Disease, illness, disorders, etc.
One of the problems in the present debate about neurochemical imbalances is that almost every word in the English language has at least two meanings, and sometimes four or five. Some English speakers deplore this state of affairs and regard it as an endless source of confusion. Others consider it an indication of the richness of the language and its ability to express finely tuned nuances. Others use it as a tool of obfuscation.
In ordinary English, as spoken and written by ordinary people, the terms illness and disease are largely synonymous, and they mean: a maladaptive condition caused by a biological pathology.
In practice, however, some such conditions are routinely called diseases, while others are routinely called illnesses. For instance, the common cold is usually referred to as an illness, but diabetes is generally called a disease.
Sometimes the term “disease” is used to mean serious illness and the term “illness” is used to denote less serious conditions. So, lung cancer is considered a disease, while influenza is often described as an illness.
Disorder is another term that is frequently used as a synonym for disease and/or illness. And, of course, “condition” is a nice generic term which can be substituted liberally for any of the above terms, as I have done in the last two paragraphs.
Similar linguistic confusions arise in almost every scientific endeavor. Physics uses the term “power”, for instance, and defines it as the rate at which work is being produced in a given system. But, of course, the common use of the term embraces a much wider range of meanings. Physicists and engineers circumvent any potential confusion in this and related areas by defining their terms with a high degree of precision, and by using symbols rather than vernacular words, especially in their written communications.
Throughout my writings on these issues, I have consistently adopted the twin notions that:
- The terms disease, illness, disorder, etc. are effectively synonymous.
- They each refer to a biological pathology.
The reason I adopt this position is that it is consistent with the way the terms are used in the speech and writings of ordinary people. In addition, it is, quite simply, the easiest way to navigate the linguistic labyrinth in which these terms have become embedded, and it presents no serious linguistic challenges or distortions.
A BRIEF HISTORICAL DIGRESSION
Prior to about 1960, psychiatry was considered a laughing-stock among medical specialties because most of the conditions that it purported to treat were not real illnesses, i.e., they did not stem from characteristic biological pathologies.
But a clarification is needed. DSM-I was published in 1952, and contained this quote in its Introduction:
“All mental disorders are divided into two major groups:
(1) those in which there is disturbance of mental function resulting from, or precipitated by, a primary impairment of the function of the brain, generally due to diffuse impairment of brain tissue; and
(2) those which are the result of a more general difficulty in adaptation of the individual, and in which any associated brain function disturbance is secondary to the psychiatric disorder.” (p 9)
In other words, there is a clear and unambiguous acknowledgement that some of the disorders in the manual are real illnesses or diseases (ie., they stem from a primary impairment of brain function, “generally due to diffuse impairment of brain tissue”), while others are not. The latter stem from a more general “difficulty in adaptation”.
It’s important to stress that the dichotomy sketched out above was emphatically not a result of careless drafting or some accident of communication. Here’s the first paragraph of Section II B: Definition of Terms:
“The basic division in this nomenclature is into those mental disorders associated with organic brain disturbance, and those occurring without such primary disturbance of brain function, and not into psychoses, psychoneuroses, and personality disorders. Other categorizations are secondary to the basic division.” (p 12)
Again, we have an absolutely clear statement: the division of psychiatric disorders into brain illnesses vs. difficulties in adaptation is the foundation of the entire psychiatric nosology. And the equally clear implication is that the majority of psychiatric disorders were not considered to be illnesses in any ordinary sense of the term. A general difficulty in adaptation is not a brain illness per se, i.e., it does not stem from a brain disorder. Obviously, some difficulties in adaptation could stem from brain disorders, but, within the framework of DSM-I, these were categorized as brain disorders.
The brain disorders were further distinguished from the difficulties in adaptation by the expedient of routinely referring to the former as syndromes and to the latter as reactions. So, for instance, DSM-I included in the brain illness category: acute brain syndrome associated with intracranial infection; chronic brain syndrome associated with central nervous system syphilis; etc.; and in the difficulty-in-adaption category: manic depression reaction, manic type; schizophrenic reaction, paranoid type; etc.. Further evidence of the DSM-I drafters’ intentions can be gleaned from their definition of psychotic reaction:
“…a psychotic reaction may be defined as one in which the personality, in its struggle for adjustment to internal and external stresses, utilizes severe affective disturbance, profound autism and withdrawal from reality, and/or formation of delusions or hallucinations.” (p 12)
Here again it is clear: the personality’s coping tactics are not illnesses.
