Pies’ Polemic and the Question of Theories in Psychiatry, Again

In a recent publication, “Debunking the Two Chemical Imbalance Myths, Again,” psychiatrist and editor Ronald Pies returned to his theme of insisting that psychiatrists and the institution of psychiatry have never embraced or supported a “chemical imbalance theory” of mental disorder:

“…psychiatry as a profession and medical specialty never endorsed such a bogus “theory,” when judged by its professional organizations; its peer-reviewed publications; its standard textbooks or its official pronouncements.” (emphasis in original)

Instead, he states:

“…academic psychiatry—for at least the past 30 years—has advocated a ‘bio-psycho-social’ model of mental illness, as originally proposed by Dr George Engel, and as reflected in the 1978 APA statement quoted above. This position has been quite consistent.”

In his conclusion, he noted:

“The (catecholamine) hypothesis (of affective disorders) has since been modified and corrected to reflect more complex biological mechanisms in major mood disorders. These disorders are best understood using a bio-psycho-sociocultural model, which has been the mainstay of academic psychiatry for over 30 years.” (emphasis added)

In a detailed critique, “The Chemical Imbalance Theory: Dr. Pies Returns, Again,” psychologist Philip Hickey has taken Pies to task, leaving little doubt that his protestations are, at best, disingenuous. Given the contents of a letter published by Pies in 1992 in the American Journal of Psychiatry (March 1992, p420), which Hickey uncovered, it is difficult to avoid the suspicion that Pies is trying to have it both ways, i.e. using the concept of a chemical imbalance while denying it amounts to a theory. Be that as it may, we need to look more closely at his claim that the concept of a “chemical imbalance theory of mental disorder” has never guided psychiatric practice, teaching or research, and that, at the very least, it is mischievous to suggest otherwise.

In the UK at present, 16% of the adult population (one in six) take antidepressants. In the US, that figure is 13%, and in Australia, 12%, up from 9.8% just three years ago, and a bare 1% in 1991. Significantly, the length of time people take these drugs is growing, meaning that once they start, they don’t stop. The consumption of these drugs is a social phenomenon, not a disease phenomenon: there is zero evidence to say that the actual incidence of depression in Australia has increased 1200% in one generation. Certainly, they don’t appear to be very effective as the suicide rate in this country has been rising for years and recently hit a peak.

We are forced to ask: What medical fact drives the explosive growth in the consumption of psychotropic drugs? The ultimate explanation is just that psychiatrists and general practitioners prescribe them and, despite their many unpleasant and/or dangerous side effects, are able to convince their patients to take them to the point where they find it difficult to stop. So why do they prescribe them? They prescribe them because they believe it is the correct response to a diagnosis of depression, which Pies affirms vehemently:

“…the clinical reality is that antidepressants are effective in many patients with severe, acute major depression.”

This is tendentious because the clinical reality is that the overwhelming majority of patients taking these drugs had mild to moderate cases of depression, if they were depressed at all (a large proportion of the drugs are prescribed for anxiety states or as hypnotics), and they take them in the long to very long term, meaning decades (i.e. non-acutely), even though all psychotropics were approved on the basis of short term trials of weeks to months at most.

Now we get to the core of the matter, but first we need to digress somewhat to try to understand what is going on in this debate. On the one hand, we see the relentlessly expanding use of psychotropic drugs based in what amounts to an urban myth, the “chemical imbalance” concept of mental disorder. On the other hand, it is true, as Pies claims, that no psychiatrist has ever published anything that would amount to a “chemical imbalance theory of mental disorder.” I suggest that what we are seeing here is an example of what philosophers of science call the “motte and bailey” doctrine (I don’t know why it is called a doctrine; it is actually a technique but no matter). It is sometimes called a logical fallacy although it is probably better characterised as a sophisticated “bait and switch” maneuvre. This is attributed to the British philosopher of science Nicholas Shackel who introduced it thus:

“One of the difficulties of getting people to behave better epistemically is that, whilst intellectual dishonesty is wrong, it is difficult to convict people of intellectual wrongs… there are indefinitely many ways of cheating intellectually (yet) there is no simple way to put one’s finger on how the cheat is effected.”¹

He bases the term on the medieval notion of a defensible castle, the motte, surrounded by indefensible fields and pastures, the bailey. When there was no danger, the villagers lived in lightly-built huts outside the motte and worked the fields. However, when danger loomed, they abandoned their fields and even their cottages and retreated into the motte where they could not be budged. There they waited until the raiders tired of the game and left, perhaps taking the fields of cabbages with them.

The parallel in philosophy is seen when people who advocate a particular position stake out a large territory for themselves (as in “all mental disorder is a chemical imbalance of the brain”) for which they have no defence whatsoever. As long as nobody challenges their bailey, they continue to make hay from it, but under threat, they retreat into the motte or defensible position: “But we never claimed there is a chemical imbalance theory of mental disorder.” True, they didn’t, but they were very happy to profit from everybody thinking they had. This leads to the crucial but unstated point behind Pies’ polemic: If the “Chemical Imbalance Theory of Mental Disorder” is a mirage, if not a frank deception, then what theory are psychiatrists using to justify prescribing their drugs?

