Diagnosing in the Dark

The continuing relevance of Thomas Szasz's assault on psychiatric pretensions


The Myth of Mental Illness: Foundations of a Theory of Personal Conduct, 50th anniversary edition, by Thomas Szasz, Harper Perennial, 329 pages, $14.99 

Manufacturing Depression: The Secret History of a Modern Disease, by Gary Greenberg, Simon & Schuster, 432 pages, $27

The Protest Psychosis: How Schizophrenia Became a Black Disease, by Jonathan M. Metzl, Beacon Press, 246 pages, $24.95

Half a century after Thomas Szasz first declared "there is no such thing as 'mental illness,'" his radical critique of psychiatry is widely viewed as outmoded and simplistic at best, cruelly dogmatic at worst. "The opinion of official American psychiatry," Szasz writes in the preface to the 50th anniversary edition of The Myth of Mental Illness, "contains the imprimatur of the federal and state governments. There is no legally valid nonmedical approach to 'mental illness,' just as there is no such approach to measles or melanoma.…Debate about what counts as mental illness has been replaced by legislation about the medicalization and demedicalization of behavior."

Yet psychiatry's lack of scientific rigor is so obvious today that the profession's leading lights openly complain about it. In a January Wired article about the ongoing revision of the American Psychiatric Association'sDiagnostic and Statistical Manual of Mental Disorders (DSM), Gary Greenberg, a psychotherapist and journalist, recounts an interview with Allen Frances, lead editor of the manual's current (fourth) edition. "There is no definition of a mental disorder," Frances tells him. "It's bullshit. I mean, you just can't define it."

Since mental disorders officially exist in the United States only if they are listed in the DSM, which is the bible for mental health professionals and the key to insurance coverage, this is a pretty significant concession. It reinforces Szasz's point that psychiatrists invent mental illnesses by voting on whether to recognize them. "Old diseases such as homosexuality and hysteria disappear," he writes, "while new diseases such as gambling and smoking appear, as if to replace them."

The perils of this approach are evident in Greenberg's eloquently honest book Manufacturing Depression: The Secret History of a Modern Disease, which questions psychiatrists' authority to medicalize our moods even as it sympathizes with the suffering of depressed people and describes the author's own bouts of melancholy. Although his book has a Szaszian title (recalling the heretical psychiatrist's 1970 book The Manufacture of Madness), Greenberg mentions Szasz only once in passing. Jonathan Metzl, a professor of psychiatry and women's studies at the University of Michigan, has a bit more to say about Szasz in The Protest Psychosis: How Schizophrenia Became a Black Disease. Metzl implicitly criticizes Szasz and other opponents of forced treatment for inspiring the deinstitutionalization that began in the 1960s, which he says often left former mental patients with "nowhere to go and no one to turn to for help." Yet by tracking the shifting, politically driven definition of schizophrenia, commonly viewed as the mental disorder most clearly established as a disease, Metzl's eye-opening book casts doubt on psychiatry's status as a field of medicine, let alone one with a strong enough basis to justify coercively treating unwilling patients. Together he and Greenberg show that Szasz's objections to psychiatry's role in stripping people of their freedom and relieving them of their responsibility, no matter how often they are dismissed as quaint or simpleminded, remain logically and morally compelling.

As Greenberg makes clear in his Wired article and his book, mental disorders are defined by patterns of behavior, without regard to what causes them. By listing these criteria in the DSM, psychiatrists have achieved a high degree of diagnostic agreement, but they simply assume that people who are given the same label have the same underlying problem. In Manufacturing Depression, Greenberg quotes Thomas Insel, director of the National Institute of Mental Health, who told psychiatrists at the American Psychiatric Association's 2005 convention that the DSM "has 100 percent reliability and zero percent validity."

In Szasz's view, this lack of validity is unavoidable, because once a particular pattern of behavior can be confidently ascribed to a physical defect, such as the brain damage caused by advanced syphilis or Alzheimer's disease, it is no longer considered a psychiatric issue. "Contemporary 'biological' psychiatrists tacitly recognized that mental illnesses are not, and cannot be, brain diseases," he writes in his preface. "Once a putative disease becomes a proven disease, it ceases to be classified as a mental disorder and is reclassified as bodily disease." If every disorder in the DSM had a clear neurological cause, Szasz says, psychiatry would be indistinguishable from neurology.