THEN CAME THE DRUGS
Psychiatry was using and promoting psychotropic drugs prior to 1950, and the history of these early products has been well documented. For our present purposes, however, we need only note that throughout the ’50s, ’60s, and ’70s, an increasing number of psychotropic drugs became available and became increasingly used. These included: antidepressants, benzodiazepines, and first generation neuroleptics.
Initially there was a measure of skepticism among psychiatrists concerning these products – a reflection, perhaps, of the similar skepticism among the general public. But at the same time, there was a growing awareness within the psychiatric leadership that the drugs held enormous potential for improving psychiatrists’ prestige and earnings.
All they had to do was convince the public, the media, the rank and file psychiatrists, and the real doctors that psychiatric disorders were in fact real illnesses “just like diabetes”, and leave the rest to the pharma marketing machine. The complication in this scheme was the fact that psychiatry had already (in DSM-I) stated unambiguously that their “disorders” – apart from those stemming directly from brain damage/malfunction – were not illnesses. They were difficulties in adaption. And the notion of promoting drugs to cope with difficulties-in-adaptation presented an enormous challenge. They had to reverse their position while saving as much face as possible. In other words, they had to lie.
Meanwhile, in 1958, two groups of scientists working, as far as I know, independently, suggested tentatively that depression, which by then was becoming more broadly defined than the older melancholia, might be caused by an imbalance of neurotransmitters in the brain. The researchers were: Guy Everett, PhD, James Toman, PhD, and several assistants from Chicago; and John Saunders, MD, Nathan Kline, MD, Maurice Vaisberg, MD, et al from Rockland State Hospital, Orangeburg, New York. A similar theory was proposed a few years later (1967) by Schildkraut and Kety. I have discussed these matters in detail in an earlier post. These hypotheses generated a good deal of enthusiasm not only in the research community, but also within psychiatry and to some extent among the general public.
However, despite the expenditure of vast quantities of time and money, the theory has never been confirmed. But the story was already gaining traction, and psychiatry and pharma (the Grand Alliance) allowed the story to stand and even started to promote it. Their justification for this was that they allowed themselves to be convinced that proof of the chemical imbalance theory was “just around the corner”, and that therefore it wasn’t really a lie. But of course it has turned out to be one of the biggest lies in the history of medical science. At first the chemical imbalance theory was pretty much confined to depression, but later other “mental illnesses” were drawn under the same unvalidated umbrella.
The chemical imbalance deception was promoted vigorously by psychiatrists in a wide range of environments, as justification for the pills, shocks, and more recently, TMS. These “treatments” were, and still are, fraudulently touted for their ability to re-balance a “mentally ill” person’s brain chemicals. This was the Big Falsehood.
The marketing was extraordinarily successful in two respects: pharma got more sales, and psychiatrists became more “respectable” in the eyes of the real doctors. But there were serious downsides. Firstly, psychiatry’s hand-in-glove relationship with pharma had a widespread corrupting effect on the quality of psychiatric research. (You give us illnesses and “proof” of efficacy of our products; we’ll give you scads of money.) Secondly, the consumers of the products were confronted with a wide range of adverse effects, including death, which continue to this day.
Most psychiatrists that I have come across, either in person or in print, rationalize the Big Falsehood along these lines: well, we don’t know that the neurochemicals are literally out of balance, but we’re pretty sure that neurotransmitters have something to do with “mental illnesses”. “Imbalance” is just a word that’s easy for the patient to understand, and isn’t really false.
These kinds of defenses are unconvincing though, because the purpose of the Big Falsehood was, and is, to sell more drugs, and this is exactly what has happened. Americans today are consuming vastly more pharma products than they were in 1960, and are being exposed to a commensurate increase in adverse effects, including death. Psychiatric promotion has been a major, if not the major, causal factor in this increase. Almost all American psychiatrists participate in this fraudulent promotion and almost all have derived benefit from it either in professional prestige or earnings, or both. From what I can gather, the situation overseas is largely similar, though psychiatry does appear to be losing some ground in the UK.
To summarize: pharma invented psychotropic drugs. The rate of these inventions increased enormously in the ’50s, ’60s, and ’70s. Psychiatrists saw the potential of these products to increase their earnings and prestige, but they needed genuine illnesses in order to cash in. They knew – and the real doctors knew – that apart from the relatively few genuine illnesses in psychiatry’s catalog (e.g., chronic brain syndrome associated with syphilis), they had no convincing candidates. Some biologists tentatively floated the chemical imbalance theory (which 60 years later is still unconfirmed). The psychiatrists grabbed onto this notion and promoted it, and continue to promote it, with all the vigor they can muster.
