Psychiatry today strikes me as being in a similar place as Infectious Disease before germ theory. We can describe symptoms, we can group them together, and we can come up with cures that sometimes work but without knowing if we are talking about a virus or a bacteria we can't really understand what's going on.
On the bright side, we did manage to improve things using the scientific method. Germ theory came from epidemiological evidence in parallel with the discovery of microrganisms. We didn't have to already know how it all works in order to figure out ways to improve outcomes.
I think that what is disturbing to a lot of computing folk is that psychiatry sounds a bit ill-posed. An imposition of magical thinking onto what we assume are complex, chaotic systems. It just doesn't feel right that something so complex can be adjusted with such gross, brute-force methods.
Imagine debugging a computer and saying, "I think your RAM hasn't enough ones in it. I am prescribing this selective ones-uptake inhibitor to restore the balance." On the other hand, we do have plenty of drugs that are a bit closer to saying, "This packet flow seems to be overwhelming the cluster. We can prescribe this traffic filter to interrupt that flow, allowing other functions to return to normal."
> Imagine debugging a computer and saying, "I think your RAM hasn't enough ones in it. I am prescribing this selective ones-uptake inhibitor to restore the balance."
ITT: sweeping criticisms of psychiatry based on caricatures drawn from pop-sci accounts of psychiatry.
I am deeply critical of quite a few facets of modern psychiatry, but this thread seems to mistake the stuff that’s slung around in Guardian and Atlantic articles as having any relationship to reality.
Speaking from personal experience. I have a sibling with psychosis, on meds, hospitalized every so often. Also, one of my parents has been treated for ptsd and depression for more than 20 years.
The shrinks are clueless to put it mildly. What they do is try out different dosages and combinations of meds to see what helps until it doesn't and then they give up. Their practice is akin to witchcraft and mixing potions in the medieval times.
My honest opinion is that psychiatry is at best a pseudo-science and needs to be abolished as a field of medicine.
IMO, we already have the mental-disease equivalent of germ theory, it’s just far more complex and not yet well-understood by enough people to have broad social impact.
“The germ theory was proposed by Girolamo Fracastoro in 1546, and expanded upon by Marcus von Plenciz in 1762. Such views were held in disdain, however, and Galen's miasma theory remained dominant among scientists and doctors.” - https://en.m.wikipedia.org/wiki/Germ_theory_of_disease
> Marcus Terentius Varro was called the most learned of the Romans. But what did he know, and how did he know it? I ask because of this quote, from Rerum rusticarum libri III (Agricultural Topics in Three Books):
> Precautions must also be taken in the neighbourhood of swamps, both for the reasons given, and because there are bred certain minute creatures which cannot be seen by the eyes, which float in the air and enter the body through the mouth and nose and there cause serious diseases.
> I get the distinct impression that someone (probably someone other than Varro) came up with an approximation of germ theory 1500 years before Girolamo Fracastoro. But his work was lost.
The ancient Greeks were long ago discussing the possible existence of “animalcules.” Fracastaro gets credit because he wasn’t just philosophizing, he described actual disease in great detail with supporting cases (I hesitate to say “data,” that wasn’t really a thing yet) to argue for its mechanism.
It’s the difference between a stoner strumming his guitar, “dude, what if we’re all, like, strings?” and string theory.
I think the advice "don't live near a swamp, because the tiny invisible creatures in there will make you sick, and if you do have a farm next to a swamp, sell it" is a little more detailed than "dude, what if we're all, like, strings?"
Describing disease in great detail is nothing the Romans didn't also do, nor does it have anything to do with the germ theory of disease.
That advice applies equally well to miasma (and, in fact, it’s ability to accurately relate to geography of disease is part of why it was taken seriously.) Which is why F. gets credit for actually making detailed observations and hypotheses that we’re borne out.
No, the advice that tiny creatures within the swamp will make you sick does not apply to miasma; those are competing theories.
The advice "stay away from swamps; they'll make you sick" does indeed apply to both theories.
Detailed observations also apply to both theories. Everyone everywhere has detailed observations of disease, usually the same ones.
Girolamo Fracastoro did not, as far as I can see, make any hypotheses or predictions that other people hadn't made thousands of years before he was born, nor did he observe in any greater or more relevant detail. He exemplifies the observation "Christopher Columbus is famous for being the last person to discover America". He made what had been common knowledge common knowledge again.
Unless you can identify something he did that was notable? What hypothesis did he make that Varro didn't already know? I ask because "tiny creatures get into your body and cause disease" is pretty much the beginning and end of modern germ theory today.
It isn't even scientifically accurate to believe that mental illness is caused exclusively by brain malfunctions. Other bodily systems, especially the gut, also seem involved - never mind the mysterious role of genetics, and the slightly less mysterious but hard to pin down influence of environmental and social stresses.
I watched the chemical imbalance theory absolutely gut the person who used to be my mother. Over a period of maybe 10 years and multiple medications I watched her gain weight, get grey hair far too early for her age, she had periods where she either couldn't stay awake past 9:00pm, or couldn't sleep at all, periods of near catatonia, periods where rest was impossible.
She was a guinea pig for decades and it became abundantly clear toward the end that none of these doctors had a god damn idea what they were doing.
Even given my experience, I wouldn't rush to vilify them as criminals. I take an SSRI daily myself and it _helps_, and I owe gratitude to the science that has been done to get this far.
The problem is that all of these doctors are operating _without data_. They'll tell you that your seratonin levels are too low, or this or that, but if you ask them how low... they can't answer. If you ask them why they're low, they can give you common answers, but none that are unique to your physiology.
So you have schizophrenia? Let's try bloodletting, leaches, and an assortment of drugs that will affect the balance of chemicals in your brain in unknown ways. Don't worry about the side effects, here's a cookie to help with the blood loss.
As somebody who has actually benefited from psychiatry, I have to disagree strongly with a lot of people in this thread (respectfully). It isn't a lot of hand-waving, and what seemed like open-ended questions in the beginning were designed to work toward an ultimate truth - my issue.
There was no guessing involved or hand-wavy incantations, just a thorough assessment of my state of mind, both in the moment and across a span of time. This required me to be honest, which I strongly suspect many people aren't (due to things like fear of judgement) and this will hamper the capability of the doctor in doing their job.