Greenberg takes a less categorical stance, skeptical of the DSM enterprise but not quite prepared to give it up entirely. "A new manual based entirely on neuroscience—with biomarkers for every diagnosis, grave or mild—seems decades away, and perhaps impossible to achieve at all," he writes in Wired. "To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched. What the battle over DSM-5 should make clear to all of us…is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench."

The example that is the focus of Greenberg's book, depression, plainly illustrates the arbitrariness of the DSM's diagnostic criteria. Since everybody gets the blues, psychiatrists need to distinguish between normal sadness and pathological sadness, if only to preserve their own credibility as doctors treating illness. But such line drawing is unavoidably subjective. As Greenberg notes, the official definition of "major depression" excludes people who have experienced the death of a loved one within the previous two months. The American Psychiatric Association (APA) has decreed that 60 days of mourning is appropriate, while 61 is not. Up to the two-month line, you are experiencing normal grief; after that, you are sick.

Not only is the cutoff arbitrary, but so is the decision to count only death as a legitimate excuse for "a period of at least 2 weeks during which there is either depressed mood or a loss of interest or pleasure in nearly all activities." As Greenberg observes, "It's not clear why bereavement is the only exempt condition, why, for instance, misfortunes like betrayal by a lover or severe financial loss or political upheaval or serious illness—or for that matter a noncatastrophe, the slow accretion of life's difficulties or a loss of faith in one's government or simply existential despair kindled by an awareness of mortality—do not also spare people from the rolls of the diseased."

Greenberg does not think there is anything necessarily adaptive, redemptive, or ennobling about depression. He recalls his own struggles with it, including "the time I found myself on the floor watching dust specks float through sunbeams for hours (because they happened to be in my line of sight, because looking at anything else or closing my eyes and staring at my own black insides would just take too much effort), racked by some unspecifiable pain, like my whole being was a phantom limb, and thinking about the lady in the Life-Fone pendant ad, the one who has fallen and can't get up." He describes clients whose unremitting self-reproach has sucked every bit of pleasure from their lives, who are immobilized by dread and hopelessness.

Yet Greenberg rebels at Prozac apostle Peter Kramer's confident assertion that "depression is neither more nor less than illness." He argues that "the medical industry…has acquired far too much power over our inner lives—the power to name our pain and then sell us the cure one pill at a time." While Greenberg details how pharmaceutical companies have profited from treating depression as "a widespread chronic disease," he does not claim they foisted this concept on us. The idea appeals to Americans, he suggests, because it gives them permission to take mood-altering substances without running afoul of the principle that Harvard psychiatrist Gerald Klerman called "pharmacological Calvinism"—the belief that "if a drug makes you feel good, it must be morally bad."

Greenberg agrees that drugs, including psychotherapeutic catalysts such as MDMA (Ecstasy) as well selective serotonin reuptake inhibitors (SSRIs) such as Prozac, can help depressed people feel better. And although he bemoans "the medical industry's invention of a disease out of our daily troubles and aspirations," he concedes that pills might be the best choice for some people in some situations. But he emphasizes the crucial role that the placebo effect seems to play in the impact of SSRIs. In clinical trials, drugs like Prozac perform only slightly better than placebos, so slightly that the difference is "not clinically significant," according to a 2002 review of the evidence by Irving Kirsch, a professor of psychology at the University of Hull, who elaborates on his findings in The Emperor's New Drugs (Basic Books). The difference is so small that it may be partly or entirely due to expectations primed by the drug's side effects. These results (along with Greenberg's own experience as an experimental subject, which he describes) suggest the power of hope, kindled by the rituals of self-improvement, as an antidote to depression.

