, to add to the absurdity — a significant increase in appetite would also have made him eligible for precisely the same brain illness!

And that, my dear and patient readers, is the “logic” behind Dr. Ghaemi’s expression of dismay towards those heretical psychiatrists who seek to “downplay a mood illness diagnosis because it was associated with many psychosocial stressors.”

The diligent suppression of the slightest whiff of heresy is one of the primary hallmarks of a dictatorial regime.

PSYCHIATRY PATHOLOGIZING EVERYDAY LIFE

At this point in the paper, Dr. Ghaemi continues with the same theme, but adds another one: that psychiatry is often criticized because it “simply diagnoses everyone.”

“Some critics of psychiatry, especially among sociologists and psychologists, take a seemingly erudite position that psychiatry simply diagnoses everyone, with conditions like depression, while ignoring the many ’causes’ in life that produce those symptoms. How many times do we hear the redundant and overworn critique that psychiatry has medicalized every day life?

The critique is not false; it’s more than half-true. We do overpathologize, always have, even before the claims of today’s biologically reductionistic psychiatry: for a century, psychoanalysts overpathologized even though they were anything but biologically reductionistic.”

The word “redundant” means unnecessary. So essentially Dr. Ghaemi is saying that criticizing psychiatry for medicalizing everyday life is unnecessary. Dr. Ghaemi is not challenging the accusation; in fact he goes on to embrace it.

“The critique is not false; it’s more than half-true. We do overpathologize…”

This strikes me as very odd. Most psychiatric “thought leaders” take the opposite position: that, if anything, not enough people are being diagnosed and enrolled as psychiatric “patients.” Dr. Ghaemi, however, acknowledges that psychiatry does over-pathologize. But apparently he sees no problem with this. He considers this particular criticism of psychiatry to be “redundant and overworn.” And he justifies this stance with the classic naughty child excuse that other people are doing the same thing:

“…for a century, psychoanalysts overpathologized even though they were anything but biologically reductionistic.”

THE GREAT RISK FOR PSYCHOLOGY/PSYCHIATRY

“The problem with these critiques and beliefs is that they reflect a deep fallacy in psychology and psychiatry, a far deeper fallacy than even the biological and genetic ones which I’ve discussed [in earlier papers]. There is no worse risk for psychology/psychiatry than the psychological fallacy.

It should be obvious; it will be once pointed out.”

So, to recap, Dr. Ghaemi has identified two beliefs expressed by psychiatry’s critics:

• that depression is a natural response to depressing events or circumstances, and
• that psychiatry medicalizes everyday life; i.e. overpathologizes

Then Dr. Ghaemi tells us that these critiques/beliefs reflect a deep fallacy in psychology and psychiatry. He had earlier told us that the second criticism is true; but now it’s a fallacy! But let’s put that aside. He tells us, somewhat condescendingly, that the fallacy “should be obvious.” And then, with the pomp and certitude of the zealot: “it will be, once pointed out.” As someone who wholeheartedly endorses these two “fallacies,” I have a particular interest in this matter, but first I need to note that there is one point on which I am in total agreement with Dr. Ghaemi. There is indeed no worse risk for psychiatry than what he calls the psychological fallacy. If the simple notion that depression (even severe depression) stems from depressing events and circumstances, and can only be resolved by addressing these events and circumstances, becomes widely accepted, then psychiatric pill-pushing will become a thing of the past, and psychiatrists will be forced to seek honest work. And for those who have ridden the pharma-fueled gravy train for decades, this must indeed seem enormously daunting.

But to get back to the main narrative, the eminent and scholarly Dr. Ghaemi is going to expose, for our benefit, what he calls the psychological fallacy; so a little reverence and awe, please.

“These psychological judgments are basically made based on common sense. But if common sense was enough to explain things, then our patients would have convinced themselves, or been convinced by their friends and family. If a patient crosses the threshold of a clinician’s door, then common sense has failed. No need to keep using it.”

I studied this section closely and with an appropriate measure of humility, but I have to say that, to me at least, Dr. Ghaemi’s primary thesis is anything but obvious.

Let’s take a look.

“These psychological judgments are basically made based on common sense.”

And remember, the judgments in question are:

• sadness, even when severe, is caused by losses and distressing circumstances, and
• psychiatry medicalizes everyday life.

So I think, other things being equal, it would be reasonable to say that these judgments are indeed based on common sense. However, as is almost always the case, other things are not equal. And the critical additional factor in this case is that these statements are not being made in a vacuum. Rather, they are being made within antipsychiatry circles in response to psychiatry’s assertions to the contrary. And they reflect not just common sense, but also well-researched study and debate.