To put this into perspective, while ill I was relatively high-functioning. You wouldn't guess I was ill, but you would likely find me abrasive and prone to apparent flights of fancy. What the worst symptom was, the crippling anxiety, you never would've been able to detect without a goal-driven conversation - the type of conversation I have with my doctor when we meet.
I think we're still largely in the dark on the methods of action within the brain that leads to these problems, but we have actually found useful tools in resolving these problems. This isn't to say it is perfect, I was put onto a completely incorrect drug by a non-psychiatrist based on my self-reporting.
The next step is going to be neuroscience explaining the modes of action in a failure state and how these drugs restore normal function.
To anybody out there suffering with mental disease, I'm with you.
I've been involved in treating patients with florid mental illness, and among people with that experience there really isn't any question that most of these illnesses must exist with some kind of underlying pathology.
There are many open questions about the mechanism(s) behind them, as well as the extremely frustrating fact that we can never truly tell if we are actually seeing the surfaces of multiple completely separate underlying pathologies that result in somewhat related loose symptom profile clusters.
But if we were to take an extreme example I encountered, a person whose life was basically over to the point of him trying to butcher people over his delusions[1], and you find a medication with which he can regain control of his own mind, can live in society rather than prison, even hold down a job and have fulfilling friendships, and over months you see numerous patients with this same dramatic reduction in symptoms, there is no question that there must be underlying pathology at play.
There might be numerous underlying pathologies all fitting the same symptom cluster, which would (potentially) help explain why even on the same symptom cluster a medication might have drastically different levels of effectiveness on different people.
The best reason to think underlying pathologies behind psychiatric illnesses are real isn't that we have clear the biology behind them, but that there exist treatments that actually have very measurable effects on the symptoms. The other reason is that we already concede our thoughts and perceptions themselves have a biological basis, so it would just be profoundly strange if 'disorders of thought and perception' somehow didn't.
[1] Just an additional note here, I'm using a specific example of a patient with violent delusions and criminal behavior, but it's important to note that people with mental illness are much more likely to be the victims of violence than perpetrators of it, and it is important we counter the unfair stereotype that mentally ill people are prone to violence.
On the 'reality' of mental illnesses, if I can be a little less serious, I do still recognise (as did my favourite professor) that it is still a very odd position to be in, to say that the illness must exist because of the presence of the treatment. Suppose that the treatment had for some reason not been invented, does that mean the illness didn't? Did the illness become 'real' the moment the treatment was discovered to be effective?
It’s why Fraud advocated cocaine use for hysteria. The work he did with Fliess is worth looking into as it’s relevant to you point about pathologies being revealed by the use of medication, cocaine in their case.
> The next step is going to be neuroscience explaining the modes of action in a failure state and how these drugs restore normal function.
We've been waiting for that next step for decades without any progress. The drugs don't predictably restore normal function, we can't predict if they will and we can't explain away this failure as improper diagnosis. In point of fact, the very theories that led to the creation of many of these drugs have been debunked as incorrect.
> Modern medicine pivots on the promise that portraying human suffering as biological disease will lead to insight and cures. Inescapably, this enterprise has a sociopolitical dimension.
The point of the article is that Psychiatry hubristicly still assumes it will find these "methods of action" wholey within the brain. This is despite some pretty compelling evidence that many psychiatric diagnosis present themselves radically differently in different cultures and time periods.
The truth is, we don't know to what degree neurological structures or patterns cause these problems. How much of it is the stories we are told about what symptoms go together, how our brain works and how it can be fixed? How much of it is because of the social structure of cities, media and our work places? How much of it is simply labeling people who naturally function differently as ill and attempting to force them to conform to some ideal for our own comfort and ease?
In all likelihood, there is a complex interplay between some or all of these factors that varies from person to person.
I am very glad to hear that Psychiatry's approach has helped you personally. That does not mean there aren't structural problems with how Psychiatry approaches and talks about mental illness. Indeed, the whole point of the article is that the same structural problems that led to some horrifying results in that past century have not changed much if at all. This is cause for concern.
I'm not sure the original commenter has a clear idea of the distinction between psychotherapy (talking cures) and psychiatry (doctoring). Beyond that there is psychoanalysis (depth psychology) and at the opposite, shallow end, just talking to a psychologist. All different things.
There is such a thing as "lay psychoanalysis", not involving a professional. I wouldn't dismiss it.
What I would definitely dismiss, as someone who has spent time in a psychiatric hospital as a patient, is the bad faith pseudoscience of psychiatry. Individual doctors may be doing their best, but the profession is very much as described in this article.
I'm interested in hearing what exactly you mean by "lay psychoanalysis." Analysis performed by someone who isn't a mental health professional? Analysis performed by anyone who never received formal analytic training?
It's an interesting question, whether there is such a thing. On one hand, Freud himself was a lay analyst. On the other hand, there's probably a reasonably large contingent of (orthodox) analysts who would assert that it can't exist for structural reasons (the setting, the lack of payment, the nature of the relationship, etc.).
Who dismisses lay analysts in this sense? Not even analysts do anymore (as evidenced by the acceptance of psychologists into analytic programs). You said not involving a "professional." Freud was talking about physicians.
I just meant that, if you want some kind of psychoanalysis, you don't necessarily need to go the professional route. Medically trained psychoanalysts don't really have a clear advantage over lay analysts in terms of insight.
We need be careful not to conflate degrees with fields. Psychiatrists can and do engage in "doctoring," psychological testing, therapy, analysis, etc. Clinician psychologists can do all of the above except for prescribing meds. So saying "this is psychiatry and that is psychology" isn't really a thing except where medication is concerned. It wouldn't even be fair, in consideration of neuropsych, to say that psychologists categorically don't treat diseases as having root biological causes.
The notion of "biological root cause" is very controversial. In fact I would say that applying the notion of root cause to a distressed individual is part of the problem with the establishment—the situation is inherently complex, involving social context and psychodynamic aspects as well as biology.
If we had a solid reductionist biological theory of mental illness, we would still sometimes discover that the cause was strictly "outside" the patient's own physiology.
Psychologists certainly go along with the fashionable talk of "chemical imbalances", but unlike psychiatrists, they don't really claim any authority when they do it.