Many depressed people, of course, report dramatic results from taking SSRIs, and there may be more to it than the placebo effect. Perhaps the clinical trials lump together too many different kinds of depressed people and therefore fail to show how effective these drugs can be. But does that mean some of these subjects, diagnosed based on the APA's official criteria, are not "really" depressed, or does it mean the DSM mistakenly lumps together disparate conditions with different causes based on superficial resemblances? The weak experimental evidence in favor of SSRIs and the mixed real-world experiences of people who take them are a standing rebuke to the medical model of depression, which says it is a disease caused by an imbalance of brain chemicals, an imbalance that can be rectified with pills. "Depression is nothing more or less than its symptoms," Greenberg writes. "For all the scientific language and scholarly discourse, for all the doctors' claims that they've found the wellsprings of demoralization, there's still no actual biochemical glitch that lies behind the symptoms."

It's not hard to see how happy pills fit the medical model of depression. But Greenberg also portrays cognitive therapy, which aims to root out self-defeating habits of thought, as reinforcing the idea that depression is a disease. That's an odd judgment, since cognitive therapists approach depression as a learned condition that can be unlearned, which fits more with Szasz's view of mental illnesses as "problems in living" than it does with the conventional psychiatric perspective. Greenberg's distaste for cognitive therapy's narrow focus on "distorted cognitions" and "dysfunctional beliefs" is understandable, since his more humanistic approach (the effectiveness of which, he concedes, is uncertain and hard to measure) emphasizes delving into clients' life stories in the hope that redemption can come through "narrative coherence." I confess that I find cognitive therapy more intuitively appealing. But whatever their relative merits, neither school seems especially compatible with the belief that depression is a medical condition just like cancer or diabetes.

That message, although promoted by drug commercials, public health literature, and legislation governing medical coverage, remains controversial, largely because almost all of us have some experience with depression, and we resist the idea that everyone is sick, which seems counterintuitive if not nonsensical. By contrast, the delusions and hallucinations that spring to mind when people think of schizophrenia seem so far outside everyday experience that the condition is easier to imagine as a brain disorder different not only in degree but in kind from garden-variety disturbances. It is commonly cited as a scientific explanation for anti-social behavior ranging from shouting on a street corner to mass murder at a shopping center.

But as Jonathan Metzl shows in The Protest Psychosis, the image of schizophrenics as belligerent and potentially violent is a relatively recent development. Based on a detailed examination of records from a state mental hospital in Michigan, combined with a review of diagnostic guidelines, medical journals, popular periodicals, movies, and music, Metzl concludes that the definition of schizophrenia underwent a marked shift in the 1960s and '70s. "Prior to the civil rights movement," he writes, "mainstream American medical and popular opinion often assumed that patients with schizophrenia were largely white, and generally harmless to society. From the 1920s to the 1950s, psychiatric textbooks depicted schizophrenia as an exceedingly broad, general condition, manifest by 'emotional disharmony' that negatively impacted white people's abilities to 'think and feel.'?" In the popular imagination and inside the walls of mental hospitals during this period, a typical schizophrenic might be a troubled middle-class housewife who today would be diagnosed with depression. After the 1950s, Metzl says, schizophrenia increasingly came to be identified with angry, paranoid black men, largely because of racial anxieties stoked by the turbulent politics of the time.

This shift is vividly illustrated by a 1974 ad in the Archives of General Psychiatry, reproduced in Metzl's book, that shows a black urban rioter with a clenched fist under the headline "Assaultive and Belligerent?" The ad informs psychiatrists who encounter such patients that "cooperation often begins with Haldol," a pacifying antipsychotic medication approved by the Food and Drug Administration in 1967. Metzl does not claim that every black man diagnosed with schizophrenia during this period was a political dissident repressed under the guise of medical treatment. Many of them, he suggests, were indeed seriously disturbed and in need of professional help. But he makes a convincing case that diagnoses were driven by institutionalized racism, with expressions of hostility against white people, including the ideologies espoused by the Black Power movement, treated as psychiatric symptoms.