But, again for the sake of discussion, let’s put that aside and move to the next part of the argument:

“…if common sense was enough to explain things, then our patients would have convinced themselves, or been convinced by their friends and family.”

The sophistry here is truly exquisite.

Consider the case of a 60-year-old man who has lost his job, which he had held for the past forty years. He’s living on unemployment benefits and his extensive job-seeking efforts have yielded no fruit. His job, and his earning ability, had always been a huge part of his identity and self-esteem, and at present he is feeling despondent to the point of despair.

If one were to ask this individual why he was so despondent, he would tell you that it was because he had lost his job and had been unable to find another. If he felt inclined to share more, he could probably articulate why the job meant so much to him, etc.

So common sense is enough to provide an explanation of the problem. Unfortunately, it’s not always enough to provide a solution to the problem, but that’s a separate issue.

What Dr. Ghaemi is doing, either deliberately or from an unfamiliarity with the rudiments of logical analysis, is confusing these two issues. A person, using ordinary common sense and self-knowledge, can know absolutely clearly why he is depressed, but not be able to see or find a way to alleviate this depression. In the example above, the individual can see that if he could get another job, his despondency would lift, but — for whatever reason — he hasn’t been able to do this. It may be, for instance, that because he’s been in the same job for 40 years, he has had no experience at job-hunting. One could say that his common sense in the job-hunting area is deficient. He has poor job-hunting skills. Or perhaps there are no jobs for 60-year-olds in his area, and he’s scared to pick up and move. Maybe employers want younger people, etc. But the notion that one should simply dismiss common-sense explanations on the grounds that common sense can’t solve all of life’s problems is not warranted.

Perhaps there should be a sign over every psychiatrist’s door:

Abandon Common Sense All Ye Who Enter Herein

Come to think of it, that might be quite apt. And in fact, it does seem to be what Dr. Ghaemi is advocating: “…common sense has failed. No need to keep using it.”

In addition, the phrase “if a patient crosses the threshold of a clinician’s door…” has enormous implications. As worded, there is the assumption that the threshold-crossing was voluntary, when in reality much of it is not. And it needs to be pointed out that organized psychiatry, at least here in the US, is currently promoting policies that will increase the amount of enforced psychiatric treatment. But that tangent would take us very far afield.

PSYCHO-SOCIO-ECONOMIC EXPLANATIONS

All of the above is pretty interesting, of course, but it is at this point that Dr. Ghaemi’s logic, up till now tenuous at best, takes an accelerated nosedive.

“A huge literature on life events and depression shows that the vast majority of depressive episodes occur with a preceding life event that ’causes’ that depression.”

No quibble there, though the quotation marks around “causes” raise concerns.

“Trouble with a spouse, a boss, a child; financial problems; medical illness. So those life events cause depression.”

They certainly do!

“And who doesn’t have those life events?”

Who indeed?

“The question should not be why those life events cause depression, but why they don’t cause depression in the 90% of the population that never experiences a severe clinical depressive episode?”

An interesting question. And if you’re stumped, never mind. Dr. Ghaemi has the answer:

“Obviously something else is at work. Contrary to all the hopes and wishes of psychologizers, there is such a thing as biology.”

And there it is. The inane fallacious kernel of the whole thing, packaged and presented with the same kind of righteously arrogant dogmatism that characterizes the entire psychiatric hoax.

Let’s take a closer look.

First, the term “severe clinical depressive episode” needs to be examined. This term has no formal definition in the DSM. The closest thing in the DSM is “severe major depressive episode,” and we must assume that this is what Dr. Ghaemi intended. This is particularly warranted in that psychiatrists routinely use the term “clinical depression” in this way.

So the implication in Dr. Ghaemi’s contention is that a “severe major (or clinical) depressive episode” is an identifiable entity that is, in some fundamental way, different from ordinary depression. Again, most psychiatrists would agree with this notion, and if asked for a definition of this entity, would point to the DSM criterion for a major depressive episode: the presence of five or more of the “symptoms” listed on pages 160-161 of DSM-5.

But this list has never been, and can never be, validated. It is simply something that psychiatrists made up. It can never be validated because there is no other definition of “major depressive episode” to which one can point, and against which one could compare the discriminant value of the 5-or-more-from-the-checklist definition. In science, as in other areas of life, one simply can’t make a silk purse from a sow’s ear. There is no such entity as a major depressive episode, and psychiatry’s claim to the contrary, and the proffering of their sophomoric checklist as evidence is self-serving nonsense. In addition, the specific items on the checklist are too vague to provide useful discriminations of any kind.