I've heard this claimed a lot, but I'm unsure what _is_ the current status quo in psychiatry.
I say this as a layman who has undergone treatment from therapists and psychiatrists for years.
I'm not sure exactly what claim you are referring to. Maybe if you articulate it I can comment properly.
My general impression is that the only way to communicate how psychiatry is would be to write a very thick novel with characters who occupy many different positions in relation to the profession. Even then it would be hard to give an all-encompassing impression.
Pretty much any competent psych*gist knows "chemical I'm balance" is a total crock of shit. But, it is reassuring to (most) patients to have their lived experience explained in terms of an understood model. Pharmacological interventions are basically running through a list of candidates drugs and asking the patient how they feel. (Limited third party observation in inpatient settings, but really everyone is too overworked). There is a bit of a flow chart to determine what classes of drugs to prioritize in the search, but it is not nearly as deterministic as e.g. antibiotics; stuff is used off label all the time. For example, I knew a person who lived bipolar 1 with extremely pronounced psychotic features. She finally ended up stable on... Amphetamine, plus an snri specifically contraindicated in anything involving mania or suicidal ideation. That's like, absolutely inconceivable. Yet it's worked for the past ten years or so.
"At last count, more than 12 percent of Americans ages 12 and older were taking antidepressants. The chemical-imbalance theory, like the revamped DSM, may fail as science, but as rhetoric it has turned out to be a wild success."
The psychological "trauma model" for mental disorders is a compelling counterpoint to the chemical-imbalance theory. The wikipedia article contains some evidence and links to related research:
"A 2005 meta-analysis of schizophrenia revealed that the prevalence of physical and sexual abuse in the histories of people diagnosed with psychotic disorders is very high and has been understudied. This literature review revealed prevalence rates of childhood sexual abuse in studies of people diagnosed with schizophrenia ranging from 45% to 65%"
From the same page, “the logic that childhood trauma causes insanity has a serious flaw: If the claim was true, the abuse of millions of children over the years should have caused higher prevalence rates of mental disorders than the literature reveals.”
This is similar to the problem with cannibis which many psychiatrists view as the primary causal factor for schizophrenia and psychosis.
This is a methods problem in my opinion. See for instance this[1]. There are so many cannibis users and so many people who have been traumatized in some way, while the number of those developing schizophrenia is relatively much smaller.
But ask a psychiatrist how many of their psychotic patients used cannibis regularly and you get a pretty clear answer. The psychiatrists don’t get to talk to the millions of cannibis users that don’t develop schizophrenia and so they tend to form their own non-scientific opinions on the origins of schizophrenia. Same with trauma. How many people get to adulthood without some traumatic event occurring. Even on this board it’s got to be a small minority.
> From the same page, “the logic that childhood trauma causes insanity has a serious flaw: If the claim was true, the abuse of millions of children over the years should have caused higher prevalence rates of mental disorders than the literature reveals.”
This argument makes absolutely no sense to me. 40 million Americans now take psychiatric drugs for depression, anxiety and psychosis, about 1 in 6, most of them longterm. How many millions more need to take drugs before this would qualify as a high enough prevalence rate?
Most psychiatrists I talked rejected the notion that cannabis causes schizophrenia. They mostly claim genetic causes. My personal opinion from observing close people to me is that if you have predisposition, a psychoactive substance can be enough to nudge you over the edge into psychosis. It's a snowball effect. Of course, more likely is it would be something that raises your dopamine levels, like speed (amphetamine) or cocaine.
I’ve had the opposite experience but maybe it depends on the demographics of the patients that those psychiatrists see. As this peice points out, clinicians are increasingly likely to see the causal link even if researchers are having a hard time establishing that link.[0] I think a large part of that is due to measurement issues and methodological difficulties I alluded to. It took many years to establish the link between cigarettes and cancer. There are scientists who argue against global warming too. So much of science is driven by bias and group think and the pendulum has perhaps swung too far on cannabis. You might ask the psychiatrists you talk to what percentage of their patients with bipolar/schizophrenic type disorders are regular cannabis users.
There's a huge gap between depression and schizophrenia. While I'm sure that child abuse can likely lead to depression, just because you have depression doesn't mean you were abused.
I don’t think anyone is claiming that. I certainly am not. I would however argue that if you have depression there is a high probability of environmental factors which might be contributing (ie bad relationship, work stress, etc)
> At last count, more than 12 percent of Americans ages 12 and older were taking antidepressants. The chemical-imbalance theory, like the revamped DSM, may fail as science, but as rhetoric it has turned out to be a wild success.
This has always been my issue with psychology. It is inherently unscientific. Given the preponderance of reported mental conditions, it's also insufficient.
My experience is that the patient is asked a series of incredibly open ended questions. I was struck with the sheer variety of ways that I could respond. And depending on my response, I would receive a diagnosis.
The following were my diagnoses from 3 different psychiatrists: Attention Deficit, Seasonal Affective Disorder, Bipolar disorder.
There was absolutely no consensus, and it's no wonder. Years later a doctor made the connection between chronic pain (Crohn's disease) and my lack of energy.
I had been consuming anti-psychotics purely because of how I answered "How are you feeling today?" and other similar open ended questions in the wrong way.
At that point I worked to improve my chronic pain condition, which was of course the actual issue.
Neuroscience is the way forward to understanding mental disorders. In the meantime, great care should be taken around psychology. The effect of an uninformed approach can be devastating.
This is why I've never gone to a psychiatrist; only therapists. Instead of pretending to have scientific rigor, many therapists focus on the more human side of mental health, working out knots and releasing mental tension like a masseuse does for physical tension.
Neuroscience is the only true way to approach the problem scientifically, but it has a really, really long way to go. It's like trying to understand how Chrome works when all you have is a voltage meter for measuring the 1s and 0s in memory. And even that is a fairly recent development.
Absolutely agree w.r.t. Neuroscience: it’s really exciting to work on. Reach out via email in profile to hear a few compelling anecdotes on an “advanced volt meter.”
"> The chemical-imbalance theory, like the revamped DSM, may fail as science, but as rhetoric it has turned out to be a wild success.
This has always been my issue with psychology. It is inherently unscientific."