In this way, the chemical imbalance theory became “true” by the modern political method of endless repetition. But it is still the Big Falsehood, and has destroyed, and continues to destroy, millions of lives worldwide.
DR. PIES’ ROLE IN THIS DEBATE
Dr. Pies’ position on these matters is unusual. To resolve the we-have-no-real-illnesses problem, he initially adopted, and promoted to the general public, the chemical imbalance theory like almost all psychiatrists at the time. Then – presumably when it was becoming clear that the biological research wasn’t going to produce the goods – he, and some other psychiatrists, changed their tune by the very simple expedient of changing the definition of illness.
Illness, he now assures us, entails no requirement of a biological pathology, but merely the presence of a significant measure of distress and impairment. So the only real requirement, if and when they want to create a new “mental illness”, is to write the presence of distress and impairment into their criteria, and voila – a new illness is created. There’s no need to spend thousands, or even tens of thousands of hours peering into microscopes. Just convene a committee of loyal psychiatric “experts”, include distress and impairment in the specs, and there it is – a brand new diagnosis – a brand new “illness”.
This is precisely how the APA turned bereavement into an illness, and was the general tactic adopted by Robert Spitzer, MD, in the creation of DSM-III. Incidentally, the APA typically requires only distress or impairment, which is a much more relaxed criterion. Dr. Pies is aware of this, and from time to time commends himself for making the criteria for “illness” more stringent, though it’s hard to imagine how this is having any effect.
ENTER THE DSM-II (1968)
By the time DSM-II was published (in 1968), no significant progress in finding genuine biological causes for the non-organic “disorders” had been made. Nevertheless, the term “reaction” had been eliminated from the names of the non-organic “diagnoses”, as had the notion that these “diagnoses” were the result of a “general difficulty in adaptation”. Here’s a quote from the Foreword, p viii.
“No list of diagnostic terms could be completely adequate for use in all those situations and in every country and for all time. Nor can it incorporate all the accumulated new knowledge of psychiatry at any one point in time. The Committee has attempted to put down what it judges to be generally agreed upon by well-informed psychiatrists today.
In selecting suitable diagnostic terms for each rubric, the Committee has chosen terms which it thought would facilitate maximum communication within the profession and reduce confusion and ambiguity to a minimum. Rationalists may be prone to believe the old saying that ‘a rose by any other name would smell as sweet’; but psychiatrists know full well that irrational factors belie its validity and that labels of themselves condition our perceptions. The Committee accepted the fact that different names for the same thing imply different attitudes and concepts.
It has, however, tried to avoid terms which carry with them implications regarding either the nature of a disorder or its causes and has been explicit about causal assumptions when they are integral to a diagnostic concept.” (p viii)
There’s a lot of concealed material in these two paragraphs. So let’s see if we can open them up.
“No list of diagnostic terms could be completely adequate for use in all those situations and in every country and for all time.”
The most notable point that needs to be made here is that at the time in question, nor indeed at any time since, has anyone suggested otherwise. There was, as far as I can ascertain, no great pressure from any source that any list of psychiatric “diagnoses” was to be set in stone and remain so for all time.
What’s happening here is that the “difficulty-in-adaptation” concept, which was the cornerstone of more than half of the APA’s “diagnostic” list, had already, behind the scenes, been slated for elimination. This decision was emphatically not based on any new research finding. Rather, it was taken to facilitate psychiatry’s self-serving decision to embrace pill-pushing-in-the-guise-of-treating-illnesses as its primary activity.
“The Committee has attempted to put down what it judges to be generally agreed upon by well-informed psychiatrists today.”
So, to get out ahead of the objection that the changes being promoted are not founded in science, here’s the APA acknowledging this very fact.
So, the committee has attempted to put down what it (the committee) judges to be generally agreed upon by well-informed psychiatrists today. So the committee decides what is “generally agreed” and which psychiatrists are “well-informed”. It’s important to remember that what they were working on here is the Big Falsehood, and it is noteworthy that they’re not even trying to disguise this, probably because, in their arrogance, they assumed that their unctuous pronouncements would never be afforded any real scrutiny.