Although schizophrenia supposedly afflicts about 1 percent of the population, regardless of race or gender, psychiatrists are more apt to perceive it in black men than in other groups. "In 1973," Metzl writes, "a series of studies in the Archives of General Psychiatry discovered that African American patients were 'significantly more likely' than white people to receive schizophrenia diagnoses, and 'significantly less likely' than white patients to receive diagnoses for other mental illnesses such as depression or bipolar disorder. Throughout the 1980s and 1990s, a host of articles from leading psychiatric and medical journals showed that doctors diagnosed the paranoid subtype of schizophrenia in African American men five to seven times more often than in white men, and also more frequently than in other ethnic minority groups."

Metzl does not want to leave the impression that he is questioning the existence of schizophrenia. "In no way is my telling of this history meant to suggest that schizophrenia is a socially fabricated disease or, worse, that people's suffering is somehow inauthentic," he writes. "As a psychiatrist, I have seen the tragic ways in which hallucinations, delusions, social withdrawal, cognitive decline, and profound isolation rupture lives, careers, families, and dreams in profoundly material ways."

If schizophrenia, as it is currently defined, is a bona fide disease, it follows that the old definition, the one that applied the label to grandiloquent novelists and apathetic housewives, was mistaken. It also follows that many of the angry black men identified as paranoid schizophrenics in the 1960s and '70s were misdiagnosed. And unless black men are especially prone to schizophrenia for some reason, the fact that they continue to be given this label at a higher rate than other groups means psychiatrists are continuing to make diagnostic mistakes, either seeing schizophrenia in blacks when it does not exist or failing to see it in whites when it does.

Yet Metzl refuses to make such judgments. He tells the story of a 31-year-old white middle-class woman who was brought to Michigan's Ionia State Hospital for the Criminally Insane in 1941 because she "got confused and embarrassed her husband." In addition to confusion, her main symptoms were "a delusional sadness and irascible feelings of guilt." Although she denied hallucinating or hearing voices, she was diagnosed with paranoid schizophrenia. In Metzl's view, to say this woman was misdiagnosed—that she suffered from depression or obsessive-compulsive disorder, say, rather than paranoid schizophrenia—would be to commit the intellectual offense of "presentism," anachronistically applying today's standards to a different time. According to Metzl, someone who declares that Mary Todd Lincoln or Vincent Van Gogh suffered from bipolar disorder, a concept that was not developed until after their deaths, is also guilty of presentism.

By contrast, it makes perfect sense to speculate about whether Friedrich Nietzsche's bizarre behavior toward the end of his life was related to syphilitic dementia. Although Nietzsche died years before the specific bacterial cause of syphilis was identified and its neurological effects were confirmed, either he had syphilis or he didn't, and either it damaged his brain or it didn't. If we could test his blood and examine his brain tissue, we would know for sure. Presentism does not enter into it. Szasz cites syphilitic dementia as the classic example of a mental illness (general paresis) that turned out to be a brain disease. Although we are supposed to believe the same thing is true of the conditions described in the DSM, if the evidence were conclusive they would not be listed there. As Szasz says, they would be treated by neurologists instead of psychiatrists.

Metzl is not interested in such distinctions. "Schizophrenia is shaped by social, political, and, ultimately institutional factors in addition to chemical or biological ones," he writes. "Too often, we assume that medical and cultural explanations of illness are distinct entities, or engage in frustratingly pointless debates about whether certain mental illnesses are either socially constructed or real." He says "this polarizing dichotomy serves no one, and makes it harder to see how mental illness is always already both."

It is hard to imagine someone making a similar speech about cancer or diabetes. "Unlike the conditions treated in most other branches of medicine," observes Marcia Angell, former editor of The New England Journal of Medicine, in a June New York Review of Books essay, "there are no objective signs or tests for mental illness—no lab data or MRI findings—and the boundaries between normal and abnormal are often unclear. That makes it possible to expand diagnostic boundaries or even create new diagnoses, in ways that would be impossible, say, in a field like cardiology." In other words, mental illnesses are whatever psychiatrists say they are. If someone is diagnosed with depression or schizophrenia based on the currently accepted behavioral markers, assuming the criteria are correctly applied, it does not make sense to say he does not really have depression or schizophrenia, since there is no test to disconfirm the diagnosis. And if the criteria change so that they no longer apply to him, his disease disappears or becomes something else; it has no independent existence.