To be clear, the chemical imbalance theory and the DSM are part of psychiatry, not psychology.
Broadly speaking, the difference between the two fields is that while they attempt to treat the same issues, mainstream psychiatry (at least for the last 50 years) views the root cause as biological; psychology looks at social or environmental factors.
If you replace "psychology" with "psychiatry" in your comment, it would make more sense.
This isn't really an accurate characterization. It's true that a lot of psychiatrists focus on meds and biological root causes these days but lets not forget that the whole school of psychoanalysis grew out of psychiatry. It's simply wrong to say the whole field is focused on biological issues.
Likewise, clinician psychologists use the DSM regularly and do loads of testing, including tests for things like personality disorders (which, again, tend to be diagnosed using DSM criteria). Psychiatrists certainly can do testing but many of them (at least in private practice) refer out to psychologists for it.
Psychoanalysis was considered bringing psychology to the psychiatric profession.
Prior to Freud and Jung psychiatrists didn’t even care about the content of delusions and did not consider that anyone diagnosed with an illness could be cured except through physical means such as electroshock therapy.
“lets not forget that the whole school of psychoanalysis grew out of psychiatry. It's simply wrong to say the whole field is focused on biological issues.”
That’s why I explicitly referred to “mainstream psychiatry”, rather than the “whole field” as you imply in your inaccurate characterization of my comment.
I’ll grant you that the DSM may provide some value for understanding the range of personality disorders at least at a high level. But it’s really messy. Other tools may be more useful for understanding specific disorders, for example the Hare psychopathy checklist.
[edit: replaced “testing tools” with “tools” in previous sentence]
(note that psychopathy isn’t even listed in the DSM, the closest thing is ASPD - just another indication of how messy and imprecise this entire field of personality disorders is, underneath the veneer of scientific rigor)
A lot of psychiatry is essentially someone following a rote decision tree process to arrive at a DSM diagnosis. So if you do 1hr of research beforehand you can probably get a psychiatrist to diagnose you with any condition - and you'll also see how unnuanced most of their questions are. In your case with the anti-psychotics, you made the mistake of believing the psychiatrist actually cared and that answering that question honestly automatically put you in the subtree of their decision tree that ended up getting medicated with those.
I agree. It reminds me of those personality tests like the Myers-Briggs INTJ/ENFP/QR5X. Everyone has an idea of what kind of personality they want to have and answers the questions in a way so that the result is biased towards their desired personality.
Similarly, when your therapist asks you a question, your answer is skewed by what you want the answer to that question to be. Or what you want your therapists reaction to your response to be. Or any number of factors.
This idea has led me to start doubting my subjective experience of basically everything. Do I not like someone because of how they act or do I not like them because I don't want to like them? Did I study computer science because I enjoyed it or because I wanted to make a good salary? Not to mention that other peoples' subjective experiences are probably even less reliable.
I have no idea how to answer my therapists questions because I don't trust the answer in the first place.
Have you ever tried keeping a journal? We all make decisions based on what we know and how we feel and both of those things change over time.
With that in mind, does it really matter why you studied computer science? You're allowed to feel differently now than you did when you made the decision to study CS.
Psychiatry doesn't need a biological theory, it needs a different approach to service delivery.
Somebody I knew drank antifreeze one day, decided he didn't want to die after all, then went to the emergency room. His family wondered where he was for 36 hours and then they found out.
A week or so later he went to a scheduled appointment at a psychiatrist's office, had to fill out his name 10 times and then tell it to 5 different people and was so enraged by the cluelessness that he went home and hung himself that night. That time he succeeded.
E-room workers are trained to believe that the vast majority of suicide attempters are seeking attention. That's true.
Inside that population, however, are a small fraction of
completers for which a suicide attempt is the mental health
equivalent of a heart attack.
Unfortunately books have a long half life. People are still influenced by R.D. Laing, Thomas Szasz, L. Ron Hubbard, and Erving Goffmann long after Ronald Reagan set the insane "free" to roam on the streets. Involuntary commitment was a problem in the 1950s, but today it can seem impossible to check into a mental hospital even for a person who is in a full-blown psychotic crisis.
Also the issues of paying for it. You could say private health insurance is bad, but just try Medicaid.
The helping relationship is fundamentally difficult too. Some people are going to do the wrong thing and face consequences if they do. Sometimes what you think is the right thing is really the wrong thing and vice versa. You can't take responsibility for someone else's life in the end.
"Modern medicine pivots on the promise that portraying human suffering as biological disease will lead to insight and cures. Inescapably, this enterprise has a sociopolitical dimension. To say which of our travails can (and should) come under medicine’s purview is, implicitly if not explicitly, to present a vision of human agency, of the nature of the good life, of who deserves precious social resources like money and compassion. Such questions, of course, aren’t always pressing; the observation that a broken leg is a problem only in a society that requires mobility seems trivial.
But by virtue of its focus on our mental lives, and especially on our subjective experience of the world and ourselves, psychiatry, far more directly than other medical specialties, implicates our conception of who we are and how our lives should be lived. It raises, in short, moral questions. If you convince people that their moods are merely electrochemical noise, you are also telling them what it means to be human, even if you only intend to ease their pain."
> Nor does ironic accurately describe the actions of an industry that touts its products’ power to cure biochemical imbalances that it no longer believes are the culprit. Plain bad faith is what’s on display, sometimes of outrageous proportion. And like all bad faith, it serves more than one master: not only the wish to help people, but also the wish to preserve and increase power and profits.
This sums up psychiatry and psychiatrists in general. Corrupt pill pushers willing to make money no matter what the outcome for the patient and what it takes. If it takes lying, so be it, as long as it's well intended. If it takes many people committing suicide after buying their bullshit chemical imbalance fiction even they don't believe, so be it. Such disregard for other human lives would usually land one in jail, but we have a whole profession built on it. At the same time, we lock up drug dealers who may potentially and inadvertently have part of the puzzle (lsd, psilocybin, mdma, ketamine). The entire existence of the field is absurd. One book, the dsm justifies these quacks pushing whatever they want and using their patients as guinea pigs in ad hoc experiments that often go wrong and lead to worse outcomes, including death. All because we refuse to believe that things like depression and anxiety might be caused by say an unhappy relationship, family problems, an unsatisfying job, lack of friends and community, and so many almost obvious deficiencies in our society. Absurd.