But even if we set those issues aside, there are still problems with Dr. Ghaemi’s analysis and conclusions. Let’s, again for the sake of the discussion, put aside the validity and reliability issues, and take another look at Dr. Ghaemi’s question:

“The question should not be why those life events cause depression, but why they don’t cause depression in the 90% of the population that never experiences a severe clinical depressive episode?”

And this, as I stated earlier, is an interesting question. It’s not abstruse. It’s not difficult to answer. But it’s interesting. And the most interesting aspect of the question is that a man of Dr. Ghaemi’s prestige and eminence; a full professor at Tufts, an experienced psychiatrist, professionally qualified to plumb the depths of human suffering, can think of no other answer to this question than biology, by which from the context it is clear that he means broken biology, or to be specific, brain illness.

So, the question is: why is it that different people experiencing broadly similar adverse events, react emotionally to these experiences in very different ways. And if, for the purposes of discussion, we stick with our example of a 60-year-old man losing the job he has held for 40 years, it is obvious that there are many possible reasons.

For one person, the job may be his primary, or even only source of self-esteem. Another may be involved in multiple fulfilling activities outside work. Or it may be that the deeply despondent individual has little or no social network outside the workplace, and so his job had been the center of his world. The other person may have a rich and variegated social life, and has multiple social supports in helping him deal with his unemployed status. Or one may have ample savings, while the other has none. Or one may have been raised in a family that stressed problem-solving and self-reliance, while the other came from a more passive, dependent background.

And so on.

But the only explanation for the differential response that Dr. Ghaemi can think of is biology! And note the tone: “Contrary to all the hopes and wishes of psychologizers, there is such a thing as biology.” In other words, the emphasis that we “psychologizers” place on common sense, psycho-socio-economic factors is a reflection of our “hopes and wishes,” while Dr. Ghaemi’s rejection of common sense and his promotion of biological malfunction as the cause of the deep despondency is based on his unsubstantiated assertion that “Obviously something else is at work.”

We “psychologizers” are accustomed to unsubstantiated assertions from psychiatrists, but in this instance, Dr. Ghaemi tells us that he has proof of his assertion. In fact, he assures us that he has the ultimate proof.

“Here is the ultimate proof of the psychological fallacy: split-brain experiments. In the 1970s and 80s, some patients with severe epilepsy were treated with corpus collasotomy, so as to prevent spread of seizure activity from one hemisphere to the other, thereby preventing generalized convulsions. This surgery allowed for some interesting neuropsychological research. By showing a picture, like a woman talking on the telephone, to the left visual field of a right-handed split-brain patient, one could test how the patient would report that knowledge. The information could not be transmitted from the right cerebral hemisphere to the left, where the language areas mainly are in right-handed persons. In such a test, the patient would say that she saw something different, like a boy playing with a ball. But if asked to show what she saw, she would pick up a telephone with her left hand. She got the information, but she couldn’t say it.

More important, instead of simply admitting that she couldn’t say it, she made something up! The patient confabulated. That is what the human brain does. As Gazzaniga, the main researcher on this topic said, the brain is a rationalizing machine. We come up with reasons for everything. Sometimes we’re right, sometimes we’re not, and we don’t know which is which in any one case. But the mere fact that we can come up with a coherent, logical, explanation for any experience means quite little; of course we can; we always can.

But sometimes common sense explanations are false, especially when something else is at work, like biology, like a disease of the body.”

There’s a lot of material here, and the pace is fast, but let’s see if we can unravel it.

So, if a person says that he is deeply despondent because his wife of forty years and his daughter have been recently killed in a car wreck, this is an example of “the psychological fallacy,” because in fact, malfunctioning biology is “obviously” the real cause of his sadness, provided only that he meets five of the nine criteria on the inane checklist.

And the proof of this assertion — actually the “ultimate” proof — lies in the fact that people whose hemispheres have been surgically separated, and who are therefore unable to recount verbally something that they have seen, will often make something up — confabulate — rather than say they don’t know.

The fact that we humans sometimes confabulate is not contentious. In fact, we don’t need examples from split brain studies. We can just concede the general point that sometimes we humans provide incorrect answers when asked to explain our thoughts, feelings, and actions. There are many reasons why we might provide such answers, and a detailed discussion would take us too far afield. But the critical point is this: the fact that we humans sometimes provide incorrect explanations for our feelings and experiences in no way establishes the general principal that such beliefs/assertions should always be regarded with suspicion.