Note that there is no reference to any kind of scientific study or finding. They simply state the ridiculously obvious point that no list of diagnostic terms can be set in stone for all places and all times. And then state that they have simply attempted to list the terms used by “well-informed” psychiatrists. All of which essentially means that they can write down whatever they choose, provided the general body of psychiatry doesn’t openly rebel.
They continue: in choosing their “diagnostic” terms, they have selected terms which “would facilitate maximum communication within the profession, and reduce confusion and ambiguity”. The phrase that they desperately needed to remove is “general difficulty in adaptation”, which actually isn’t all that confusing or ambiguous. What they are really trying to do is disguise their self-centered skullduggery as virtuous elimination of non-existent confusion.
But watch where they go next. This is spin-doctoring before the term had even been invented.
“Rationalists may be prone to believe the old saying that ‘a rose by any other name would smell as sweet’; but psychiatrists know full well that irrational factors belie its validity and that labels of themselves condition our perceptions.”
First, the quote from Shakespeare’s “Romeo and Juliet”. How nice! Then “… but psychiatrists know full well that irrational factors belie its validity and that labels of themselves condition our perceptions.”
This strikes me as a most extraordinary entry in a “diagnostic manual”. It’s either hubris of an extremely childlike quality (“psychiatrists know full well”) or a total lack of critical self-scrutiny, or perhaps both. Here they are, laying the groundwork for a completely bio-bio-bio labeling system, while po-facedly lecturing their readers that labels “condition our perceptions”. In other words: we’re about to change some labels in the full knowledge that changing labels changes perceptions. We’re doing away with general-difficulties-in-adaptation throughout the manual. We know that this is a deception, but it’s the only way we can go on increasing our prestige and our earnings, and get people to stop making fun of us.
And to make sure there were no lingering doubts, they “…accepted the fact that different names for the same thing imply different attitudes and concepts.” They also claimed that they had “…tried to avoid terms which carry with them implications regarding either the nature of a disorder or its causes”, even though it was clear that their primary agenda was to eliminate the general-difficulties-in-adaptation notion that they had built into DSM-I.
These two paragraphs in the Foreword of DSM-II were the beginning of the Big Falsehood, and need to be read in conjunction with this extraordinary Acknowledgement which received no page number as such, but is included in the manual where page iv would have been:
What’s extraordinary about this acknowledgement is that responsibility to produce the DSM-II had already been vested in the Committee on Nomenclature and Statistics, which had been in existence since at least 1936, with retiring members being replaced. Both Robert Spitzer and Morton Kramer had been co-opted to the Nomenclature and Statistics Committee as consultants. But apparently there was also this further committee (Glueck, Spitzer, and Kramer) charged with the task of approving the final form of the manual prior to publication.
Obviously I’m not privy to the internal machinations within the APA at the time in question, but it looks like there were deep concerns in high places, that the Nomenclature and Statistics Committee would balk at going completely biological, and that an additional layer of “protection” was needed to keep “unorthodox” views out of the final draft. Note that the Glueck, Spitzer, Kramer committee itself also co-opted two consultants, Wilson and Robinson, who reportedly “undertook extensive editorial revision of the original manuscript” and were “notably successful in clarifying and adding precision to the definition of terms.”
Paul Wilson, MD, died of COVID on August 28, 2020 at the age of 88. The Washington Post published an obituary on December 6, 2020. Here’s a quote from the obituary:
“…Paul worked for The American Psychiatric Association. His most notable contribution was being asked to assist with The second version of The Diagnostic and Statistical Manual of Mental Disorders (The DSM). The original version was awkwardly written and Paul was asked to edit and re-write the next version of the DSM (DSM 2). It needed to be more “Usable” for the reading audience of general practitioners, medical students, Insurance companies. With the help of newspaper reporter, Robert Robinson, the two rewrote the DSM 2.”
Robert Spitzer’s name is usually associated with DSM-III, but in fact it is clear that he was a major player in DSM-II also. Here’s the closing paragraph of the Foreword, which was written by Ernest Gruenberg, MD, chair of the Nomenclature and Statistics Committee:
“As Chairman since 1965, the writer wishes to express his personal deep appreciation to the hard-working members of the Committee and its two consultants, all of whom participated vigorously and thoughtfully in the Committee’s deliberations and the formulation of the many draft revisions that were required.” (p. x) [Emphasis added]
The two consultants, of course, were Drs. Kramer and Spitzer, and the degree of influence they wielded in successive “draft revisions” and in the final approval of the manual can only be imagined.