Psychiatry indeed has a pretty bleak history, and it's fair to criticize that history. It is true that the DSM as it categorizes mental disorders is not biologically valid in general, however, most psychiatrists today recognize it just as a communication tool. Two psychiatrists with patients exhibiting similar symptoms can be concisely described using DSM vocabulary.
It is also necessary for billing purposes. Insurances want to put labels on things so they can price and track things. This is true of all medicine, however. When do you call high blood pressure too high? Greater than 140 mmHg? 130? Someone has to pick an arbitrary threshold for practical reasons.
"The pathological basis of almost all mental disorders remains as unknown today as it was in 1886" (article quote) I don't think this is true. We don't know enough to make targeted treatments quite yet, but we do know a lot more about the brain now and have much more reliable theoretical conceptions of mental illness.
There is a ton of research going on in understanding mental illnesses at computational and circuit levels, and we're already starting to see the fruits of that research. Researchers are developing targeted treatments using transcranial magnetic stimulation (TMS) and similar modalities to directly perturb circuits that are believed to be deranged.
I think psychiatry will change significantly over the next decade or so as we learn what is wrong with a specific individual's brain and intervene directly at the circuit level. I don't see how drugs will play a major role in this as it is very difficult to develop a drug that could target specific circuits.
This time really is different.
(Psychiatrist in training here)
> When do you call high blood pressure too high? Greater than 140 mmHg? 130? Someone has to pick an arbitrary threshold for practical reasons.
We have no choice but to stratify disease into low, medium and high when there are only low, medium and high dose interventions.
For the most part, this works because individualisation is such a pain.
But if individualisation wasn’t, you’d get 1 of a thousand different doses to optimize and eek out slight additional benefits.
We could apply high frequency trading algos to an implanted infuser, or deep brain stimulator or wearable TMS when we get around to accepting/funding them for more common and non-extreme diseases.
Well neural computations happen at the level of individual neurons up through complex multi-neuronal circuits, cognition and behavior are the result of neural computation, therefore if cognition is abnormal then computations at the level of neurons up to circuits must be deranged. Nothing fancy.
>cognition and behavior are the result of neural computation
That's like saying if someone gets shot and dies it's because they merely had a faulty brain -- it's ignorant of the actual cause.
Neurons don't exist in a vacuum, they respond to social, environmental, and biological inputs.
How does psychiatry scientifically decide if a persons deranged mental behavior is due to mere deranged circuits or deranged social, environmental, or biological inputs?
I see where you’re coming from. I think a great deal of mental illness is social and environment. We did not evolve to live in the circumstances of developed societies. So absolutely if we could change environment and social factors that would help a lot.
But just take depression for example. Let’s say Bob goes to a psychiatrist with depression. Bob recently lost his job and his girlfriend left him. He has every reason to be depressed. He would probably feel a lot better if he had a job he likes and wasn’t so alone. The problem is he’s too depressed to look for a job or to go out and meet new people, the things that would help his depression. This is where I think psychiatry can be helpful; some people just need something to break them out of their depression for long enough to be able to make the social/environmental changes in their life that will help them in the long run. Therapy alone may be enough for some people but not for everyone.
>some people just need something to break them out of their depression for long enough to be able to make the social/environmental changes in their life that will help them in the long run
I think it's very easy to be dismissive of counseling.
Of course it isn't an exact science, maybe not even a science at all.
I like to think of it this way.
Think of your mind like an iterative non-linear system with thousands upon thousands of inputs.
It operates completely by cause and effect, but because it's non-linear, that doesn't mean it's easy to figure out how it got stuck in a loop.
>In the mathematical field of dynamical systems, an attractor is a set of numerical values toward which a system tends to evolve, for a wide variety of starting conditions of the system. System values that get close enough to the attractor values remain close even if slightly disturbed.[1]
Sometimes when our mind gets stuck, the efforts on our part to get out aren't enough to get us unstuck.
Psychologists or psychiatrists are people who are familiar with some of these mental paths and how it can lead people to become stuck.
They are also familiar with some of the paths that lead to an exit from those undesirable states.
They are attempting to deal with such a complex system, that I don't think it's fair to hold them to the same standard as the so called 'hard sciences.'
For another perspective on the problem of 'getting stuck', from a Buddhist point of view (which is also based on cause and effect) see [2].
Your entire argument works just as well for shamans as psychiatry; except the drugs shamans use have far fewer and more benign side-effects, with thousands of years of history instead of 20-40.
Many of the psychiatrists I have encountered "believe" in their medications, and when questioned as to how (and how well) the drugs they were informed about work have no real substantive argument for all their years of med school.
But fuck, do they get paid better. You won't see many shamans on a Pfizer sponsored golf trip in Hawaii.
I think this is a very valid counterpoint, but I'd just like to point out that Shamans must have actually helped people throughout history as well. Now, I'd argue it might have been some combination of talk therapy, social expectation, and whatever else.
Yes, I could have been clearer that I was talking about 'talk therapy' not medication.
Does the argument work as well for shamans? Maybe,except that I was kind of implying a materialist point of view behind psychology, which might not apply to shamans.
But who says that shamans might not 'cure you' of your depression just as well?
> The biology of mental illness is still a mystery, but practitioners don’t want to admit it.
I believe we started with a faulty premise, that perfectly natural states of mind are an "illness". They may not be pleasant to behold but our brains have these mental states built in, for whatever reason. The mental health system wants to aggressively impose conformity of psychology across the population, which causes real mental illness. And the most evil thing we do is giving psychoactive drugs to kids.
I believe we started with a faulty premise, that perfectly natural states of mind are an "illness"
I tend to agree, but this is only partly true. It isn't because something is "natural" that it is therefore healthy and desirable. Some mental states, whether genetic or environmental, are very debilitating to the individual that has to live with them. So there is value in trying to "cure" certain mental afflictions.
But yes, the field of psychology suffers from a fashion-based ideology that appears to want to mold every individual to the same narrow (and flawed) ideal. But in my experience, this fashion trend diminishes with expertise: most behavioral and forensic psychiatrists I've sproken explicitly eschew that type of prescriptivism.