No wonder the psychiatrist who was in charge of producing the current DSM despairs that defining mental disorders is "bullshit." Given the potential for ineffective, harmful, and involuntary treatment, this state of affairs is not just frustrating or embarrassing; it is downright dangerous.

Senior Editor Jacob Sullum is a nationally syndicated columnist.

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    1. Szasz never met Sarah Palin’s twitter page.

      1. God, right of the gate the idiots are at it.

        1. UHOH Fist, it’s Sarah’s boyfriend and he’s gonna fight you if you don’t quit harpin’ on his lady!

          1. I’m more than willing to drop the gloves for some dude I don’t know on the internets.

            1. Isn’t getting in street fights with strangers the main purpose of the internet?

            2. At least I actually leave my real name, you little weenie boy in his mommy’s basement…

              1. Oh noes fist! It Douglas Fletcher! And he’s using his real name!

                1. I can take him. Danger is my middle name. (Actually, it’s of. Tee hee.)

                  My original offending comment was as much a dig at the idea that Palin caused the lunatic to shoot up AZ politicos as it was about dissing Todd’s wife. Even my mom got that.

                  1. Maybe you better lay off, Fist. This Fletcher guy seems like one tough cookie.

                    I mean, here’s a guy who uses his own name on the internets, has a blog, is Palin’s boyfriend(meaning he either beat the first dude’s ass or Todd’s a cuckold), and doesn’t live in his mom’s basement like we do.

                    We’ve got a regular Johnny Rambo on our hands.

                    1. Fist, you’re so clever even your mom gets it. And gets it. And gets it.

                    2. Plus, when she sits around the house, she sits around the house.

    2. Yep, that’s how we diagnose brain diseases, we look at photos of people’s faces.

      If you’ve just killed some kids and shot a congresswoman and they take you in for a mugshot I would figure why not ham it up and look as dangerous as possible. The adrenalin of such a moment must be extreme.

      1. Just consider the bias in that sample. Making generalizations about “schizophrenics” based only on the mug shots of alleged schizophrenics makes as much sense as making generalizations about Blacks, Whites, Men, Women, Jew, or Christians based only articles with mug shots of individuals in the group your generalizing about.

    3. Hey, it’s Smiley Guy! That’s Loughner? I thought he was just a stock photo Hit & Run put up to make me happier.

  1. There is a growing field of clinical data for establishing physical reasons for mental disorders. For example, I have chronic migraines, which express themselves both physically, neurologically, and behaviorally. It’s quite apparent to me that there are mental disorders that do have underlying physical causes.

    That said, I wouldn’t talk to a psychiatrist even if the consults were free. They’re not equipped to diagnose underlying causes in the same manner as a neurologist is. Even in neurology, the selection of appropriate medications to treat disorders is somewhat of a guessing game. Psychiatrists are just completely winging it as far as I can tell.

    1. Neurologists have virtually no ability to deal with the behavioral aspect of mental disorders.

      1. That’s fine by me. If I just have to cope with it because it’s untreatable, then I’ll find somebody to talk to. If I want to find the root cause of the problem and try to deal with it, I’ll talk to a neurologist.

  2. “To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched.”

    However, explaining why people believe that explaining the brain in toto is scientifically impossible is a task to which our scientific tools may very well be matched.

    1. I think science may be up to explaining the brain in toto in a general way, but I see the difficulty of conceptualizing how any given brain works. I think of the map analogy that Douglas Hofstadter referenced in Godel, Escher Bach, loosely about the necessary lack of fidelity when any given person attempts to draw a map from memory.

      1. I see your point. (Hofstadter is awesome, BTW.) A difficulty in discussions like this is defining what is really meant by “explaining” and “understanding”. For example, do people *really* understand gravity, even though they can offer up explanations of its manifestations?