The general point in all of this is that the shift away from general difficulties in adaptation that occurred in DSM-II was no minor matter for the APA. Whilst we may never be able to appreciate the full scope of the deliberations and in-fighting, it is clear that great efforts were expended to “sanitize” the text and make it increasingly compatible with the bio-bio-bio perspective that emerged in subsequent editions and particularly in psychiatric practice. It is also clear that great efforts were made to conceal the true agenda from the general public, and perhaps even from the rank and file psychiatrists.
Robert Spitzer died on December 25, 2015, at age 85. Four days later, Mickey Nardo, MD, now also deceased, wrote this on his blog site 1 Boring Old Man:
“So back to Spitzer’s legacy. Alongside of his depression gaff, there’s another place where I think he deserves to be personally blamed. He kept a lot of what he was doing under his hat, shared only with his confidants. So the DSM-III process was something of a politically maneuvered bloodless coups d’etat orchestrated in concert with an inner circle of the APA. That behind-the-scenes oligarchy has persisted, undermining any sense that the APA represents its membership [better characterized these days as its following]. Whether the stealth and all the palace intrigue was necessary or not [ends justifying the means], it has persisted as a style for 35 years to all of our detriment.”
. . . . . . . . . . . . . . . .
So while the search for the chemical imbalance (psychiatry’s holy grail) continued, the APA, perhaps realizing even then that it would never be found, had the perverse foresight to ensure that it wouldn’t matter anyway. It is from this perspective that Dr. Pies’ stance needs to be seen: we don’t need biological pathology because the non-biologically-caused-entries in the DSMs are just as much illnesses as those with clear biological causes. And we know this because they all entail the requirement of distress or impairment, and we know this because we wrote this requirement into the definition of each DSM entry. This is spin-doctoring gone berserk.
PRE-BIOLOGICAL AND PRE-SCIENTIFIC
Dr. Pies discussed this matter in his interview with Awais Aftab, MD, The Battle for the Soul of Psychiatry, which was published on June 23, 2020 in Psychiatric Times. Dr. Aftab asked:
“Can there be legitimate disagreement about the characterization of something as a disorder, ie, disagreement that cannot be resolved by appealing to empirical facts and springs instead from conflicting value judgments?”
To which Dr. Pies replied:
“Indeed, I think the delineation of terms like ‘disorder,’ ‘disease,’ ‘illness,’ ‘malady,’ etc. is closely tied to very general values regarding ‘desirable’ and ‘undesirable’ states of mind and body; for example, witness the positive value we accord to being able to function in social and vocational roles. And this is true not only in psychiatry, but throughout general medicine – witness the intense debate over whether obesity is or is not a ‘disease.’ (A 2008 commission of experts from The Obesity Society concluded that the term ‘disease’ is too complicated to be fully defined!)
This admission points us to the later work of the philosopher Ludwig Wittgenstein, regarding the pitfalls of ‘essential definitions’ – for example, definitions of ‘disorder’ or ‘disease’ that specify necessary and sufficient conditions for these states. Wittgenstein famously argued (in his Philosophical Investigations) that the search for such Platonic ‘essences’ is misguided; and that, at most, we can identify certain ‘family resemblances’ among entities and conditions that we would call ‘disorders’ or ‘diseases.’ That said, like Wittgenstein, I believe our ‘ordinary language’ is as good a guide as any, with respect to defining these terms. In our ordinary parlance, when someone shows evidence of prolonged or severe suffering and incapacity that is not due to an obvious wound (eg, a bullet wound), we are perfectly justified in saying that the person is ‘ill’; has some kind of ‘disorder’; or is ‘diseased.’ No labs or imaging needed! Indeed, the concept of disease (dis-ease) arose to explain just such instances of suffering and incapacity. In short, ‘disease’ is a pre-biological, pre-scientific construct. To be sure: not all instances of prolonged or severe suffering and incapacity are instantiations of ‘disease.’ For example, someone might be tied to a chair by kidnappers or terrorists, then beaten and starved, and thereby experience profound suffering and incapacity – but we would not ordinarily attribute this to ‘disease.'”
The first paragraph is fairly straightforward: terms like disorder, disease, illness, malady, etc. denote negative states, while feelings of success generally denote positive states.
But the second paragraph is a great deal more complicated. Dr. Pies contends that the fairly obvious material in the earlier paragraph points us to the later work of Ludwig Wittgenstein (1889 – 1951), an Austrian-British histrionic and anti-social philosopher, regarding the pitfalls of “essential definitions”. Well, I have to say that the banal observations in the earlier paragraph do not in the slightest point me to anything of the sort.