What absolute bullshit. All congenital disease is natural. That doesn't mean patients should suffer. We treat children for mental illness, because we have comprehensive studies that shows it improves their life.
So, let's say I think I am depressed. Should I seek out a psychiatrist, a psychologist, or a clinical social worker?
I sort of think psychiatrist is someone who treats personality disorders like schizophrenia, bipolar, borderline, etc. Almost always will involve use of medication as primary treatment.
Psychologist more for depression, anxiety, mood disorders. Not an MD so can't prescribe meds but often works with the patient's primary care physician if this is needed.
Clinical social worker for .... not sure? Interpersonal issues, behavior issues, anger management, etc.?
But no idea if that is even close to being on target.
Psychiatrists can prescribe medication (I think the "ch" are related - psychiatry and chemical?). They can do what I'd call "conversational therapy" but they're main job is dealing with medication.
Psychologists are usually more of a traditional conversational therapy - and there's different forms of that, CBT, DBT, etc.
Social workers - I'm not 100% sure but in my experience they're more of a "intermediary" - they diagnose and refer you to an appropriate therapy. That or they're more of a "general psychologist" say with a school. I don't think you really meet with them regularly. There's a huge shortage of Psychiatrists/Psychologists at least here in Michigan, and a becoming a social worker requires less schooling I believe.
(I've suffered from depression for years, I've met many doctors, social workers, etc. and currently see a Psychologist and Psychiatrist regularly)
You've got this somewhat wrong. It's true that many psychiatrists these days focus on med management rather than therapy, but until maybe 30 years ago psychiatrists were actually the only mental health professionals who were allowed to become psychoanalysts, the folks who more or less pioneered talk therapy.
Also CBT/DBT are not forms of psychodynamic therapy (which is what people usually think of when they think of talk therapy). That's why they're called "behavioral" therapies.
My answer is based on what I find true today and from my experience. I'm only 20 so that explains that part.
Not sure what you mean by "CBT is not a form of talk therapy". The first sentence according to the Mayo Clinic is "Cognitive behavioral therapy (CBT) is a common type of talk therapy (psychotherapy)." [0]. Are you confusing CBT with CBD?
I'm just using a phrase that the average joe understands (And is also used by the Mayo Clinic). We can agree to disagree if you want, but to be fair what I call it doesn't really matter, I'm but a young lowly programmer :)
It matters in the sense that the difference between a "list" and an "array" matters. I'm just trying to clarify the language so anyone who reads is on the same page. When most people think of talk therapy I think that they think of lying on a couch and not stuff like CBT but perhaps I'm wrong.
All three have talk therapy within their scope of practice, and "the talking cure" originated with 19th century German doctors. Until the middle of the 20th century it was exclusively the domain of MDs.
In modernity, insurance reimbursement policies incentivize psychiatrists to focus on medication management, but there are still many of the old guard (and cash-only practices that set their own rates) who will perform psychotherapy. Additionally, in certain states, Licensed Psychologists (PhDs and PsyDs) who have completed additional training in psychopharmacology are allowed to prescribed a limited set of psychotropic medications in collaboration with a fully licensed MD (not necessarily a psychiatrist). Also in the prescribing realm are PMHNPs, mid-level providers trained in the nursing model who focus on psychiatric care. As with psychiatrists, they tend to focus on medication management, but are able to provide talk therapy as well.
Psychologists (PhDs and PsyDs) are Doctoral level providers trained in research, talk therapy, and administering psychological assessments such as personality inventories, IQ tests, and capacity determinations for forensic purposes.
Licensed Clinical Social Workers, Counselors, and Marriage & Family Therapists are all Masters-level providers trained to provide talk therapy. There are different histories and underpinnings that have created these distinctions and is reflected somewhat in the specifics of their graduate studies, but it's largely irrelevant to you as a client; much like engineering, therapy is as much art as science, and most of the "real" training comes once you have graduated and begun working in the field.
The current trend in outcomes research indicate that the license and professional background is not a significant factor in the efficacy of psychotherapy. To quote Irvin Yalom, a giant in the field of talk therapy (and a psychiatrist by training), "it is the relationship that heals".
There’s a lot of overlap. The main difference is in what they’re allowed to do, but not in what they treat. As you identified, psychiatrists can prescribe medicine. Psychologists and psychiatrists can administer tests and make diagnoses, an LCSW can’t.
I would also note that bipolar is not a personality disorder, it is a mood disorder like depression.
The overlap in professions can illustrate a lot of what is wrong with this branch of medicine. If you see a psychologist they'll recommend more sessions, CBT, books etc. If you see a psychiatrist your're walking out with a prescription.
When you're a hammer, everything starts to look like nails.
Hm, this doesn’t even remotely match my personal experiences. In my experiences, they’ll refer you to each other as warranted but ask you for your preferences first. I’m sorry that you’ve had such a bad time. What happened for you?
This is mostly observation from myself and people I've known. Most of them, when referred to a psychologist, simply go through therapy sessions. Definitely if there are issues that are likely not treatable through talk therapy options they would be referred to a psychiatrist, but I've never seen someone walk out of a psychiatrists office without a prescription or a recommendation for one.
This year, I walked out of a psychiatrist's office without a prescription or recommendation for one. I went into the office:
1. With the specific goal of treating my condition with medication,
2. An ongoing condition which was diagnosed years ago,
3. I am already treating the condition with therapy, and have decided that therapy is not enough, a conclusion which others agree with,
4. The condition responds well to a variety of different medications, and is considered "very treatable",
5. The medications do not have much risk for abuse. We're not talking dexedrine or xanax, here. I couldn't sell these medications on the black market if I wanted to.
For sure there are plenty of psychiatrists and psychologists out there which aren't very good at their jobs, and I've heard plenty of horror stories. Fortunately, the people I know who have had bad experiences have switched doctors or switched therapists.
There is plenty of selection bias. For me, and the people I know, the purpose of visiting a psychiatrist in the first place is in order to evaluate medication. If you don't want to take medication, then you don't schedule an appointment with a psychiatrist, which is hard anyway (due to the psychiatrist shortage--it's difficult in at least the US and UK, to my knowledge). If you want therapy, you see a psychologist, LCSW, or someone else. And if you think that you need therapy, I don't find it unreasonable when the therapist agrees with you!