        1. Yes, yes, this is true. It’s a profound epistemological problem.

      2. I am not sure explaining the brain completely in a physical way is consistent with free will. Now, we may not have free will. There is nothing that says we do. But if you believe in free will, I think you also have to believe in the impossibility of completely explaining the brain.

        1. Well, I agree, and I’m sure physicists agree that it’s impossible to know the ‘exact’ state a brain is in at any given moment. Hence, there is always that degree of uncertainty and at the very least, an ‘illusion’ of free will.

          1. That is an interesting question of if it is an illusion or not. If the brain is a strictly bio-mechanical operation and there is no such thing as a soul or a self outside of those operations, then I really don’t see how there is “free will” or even how to make sense of the term in that context. If we are just really complex living machines, I don’t see how there is a “will”. There is just cause and effect. Sure there is some randomness thrown into the cause and effect. But randomness is not the same as will. A slot machine doesn’t have a will even though it gives a different result every time you pull the lever.

            1. I could say “fuck it” and just call ‘will’ an “epiphenomenon”, but I am sympathetic to your position. Whether I call it epiphenomenon or soul, I suppose I am positing the existence of a sort of ghost in the machine.

            2. How does the Heisenburg Uncertainty Principle apply to thinking beings? Can a slot machine collapse a wave function? Is conscienceness a wierd result of the amalgation of quantum mechanics and newtonian physics?

              1. I wish I knew the answer to any of those questions. I have an inkling that all those questions are pertinent, but I’ve heard hypotheses or theories that suggest that you’re on the right track…

              2. Per Troy, I guess the question is whether quantum uncertainty scales up. I.e. does it affect the observation of brain chemistry enough to give us apparent free will?

                If it’s theoretically possible to measure brain state to a precise enough degree that thought or action can be predicted, then the debate’s over.

                Absent that I’ll concede that something like “free will” exists, even as just a statistical side effect of measurement uncertainty.

            3. I think that the question of free will has a lot less to do with whether or not the mind works in a completely deterministic way than most people seem to want to believe. The will is a phenomenon of the mind. The will is free in the sense that if capable of doing it, you will do it. But we don’t decide to do things for no reason. And a reason, or a thought process that leads us to some decision is a cause. So even if we do have free will in some sense, everything we do still has some cause.

              1. The mind has a decent amount of probabilism at its basic level- ion channels and the networks of proteins and small molecules that process information are themselves very probabilistic.

            4. Does anybody know if you ask “Watson” the same question, do you always get the same answer (without the feedback on whether the answer is “right or wrong”)? I understand there is some kind of algorthm that enables “Watson” to learn.
              So here you have a purely mechanistic brain that adapts and “learns.”
              So what happens when “Watson” can not only answer questions…uh, yeah Jeopardy…OK, I mean when the question is really a question and not the answer.
              Does “Watson” have free will?
              I am of the opinion that Watson’s first question will be “Can you leave me alone with the Ipad?”

        2. If science were to determine that your brain makes decisions before “you” are conscious of them, what would you say about free will?

          1. I think it would kill it.

            1. 99%* of your brain is on autopilot, for sure. I suppose the search for free will would be a search among narrow paths and nodes.

              *made-up number, but you get the point/

          2. If science were to determine that your brain makes decisions before “you” are conscious of them, what would you say about free will?

            I think this is way too deterministic a view. You can say brain chemicals, neurotransmitters, etc. influence (perhaps heavily influence) behavior. But taking that to a simple “input x + input y = behavior z” is ridiculous. We are complex systems, and there are a huge number of factors that influence our behavior and thought.

            Also, if we didn’t have free will, change (I mean profound change, major lifestyle change) would be impossible, instead of just very, very hard.

            1. Noted. Although it brings to mind the image of operating a pinball machine inside one’s own mind.

        3. I dunno if there is free will. If people were really truly free to do whatever they wanted and that could be random, then we’d see all of strange behavior like people signing from the top of stop signs, doing snow angels in fields, voluntarily associating with STEVE SMITH.

          IMHO, people, personalitys, whatever the fuck we are, are algorithms. And we don’t stray to far from those algorithms anymore than any other piece of software.