That is, what is the current accepted theory or model of mental disorder by which psychiatry justifies not just its extensive and unequalled powers, but its very existence? I exclude at the outset such notions as demonic possession, any idea involving astrological bodies, or anything to do with meridians, gravity, morality, sunspots or solar flares, faith, tides, red food coloring, masturbation, homeopathy and so on. This doesn’t leave a lot of contestants for what we could call the Standard Modern Theory of Mental Disorder, the one that justifies the unprecedented use of psychotropic drugs. Fortunately, Pies has defined theories for us:

“…a genuine theory requires an integrated network of well-supported, interlinked hypotheses.” (emphasis in original)

There’s more to a scientific theory than that but his definition will do. We can quickly dispense with one of the main contenders from the last century, Freud’s Psychoanalytic Theory. While Freud claimed his theory was original, universal and scientific, we now know that it was none of these. It was not original but was largely lifted from the Kabalah. It was not universal as it was based entirely on his study of a minuscule fraction of the world’s population and cultures, and it was not scientific just because it was irrefutable (I summarised most of this in 1987²). In any event, psychoanalysis was a psychological theory of mental disorder, and was strongly opposed to the profligate use of drugs and other physical treatments. Since its demise, there has been precious little intellectual effort applied to the question of whether mental disorder can be explained in psychological or mental terms, certainly among psychiatrists, many of whom who are openly dismissive of the idea.

The other major contribution from the last century was behaviorism, in its various forms. Talking of stakes being hammered through misbegotten hearts, as Pies did, behaviorism never recovered from Chomsky’s devastating critique of Skinner’s Verbal Behavior (1957)³, although the corpse took some time to fall to the ground. For a brief historical survey of the philosophical failings of behaviorism, see chapter three in my book Humanizing Madness: Psychiatry and the Cognitive Neurosciences,⁴ but the point surely is that behaviorism was wholly a psychological model of mental disorder. It specifically excluded any and all ‘intervening variables,’ which includes brain chemicals and, of course, mentalist constructs. Psychiatrists therefore cannot appeal to that approach to mental disorder as their justification for widespread drugging of the population, so what’s left? As it happens, not much.

The major alternative is summarised in the aphorism, variously attributed to Benjamin Rush and Henry Maudsley, that “All Mental Disorder is Brain Disorder.” That is, it relies on the physicalist notion that the behavior or properties of a higher-order entity can be reduced to and thus fully explained by the behavior or properties of the lower-order entities of which it is composed.⁵ In brief, biological reductionism avers that for every mental disorder, there is a physical disorder of the brain which is both necessary and sufficient for that mental disorder (necessary means that the mental disorder won’t appear without the underlying physical disorder, while sufficient means that every time the physical disorder is present, the mental disorder will also be present). It says that a full understanding of the brain will explain all there is to know about mental disorder, with no questions left unanswered.

This is the unstated justification for the allegedly atheoretical DSM model of categorical classification of mental disorder, that every surface manifestation of mental disorder will ultimately map down to a specific error in the genome, for which (ideally) there will be a single, discrete biological treatment. Nearly thirty years ago, I showed that this project must fail.⁶ Moreover, even in its latest iteration, the Research Domain Criteria project, it cannot succeed but will simply be another hugely expensive wild goose chase.⁷ Given these ontological problems, why does biological reductionism persist? Its major justification appears to be that it seems more scientific than mentalist theories, in the sense that it has a beginning, whereas we don’t even know where to start with mentalism. By default, the research funds flow to reductionist models.

In case anybody should think that dismissing biological theories on theoretical grounds is a little hasty, it remains the case that there is no extant reductionist model of mental disorder.⁸ No psychiatrist has ever written anything that could possibly count as an articulated theory or model of mental disorder as biology. The proposition “All Mental Disorder is Brain Disorder” is metaphysical, purely an ideological claim, and not of a form that empirical science can investigate.

The field is now looking a little bleak, but Pies has ridden to the rescue, as it were, with his concept of “…a bio-psycho-sociocultural model, which has been the mainstay of academic psychiatry for over 30 years.” He uses a recent publication from the APA to show that mainstream psychiatry’s understanding of the causation of depression includes biochemical, genetic, personality and environmental factors. He notes that the original formulation of the biopsychosocial model (BPSM) by George Engel, in 1977, has attracted criticism, but he then gives a number of examples of how the biological understanding of mental disorder is powering ahead. Ultimately, the BPSM will allow us to provide “holistic, comprehensive psychiatric care.”

Regrettably, Pies’ program runs into the very practical difficulty that there is no such thing as a “biopsychosocial model” of mental disorder. It doesn’t exist. George Engel certainly didn’t write one,⁹ and nobody else has. In a number of settings, including lectures and publications, I have stated that anybody who claims that such a model exists is exposed to accusations of culpable deception, with no conceivable defence.

As it happens, I watch the literature on this topic quite closely but I may have missed a paper that actually gives such a model. However, it seems highly unlikely, just because a genuinely “bio-psycho-sociocultural model” must first resolve the mind-body problem. On this point, be assured there has been no progress since the late René Descartes, who left us in 1650. Alternatively, before one can solve the mind-body problem, one needs a formal model of mind, which psychiatry has long since discarded. So I feel I am on strong grounds if I say that the claim above, that such a model “…has been the mainstay of academic psychiatry for over 30 years,” is false and without warrant.

Nonetheless, I am prepared to admit that Dr. Pies may be right and I may be wrong. It is feasible that psychiatry has quietly pulled a metaphysical rabbit out of an empirical hat, developing an integrative theory of body and mind to replace the wholly spurious “chemical imbalance trope,” as he rightly puts it. In fact, I’d be delighted to be proven wrong. If Dr. Pies can name the actual model of mental disorder he has championed in his article (including “…an integrated network of well-supported, interlinked hypotheses“), citing the original author’s primary publication, and give three seminal references in which the model is developed as a series of testable propositions, then I will fall to my knees in gratitude, not least because it will sound the death-knell for psychiatry’s biological hegemon.

If, however, he can’t do that, then I don’t see how he could defend himself and, by extension, his profession (and mine) against a charge of culpable deception, if not of frank scientific fraud.