What’s clear, I suggest, is that Dr. Pies wanted to invoke Wittgenstein’s wholly implausible notion that the theory of essences is “misguided”. So he dragged Wittgenstein into the debate by the proverbial scruff of the neck as an appearance of support for this contention. Dr. Pies needed to undercut the theory of essences because that is the crux of the issue: What is the essential definition of disorder, disease, illness, malady, etc.?
Wittgenstein proclaimed, without evidence, that seeking to understand the essence of things is a futile or misguided endeavor, and so he is an ideal “authority” for Dr. Pies’ primary purpose: to discredit the simple reality that the essential nature of disorder, disease, illness, malady, etc., is more important to their understanding than any incidental or accidental properties that they may possess.
For instance, the essential nature of water is burnt hydrogen (H2O), and knowledge of this reality underpins and supports any other incidental feature of this substance. But the fact that water is burnt hydrogen is not superficially obvious. Knowledge of the essential nature of things is usually hard-won, but is a necessary ingredient of understanding. When we don’t know the essential nature of something, we remain in the dark, and more particularly we remain prone to cumulative errors when discussing it. Indeed, it could be argued that exploring and discovering essential essences is the primary aim of science, to which all other facets of scientific exploration are subordinate. The Periodic Table is perhaps the paradigmatic example of this kind of scientific endeavor and achievement.
Back to the Pies-Aftab interview.
Note the phrase: “…at most, we can identify certain ‘family resemblances’ among entities and conditions that we would call ‘disorders’ or ‘diseases.'”
So, based on Wittgenstein’s unevidenced claims, and Dr. Pies’ personal need to discredit the concept of essence, he asserts that all we can manage to do in our attempts to define “disorder” or “disease” is to note the “family resemblances” between different diseases. Any attempt to go deeper than this is an error. All we can know are the family resemblances, and as we shall see below – to nobody’s surprise – the “family resemblances” for disorder, disease, illness, malady, etc., according to Dr. Pies, are distress (or suffering) and incapacity (or impairment). What a coincidence!
Here are some illnesses and their essential definitions, as given in Taber’s Cyclopedic Medical Dictionary (Edition 22). The reader can see that all the examples give the nature and cause of the biological abnormality, which is the standard practice in Taber’s and other similar medical reference books.
Pneumonia: “Inflammation of the lungs, usually due to infection with bacteria, viruses, or other pathogenic organisms.” (p 1833)
Diphtheria: “A rare toxin-mediated bacterial infectious disease marked by the formation of a patchy grayish-green membrane over the tonsils, uvula, soft palate, and posterior pharynx.” (p 693)
Tuberculosis: “An infectious disease caused by the tubercle bacillus, Mycobacterium tuberculosis, and characterized pathologically by inflammatory infiltration, formation of tubercles, caseation, necrosis, abscesses, fibrosis, and calcification. It most commonly affects the respiratory system, but other parts of the body…may also become infected.” (p 2389)
Diabetes: “A general term for diseases marked by excessive urination and elevated blood sugar, esp. diabetes mellitus” (p 667)
Diabetes Mellitus Type 1: “DM [Diabetes mellitus] that usually has its onset before the age of 25 years, in which the essential abnormality is related to absolute insulin deficiency. It was formerly known as juvenile diabetes.” (p 672)
Diabetes mellitus Type 1a: “The most common form of type 1 DM. It is caused by autoimmune destruction of the beta cells of the pancreas and inadequate insulin production.” (pp 672-673)
Myocardial Infarction: “The loss of living heart muscle as a result of coronary artery occlusion. MI or its related syndromes (acute coronary syndrome or unstable angina) usually occurs when an atheromatous plaque in a coronary artery ruptures, and the resulting clot obstructs the injured blood vessel. Perfusion of the muscular tissue that lies downstream from the blocked artery is lost. If blood flow is not restored within a few hours, the heart muscle dies.” (p 1234)
Similar definitions of diseases/illnesses can be found throughout the text.
So, Dr. Pies is willing to write off, as misleading and invalid, more than two centuries of dedicated research by insightful researchers and scholars into the essential natures and causes of disease. And he actually presents this spurious notion as a useful and helpful perspective.