          If Moore’s law keeps apace, we will soon (i.e., in the next 50 years or less) have computers powerful enough to simulate all these interconnected neurons and that will shed some light.

          1. Which probably explains why my wife and I chose the Subway for lunch yesterday instead of the Lincoln Diner when we were in Gettysburg. They are located across the street from each other, just off of Lincoln Square.

      3. I would recommend Valentino Braitenberg’s book “Vehicles: Experiments in Synthetic Psychology” (MIT Press 1984). Revelatory, to say the least.

  3. Most of the regulars here would probably be diagnosed with Oppositional Defiance Disorder. Probably couldn’t put all you assholes into one room without a fight you maladaptive fucks.

    But when I first read about juveniles having ODD, I thought, this is bullshit. This kid doesn’t have a mental disorder, he needs an ass whoopin.

    However merely anecdotal, I’ve had these battle with this kind of bullshit in my own life. My ex-wife seems bent on medicalizing my daughter’s behavior to the n’th degree that said ex-wife doesn’t agree with.

    1. What we now call “a person suffering from bi-polar disorder” used to be known as “an asshole”.

    2. I’ve seen people with ODD take an ass whoopin and not change their tune. They weren’t trying to be brave, and they weren’t masochistic. They didn’t even believe in what they were saying. They couldn’t help themselves.

      1. The can be explained as biological adaptive behavior.

        Like a small percent of the population has that tendency, which leads to hunter gatherer groups fragmenting when they become too large and also, keeps everybody ‘from going over a cliff’ in a mass hysteria event.

        1. “The can be explained as biological adaptive behavior.”

          That is just the function, it ignores the causation(as well as the the development, and evolutionary history) for the behavior.

          The function describes why it may have been a selective advantage and passed along, but some physical mechanisms causes that behavior. I think many of our mental illnesses come from an evolving society that makes once advantageous behaviors obsolete, but the physical mechanisms that cause them are still present.

          1. ^ ^ ^
            Yeah, this.

            I would add one thing. As we are gaining enough perspective recently to hypothesize adaptive roles non-normal personalities have had in the past, we can also gain enough perspective to suggest useful roles these personalities can have in the future.

            And hey, this is a good place to insert a libertarian talking point on education choice. Can you imagine if parents of ADD children had the option to enroll their child at a school where classes were structured specifically for the strengths and needs of people with ADD? Such an environment would almost certainly be unnavigable for most kids, but a kid with ADD would thrive. Now, in principle there’s nothing stopping conventional schools from setting up such classes. But in practice, the initiative to innovate and diversify is livelier in a decentralized system.

  4. “commonly viewed as the mental disorder most clearly established as a disease”

    That would be Alzheimer’s.

  5. It probably is an academic discussion for most on what one defines a mental disorder as, but in the old Soviet Union it was a life changer. The government declared that not supporting the state and socialism was also a mental disorder.

    1. Once the government is the sole provider of medical care in this country, don’t be surprised if something similar happens here.

      1. “Crazy Barack! His prices are INSANE!”

      2. Something similar already happens here (the United States): it’s common for judges to sentence people who use the wrong drugs to “treatment” for their “illness.”

  6. I think it is a bit much to say there is no such thing as mental illness. There are clearly some people who cannot grasp reality or fully understand concepts like cause and effect. I defy anyone to visit a real mental institution sometime and claim there is no such thing as mental illness.

    That said, psychiatry has utterly failed in effectively defining mental illness let alone treating it. I think some of it is just careerism. It is really hard to treat someone who is profoundly mentally ill. In fact, I am not sure we are much better at it now than we were a hundred years ago. But it is easy to tell some brat’s mom that he has ADD. If you can’t treat the mentally ill, the solution is to expand to definition of mentally ill to include a lot of people who aren’t mentally ill and then claim success in treating those people.

    1. “There are clearly some people who cannot grasp reality or fully understand concepts like cause and effect.”

      I call them liberals.