I don't mean to diminish the problems in the field of psychiatry, but by no means is the field on the level of alchemy or astrology.
And if you or anyone is trying to navigate the mental health system, I am more than willing to provide what little advice I have.
I think you should seek out someone whose priority is understanding your problems and helping you understand them. Practitioners from any of the groups you mentioned can take that approach but not all do. My opinion is that, all things being equal, a psychologist or psychiatrist with an analytic approach is the best general purpose choice.
The topic of Psychiatry is interesting to observe. I'm reading pessimists vs optimists in the comments and find it amusing because of the impossibility of knowing who is right. I want to believe society has best intentions and is on the right path. Yet what does the science really exhibit? A lot of psychiatry has been horrific the past hundred years and cases exist where the person does benefit. So what's the majority verdict because even snake oil has some satisfied customers.
I think psychiatry is in for an interesting surprise soon when it discovers that the information it lacks has already been uncovered through an extensive series of informal experiments being conducted in a collective, ad-hoc, slapdash fashion through a seemingly unrelated field - that is, the world of recreational psychedelics. There's a whole global community of pioneers who have been quietly working hard at understanding the insides of their own brains for at least two generations now, and they've made a lot of progress. To make things even more interesting, many of these people are connected with the world of technology and computing, which has been expanding rapidly into an understanding of consciousness through the work on neural networks, deep learning, and artificial intelligence. All of these worlds are about to collide, in the next 10-20 years, and something really interesting is about to happen.
Not to diminish the spirit of your post which I very much suport, I would however like to point to the fact that psychiatry is very much aware of psychadelics and is engaging more and more in formal research using it for all kinds of very promising applications, PTSD therapy with MDMA and Psilocybin for instance. I am sure is just as influenced by the recreational experiences of people in this field as in others.
Additionaly, though I give psychedelics much credit, if we are going to point to the value and promise of subjective first person research into the nature of the mind, its worth mentioning meditation and mindfulness, another subject area that is widely studied by psychologists, psychiatrists and neuroscientists and is also gaining wide spread adoption clinically, for instance in the treatmentment of depression and anxiety.
Additionally, though both psychadelics and meditation have only really been studied widely in the west recently (you mentioned two generations, might be a bit more) they are both built upon long traditions of study in cultures around the world. I would argue that budhism contains one of the most in depth, analytical and methodological studies of the mind from a direct and subjective first person experience amongst millions of practioners for thousands of years. I am truly inspired by the synergetic results of combining the scientific and emperical tools of science with the considerable knowledge and tools of these traditions.
It seems to me that the biggest problem in tapping into these worlds is that science just doesn't like self reported subjective studies, it really likes to measure things objectively, hence all the brain imaging etc. However, it seems as though with a system as complex as the brain, it might just be that the best tool to measure and understand the mind we have is our own mind. I hope that the scientific pardigm can shift to make use of it.
Can you point us in a direction on this? I have never read a lucid attempt to describe the "anatomy of the psyche" on "psychonaut" websites, just a lot of people who may have had some personal experience of enlightenment but don't describe it super well. The closest thing I can think of is Jung whose description of the psyche was heavily influenced by mystical experiences he had, sans drugs.
I can't comment on the parts about psychiatry and recreational drug use. However, machine learning and other AI technologies have nothing to do with the study and understanding of the human mind at this point, beyond a very vague metaphor.
While in theory AI could have been explored as a science, trying perhaps to simulate human or animal thought processes in hopes of understanding them and perhaps coming up with useful abstractions that could help us reason about them, the field has never really evolved in that direction.
Perhaps you're right - I'm no scientist and I'm not involved in research, I'm just an engineer working on building machine learning tools. Maybe I'm reaching too far. From where I sit, though, the concepts I hear people talking about when we discuss the design of machine learning systems, especially the sort of cutting edge research on concepts like attention and adversarial networks, sounds a whole hell of a lot like the ideas and techniques that come up when people try to sort out the conflicts and malfunctions that occur in the pattern-matching and story-telling mechanisms inside their own brains. Metaphors they may be, but they seem to work, and that tells me that we're on to something. I look forward to learning more about what's going on as this work proceeds.
Nonsense. I have Bipolar. Psychedelic microdosing consistently triggers a manic episode. Extreme trips are known to trigger psychosis in those with related mental conditions. There is very little empirical evidence that microdosing has any benefits at all. James Fadiman is a serial fabulist. The original creativity study he was involved with (and I use the term involved very loosely), and constantly keeps harping on about, was a terribly conducted farce. Just keep that in mind.
I'm sorry to hear about your struggle. These things can be difficult and not every tool works for everyone. Keeping one's mind in balance and on track can be a lot of work. I don't know who James Fadiman is and I can't speak to the science involved, but from what I've seen in the experiences of people around me who have had mental health struggles, a mild form of mania can be a really useful state of mind for getting lots of work done. Mania becomes a problem when people get so wrapped up in the storm of thoughts that they can no longer communicate effectively with the people around them, but as long as people stay grounded and keep some empathy open, being in a state of mind where you feel full of energy and connected to the big picture really helps in motivating yourself toward productive action. Nothing lasts forever, people need space and time to rest and recharge, but nudging yourself a bit in that direction isn't necessarily harmful if you have some work to do.
The problem with psychology and psychiatry is that they have ZERO understanding of the definition of a baseline healthy human being who has an integrated set of physical instincts, emotional responses and mental processes such that they lead a fulfilling, happy life. Without a definition for "health" there can be no defintion for disease. Of course, our modern medical systems are rarely concerned with cures and are thus ultimately content with the financial outcome that results from treating the symptoms. This is a result of the for-profit corporate structure's dominance of all aspects of our world, and affects what gets studied and, more importantly, what does not get studied. (See: Chris Rock's "ain't no money in the cure" bit.)
As such, nutrition science is literally less than four hours of medical school education (my wife's first son is finishing his residency at his first-choice program, one of the East Coast's premier programs). [To learn more about this, I highly suggest the fantastic documentary "Eating You Alive". I have switched to a whole food plant-based diet as a result and feel better every week (it's been about eight weeks now, with a few cheat days along the way).]