“That said, like Wittgenstein, I believe our ‘ordinary language’ is as good a guide as any, with respect to defining these terms. In our ordinary parlance, when someone shows evidence of prolonged or severe suffering and incapacity that is not due to an obvious wound (eg, a bullet wound), we are perfectly justified in saying that the person is ‘ill’; has some kind of ‘disorder’; or is ‘diseased.'”
But he misses the reality that our “ordinary language” use of the terms “disease”, “disorders”, “illness”, and “malady” entails references to the causes and essential natures of these entities. Suppose for the moment that a person has been spitting up a good deal of bloody phlegm for the past two weeks, and presents himself to a real doctor. The doctor will probably ask him for a sputum sample, and will send it to the lab for analysis/culture. Based on the lab findings, and what the doctor can gather by peering down the patient’s throat, and asking discriminant questions, he/she will begin to formulate a diagnosis, which Taber’s, incidentally, defines as: “The use of scientific or clinical methods to establish the cause and nature of a person’s illness or injury and the functional impairment it produces.” Note that the cause and nature are the primary considerations; impairment and, incidentally, distress are always secondary. One can’t properly evaluate the level of impairment until one has first established the cause and nature of the problem.
And then Dr. Pies’ narrative plumbs the very depths of self-congratulatory arrogance and invalidity:
“No labs or imaging needed! Indeed, the concept of disease (dis-ease) arose to explain just such instances of suffering and incapacity.”
There is layer after layer of obfuscation here. Psychiatry is often criticized on the grounds that none of its non-organic “disorders” can be verified by any lab or imaging or other objective test. This is a valid criticism. But if we accept the definition of disease promoted by Dr. Pies and other like-minded psychiatrists, it becomes irrelevant. If all one needs to establish is the presence of distress and impairment, then labs and imaging clearly are not needed. But if one insists that psychiatric disorders are “real illnesses just like diabetes”, then one needs to demonstrate the characteristic pathology. That’s what the term “real illnesses” means. And labs and imagining can be very helpful in this regard. But there are no labs or imagining techniques or other objective tests that can establish the existence of any psychiatric “disorder” other than those that are clearly caused by a general medical condition.
This is psychiatry’s most profound source of embarrassment. They gambled their entire professional standing on the belief that the famous chemical imbalances would be promptly discovered – but they haven’t been discovered. In fact, in many contexts today, the quest is being quietly abandoned.
And here’s the eminent and learned Dr. Pies, who himself promoted the chemical imbalance notions to professional and lay readers in the past (here and here), stating that no evidence of chemical imbalances is needed. We just state – contrary to the belief espoused by the great majority of real doctors – that the essential feature of disorder, illness, disease, malady, etc. is distress and impairment, and voila, out of the very ashes of defeat he, and like-minded psychiatrists, have snatched the mythical philosophers’ stone, capable of turning base metals into gold, and non-illnesses into bona-fide illnesses. What an achievement!
. . . . . . . . . . . . . . . .
“In short, ‘disease’ is a pre-biological, pre-scientific construct.”
Here again, Dr. Pies appears to be under the impression that this throwback to the pre-scientific era represents some profound and stirring insight!
To appreciate the significance of this contention, let’s consider the word “planet”, which entered the English language in the 1200’s. It came from a Greek word meaning wanderer, and was used to describe the seven celestial bodies: sun, moon, Venus, Jupiter, Mars, Mercury, and Saturn, which were mistakenly believed by the ancients to have proper motions of their own against the background of the “fixed” stars. So that’s what the English word “planet” meant from its earliest introduction until the Copernican Revolution (c 1543). Prior to Copernicus, the word planet was used in its pre-scientific sense; since Copernicus, the word is used in its scientific sense – meaning a celestial body that orbits the sun. And of course, since then, an additional two planets have also been discovered (Uranus and Neptune).
By choosing to use the words disorder, illness, disease, malady in their pre-scientific sense, Dr. Pies and a small number of like-minded psychiatrists are effectively choosing to ignore the progress made in biology and other life sciences in identifying the real nature and causes of disease. They are placing themselves in the position of astronomers who reject the Copernican Theory. The reality today, however, is that such astronomers would simply be mocked, drummed out of their societies, and stripped of their honors and credentials. They would get no telescope time at any of the great observatories, and would probably have to resort to horoscope-writing to make a living.
Psychiatry, to the best of my knowledge, is the only medical discipline (and I’m applying the term loosely) where one can boast that one is using pre-biological and pre-scientific definitions, and incur no consequences.