But that is exactly the position that Dr. Ghaemi is taking.

“The patient confabulated. That is what the human brain does . . . the brain is a rationalizing machine.” [Emphasis added]

In other words, the human brain is inherently flawed, which of course is the essential underpinning to psychiatry, and particularly to the enormous expansion of psychiatry in recent decades. The human brain, which in fact is an extraordinarily effective organ in enabling us to understand ourselves and our environment, and to successfully navigate the difficulties and challenges of life, is now to be routinely regarded as suspect. Is it a coincidence that this message is coming to us from a member of a profession that pushes drugs that purport (falsely) to fix broken brains?

Dr. Ghaemi concedes that our inherently flawed brains don’t always lead us astray.

“We come up with reasons for everything. Sometimes we’re right, sometimes we’re not…”

But he promptly devalues this concession:

“…we don’t know which is which in any one case.”

So therefore, we must distrust all of our beliefs and assertions in this area. We must adopt a stance of skepticism and doubt in these matters and place our frail and inherently fallible selves in the welcoming and drug-promoting embrace of psychiatry. For it is the psychiatrists who possess the Rosetta stone of human experience. It is the psychiatrists, with their overflowing storehouses of wisdom, insight, erudition, and compassion that know why we do the things we do, think the things we think, and feel the things we feel. And through this great wisdom, insight, erudition, and compassion, they know that whenever our feelings of sadness cross some arbitrary and vaguely-defined thresholds of severity, duration, frequency, and impact, the root cause is aberrant biology, for which they, by great good fortune, have equally vast reserves of curative chemicals which are “safe and effective.” What a stroke of luck!

Finally, like the great psychiatrist that he is, Dr. Ghaemi summarizes the psychiatric position beautifully:

“Psychosocial life events can influence the timing of a depressive episode, but if someone has repeated depression, biology is the underlying cause of the predisposition to those episodes. That’s why 10% have episodes with the same life event that doesn’t cause episodes in 90%.

That’s why we have to take disease concepts seriously in psychiatry, and we have to accept biology, and not constantly write it off as reductionism.

Psychological reductionism exists too, and we seem to biologically hard-wired for it.”

So “repeated depression” couldn’t possibly stem from repeated adverse events or from enduring adverse circumstances. No. Repeated depression — and by “depression” I think we have to presume that he means five or more yesses on unvalidatable, mickey-mouse checklist — always stems from aberrant biology.

So we have to “accept biology,” and we need to recognize the existence of psychological reductionism, to which incidentally we humans seem to be “biologically hard-wired.” In other words, the belief that living in sub-standard accommodation in a context of exploitation, victimization, and discrimination causes people to become enduringly and severely depressed isn’t just an error in thinking in the ordinary sense of the term. It is — and this is the very apex of psychiatric arrogance — an error in thinking that stems from aberrant neural hard-wiring!

And now we know.

CLARIFICATIONS

To guard against any misunderstanding, it needs to be acknowledged that our common sense intuition is indeed fallible. Sometimes we’re right; sometimes we’re wrong. But despite decades of lavishly-funded and highly motivated research, there is not one shred of evidence that all the individuals who score five or more yesses on the APA’s inane checklist (even if we set aside the vagueness and validity problems), have any biological malfunction in common.

It also needs to be acknowledged that despondency, even deep despondency, is sometimes (rarely) the result of a biological problem. But this in no way supports the psychiatric dogma that all instances of sadness which score five or more yesses on the mickey-mouse checklist stem from biological malfunction.

It’s a hoax, folks! The biggest hoax in history.

AND INCIDENTALLY

“Dr. Ghaemi has provided research consulting to Sunovion and Pfizer, and has obtained a research grant from Takeda Pharmaceuticals. Neither he nor his family hold equity positions in pharmaceutical corporations.” (2015 and 2016) (here) and (here)

“S. Nassir Ghaemi has received a research grant from Pfizer. Neither he nor his family holds equity positions in pharmaceutical corporations.” (2013) (here)

“SNG has received research funding from Janssen Pharmaceutica.” (2006) (here)

“SNG has received grant/research support from Elan Pharmaceutical, Janssen; consultant for Janssen; and serves on the speakers bureau for GlaxoSmithKline, Eli Lilly & Co., Janssen.” (2004) (here)

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“Of course I’m anti-psychiatry. Aren’t you?”
Auntie Psychiatry