We are only now realizing the direct link between our gut biome and our mental health, and our gut biome is directly related to the foods and/or poisons we ingest. Once again, the for-profit corps provide foods that harm us but cannot be proven to do so, medicines that harm us but cannot be proven to do so, and an environment polluted by their machines and chemicals whose effects cannot be measured enough to hit them in the only place they care about: their purses via tort law. They have crafted the laws and staffed the regulatory agencies while lobbying the government to dismantle and detooth those agencies' abilities to provide scientific oversight. Every single one of these factors affects our mental health, and all the while there is very, very little research being done on nutrition and how to measure toxicity and remove it from the body.
And yet that only peripherally approaches the truth of our human baseline because our human nature goes deeper still, and yet that pervasive corporate mentality to put profit over human well-being is intrinsically related to what we are as moral beings. We each have a moral compass, however subtly different our societal tunings. It is an intrinsic part of our human nature, and our lack of moral teaching as societies is the source of all our problems including our inability to address psychological issues. We have sick societies the world over and it is foolish insanity to think that mental illness is not an absolutely natural result of such selfish, competitive societies.
The misunderstanding of the cocaine rat study illustrates this all-too-well. When the studies were re-run years later with non-overcrowded, healthy environments the rats wanted nothing to do with the cocaine.
The solution to all our problems is to selflessly choose, first individually and then collectively, to form cooperative, caring societies instead of the dog-eat-dog world of economic competitiveness we currently live under, competitiveness that oft leads to physical competitiveness. Beyond promoting mental and physical health, such compassion lets one see the true nature of the other person, which is essential when one is dealing with psychopathy or sociopathy. Psychiatry is built upon a lack of compassion and its systemic harms all result from their hubris, ignorance and profit motive.
Even our precious traditions that should be leading us towards that loving ideal have been conquered by the animalistic persons who live for mammalian alpha-dominance games within and among groups, be they defined by class, ethnicity, form of religion, political affiliation, gender identity or sexual preference. We must live in groups to survive and prosper and our moral nature's purpose is to nudge us towards peaceful cooperation so that we may ALL happily explore this world, whatever our predilection. This is why there is a Law of Karma that only works at the human level, where we reap the happiness or unhappiness we sow in others; it is the feedback mechanism that nudges us towards humane cooperation and away from animalistic competitiveness. Our Creator does not intervene because the gift of free will to choose either selflessness or selfishness, love or its antitheses, wisdom or ignorance, the good of the whole or the benefit of the few -- that gift of free will is freely given. Thus, a group of Nazis can go about their hateful, oppressive business just as freely as we Sufis can ours. It is up to each one of us to choose the better path, for ourselves first and then as societies.
As the great Poet of God, Rumi said, "The Way goes in.", but in this materialist world culture of self, there is a communal disdain for and utter denial of the internal spiritual pursuit that leads us to moral perfection, first individually and then collectively. As such we cannot comprehend the difference between physical mental illness (caused by disease or nutritional imbalance) and a person who's just a selfish, sociopathic bastard and a person who is just naturally having a difficult time dealing with our sick society and the sick world that is making us physically ill via its pollution and constant stress.
The fundamental truth is that no one's health, mental or physical ("Not two, not one"), can EVER be successfully treated without clear-minded, compassionate care, and that must involve first getting them away from negative environmental factors and into a nurturing environment. Creating such a compassionate society requires compassionate human beings, and that requires the humble work of self-reflection and self-evolution beyond the negative traits we all possess.
Psychiatry is not a science. And their business model literally depends on you not getting better. Those $200/hr sessions aren't big business unless you keep coming back for more.
While we're at it, let's prescribe some pills for underlying deficiencies we can't measure in the first place.
I don't think your first point very well thought out.
Any doctor (or mechanic, accountant, etc...) could benefit by providing false/sub-standard services to keep the client returning regularly.
As for the measurement, it's almost entirely based on feedback from the patient.
I can see how a depressed or mentally ill person could be more susceptible to accepting medication that wasn't in their best interest, but that problem seems intrinsic to all medication.
Wrong. Doctors would (hopefully) lose licenses and have big legal consequences. Mechanics are also subject to some form of objective measurement as even the average driver has some sense if a problem is being fixed or not.
But psychiatry? Forget it. You pay to talk to someone, they have a nice couch, soothing voice, make you feel good for an hour, but nothing really changes. But hey, I liked that hour, I should keep coming back!
Patient acting crazy? Label them schizophrenic, schizo-affective or bipolar(doesn't really matter which, they are all subjective); Hit em with some major tranquilizers and dopamine inhibitors and rack up that sweet insurance money.
I wish. In my country you have to wait till they harm someone before anyone will do anything. Human rights and all that. How can someone with a visible mental illness be considered to know and make decisions about their health is beyond me. It's wonderful how they simulate normal behavior that even experienced psychiatrists don't notice until it's really bad. I witnessed someone calmly and rationally explain that they have a messianic delusion, like they don't really believe it. Back home it was a different story, performing miracles and whatnot.
Your use of Schizophrenia and Bipolar as examples are both at the top of the heap in terms of what modern psychiatry has been successful in managing.
Depression, as a general term, and anti-depressants on the other hand, not so much. The world of psychology is far more of a fail. CBT therapies, mindfulness, and various other fads have all turned out, in meta-studies to be either hot air or incompetent application of the scientific method.
The human brain is the most complex organ in the known universe. At least psychiatrists are required to have an MD to practice. Psychologists just wave their hands around and maybe scrape by on some basic statistics to get qualified to rummage around like demented apes in the windmills of your mind.
CBT has a large evidence base and appear to work for 50% to 60% of the people who take it. We have huge amounts of data from the English NHS IAPT scheme.
That number needed to treat is pretty good. You may want to compare it to other routine medication such as statins or blood pressure meds.
CBT has been debunked by multiple meta-studies. Psychology, as a science, is a joke. The brain is the most complex structure in the known universe, but to be a psychologist you don't need even a basic MD. It should be struck off as a science all together.
Nope. There are side effects. And some times they are worse. But most times they're better than the disease. Good luck being manic with psychosis without meds.
nobody is arguing that major tranquilizers don't have their place for controlling psychosis in emergencies but long term use of them has a degenerative effect on the brain