And this is because psychiatry is not a genuine scientific endeavor. Rather, it is a hoax, whose sole purpose is to push drugs and electric shocks regardless of the conceptual invalidity, the harm done, and the lives lost.
BACK TO THE DISTRESS/IMPAIRMENT DEFINITION
Earlier I described the chemical imbalance theory as the Big Falsehood. It is false, but it can be demonstrated to be false by the consistent failure to confirm it over several decades of intensive searching.
But Dr. Pies’ current falsehood which I think should be called the Monster Falsehood, can’t be demonstrated to be false because it hinges, not on any matter of fact, but rather on a refusal to acknowledge the ordinary meaning of the term “illness”. Here’s how a possible refutation attempt might go:
Disciple of Dr. Pies: Schizophrenia is an illness.
Ordinary person in the street: No it isn’t. There’s no characteristic biological pathology.
Disciple: That’s not needed for something to be an illness.
OPITS: Sure it is – that’s what the word illness means.
Disciple: No it isn’t. Illness just means distress plus impairment.
OPITS: What? Where did that come from?
Disciple: That’s always been the definition of illness.
OPITS: That was before there was any knowledge of bio pathology.
Disciple: But it’s still the definition of illness.
OPITS: That’s crazy.
Disciple: But it’s true. I’m right, you’re wrong.
OPITS: How do you know that?
Disciple: Because mental illnesses have no identifying bio pathology.
OPITS: That’s because they are not real illnesses.
Disciple: Oh they are real illnesses. They entail distress and impairment.
OPITS: But that’s just an outdated pre-biological perspective.
Disciple: Perhaps, but it still applies.
And on it goes. There’s no way out. It’s obfuscation on steroids.
And make no mistake. Dr. Pies knows exactly what he’s doing. He took an active part in the development of the Big Falsehood, and later, the Monster Falsehood, which he still promotes avidly.
In addition, it should be noted that even the illustrious psychiatrist Jeffrey Lieberman, MD, who is certainly no friend of the anti-psychiatry movement, acknowledges the need for biological pathologies as the essential ingredient in the definition of illness/disease, In a recent Medscape article, he was quoted as saying:
“It’s easy to criticize the DSM,” said Jeffrey A. Lieberman, MD, professor and chair of psychiatry at Columbia University College of Physicians and Surgeons in New York City. “But at this point, it represents a system that is as good as we can have, given our current state of knowledge.”
“Is it ideal?” asked Lieberman, who served as APA president from May 2013 to May 2014. “By no means. But there’s no better alternative. Hopefully, research will soon enable modifications that will lead to pathologic diagnostic assessments, like every other field of medicine has.” [Emphasis added]
Note the word “soon”, which we’ve been hearing from psychiatry for the past fifty years.
Modern Psychiatry is based on the Big Falsehood: that “mental illnesses” are caused by chemical imbalances in the brain. This notion has been actively promoted by psychiatrists for decades, though it has never been validated, and has been critiqued by members of the anti-psychiatry movement pretty much since its inception. Many psychiatrists have learned to stop using the phrase “chemical imbalance” but continue to use essentially similar and equally invalid concepts on their websites and other documents.
Other psychiatrists have abandoned the “chemical imbalance” concept altogether and instead use the pre-biological and pre-scientific notion that the hallmark of disease/illness is the presence of distress or impairment. This I have called the Monster Falsehood.
Intellectually and conceptually, psychiatry is dead. Psychiatrists gambled their entire professional fortune on the hope that the “chemical imbalances” would be discovered, and would at last make them real doctors, treating real illnesses, and receiving reimbursement from insurance companies. But they lost. At the present time, not a single one of psychiatry’s non-organic “diagnoses” has been linked consistently to a characteristic biological pathology. And, of course, following from this, there are no defining biological markers for any of these “diagnoses”.
Psychiatric “diagnoses” have no explanatory value, and are nothing more than loose collections of vaguely-defined problems of thinking, feeling, and/or behaving. A person with a perfectly functional brain can develop counter-productive habits just as readily as he/she can develop productive habits. The dynamics of habit formation are essentially identical in both situations.
Psychiatry is on life-support provided by pharma advertising and the social flywheel effect which can keep spurious endeavors and concepts afloat even after they have been authoritatively debunked. (There is, for instance, an active flat Earth movement here in the US.) But neither pharma promotions nor the social flywheel can last forever, and gradually psychiatry will slip quietly and ignominiously into the clinging morass of scientific wrong turns, iatrogenic damage, and moral degeneracy.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.