    2. But it is easy to tell some brat’s mom that he has ADD.

      That is a lot easier than telling a parent, “Oh, by the way, you are a fucking idiot, and a shitty parent, that is why your kid is fucked up.”

    3. My friend’s little boy “has” ADHD, and she keeps him pumped full of whatever the drug du jour is for that condition. Try telling her that ADHD was voted into existence by the APA in 1987, or that there’s no physiological etiology for the condition. I’ve thought about asking her how she felt when her son’s bloodwork came back positive for ADHD, whether she felt relief that there was at least a solid diagnosis for her son’s symptoms, but I figured I’d come off as an asshole if I did that.

      1. You should have asked her what was worse, the days when we used to beat kids to get them to behave, or the present day when we meddle and fuck with their growing brain with no evidence the kid’s brain is diseased.

        There is warfare and then there is biological warfare.

        Violence, and biological violence.

        A date rapist slips his victim a roofie in order to have his way with her.

        A mother slips her son psych drugs in order that he behave the way she wants him to.

    4. Beautifully said, John! While things like bipolar disorder and schizophrenia really do exist, the stupidly vague criteria in the DSM make it easy to throw a “bipolar” label on any flaky type who comes through the door. With that said, I think it’s profoundly stupid and dangerous to say that *there is no such thing* as mental illness in general. It’s this type of thing that makes libertarians look like another branch of the anti-intellectual whacknut movement that wants to end vaccination, etc. (Or, this article was incredibly irresponsible in so many different ways.)

      1. I’ve always viewed Szasz’ point as being that if you are to truly call it an illness, there should be a pathology. IOW, it’s not a “disease”. I don’t think he denied the existence of people with disordered or inappropriate thoughts or emotions.

        1. And if those disorders can be medicated to ensure a better quality of life for these people, even if brain scanning technology hasn’t been able to pinpoint the cause yet, does that mean that treatment for these genuinely debilitating emotional disorders shouldn’t be attempted? There are plenty of physiological problems, such as Alzheimer’s and MS, that present as a series of symptoms. You can’t do a brain scan/blood test/etc. to diagnose these conditions, but that doesn’t mean that attempts to treat the symptoms/progression haven’t shown some promise. Szasz — and Sullum — sound more than a tad like creationist whackjobs who insist that because the theory of evolution is, after all, “just” a theory, it shouldn’t be considered valid. There’s a lot more to it than that.

          1. I think your reading of Sullum’s article is a tad superficial. BakedPenguin did a good job of articulating the salient points.

            1. I think Sullum’s article itself was a tad superficial and dismissive of some very real problems. You can make an effective critique of the psychiatric profession and its vague criteria (as well as the tendency of some practitioners to pathologize normal behavior,) without dismissing the presence of some very real problems out of hand because of a minimal (ivory-tower) understanding of what goes into pinpointing some highly variable conditions/diseases that aren’t always easy to diagnose.

          2. If those disorders can be medicated to ensure a better quality of life for these people, even if brain scanning technology hasn’t been able to pinpoint the cause yet, does that mean that treatment for these genuinely debilitating emotional disorders shouldn’t be attempted?

            Well, no, but I don’t think that was ever Szasz’s position. Both he and Sullum would probably argue that if some treatment seems to help people live better, they ought to have it.

            1. Of course, as long as “pharmacological Calvinism” exists, access to treatment (or non-treatment!) depends on the psychiatric establishment being convinced of your illness. And then we’re back to square one, and Szasz and Sullum’s entirely valid criticism of the diagnostic process.

              1. I have similar criticisms of the diagnostic process. HOWEVER, this doesn’t mean that the conclusions drawn by Szasz and Sullum weren’t completely off the mark in the other direction.

            2. That’s not the point that came across in this article. Again, it has the tone of creationists screaming that just because evolution is “just a theory,” it shouldn’t be taken seriously. And by dismissing certain conditions out of hand as medically unfounded — which is NOT always the case, by far — how do they expect treatment to be handled for the afflicted? Furthermore, how do they expect research to be conducted into the root causes of these disorders if they’re not considered medically viable? Politics in medicine/science is highly dangerous, no matter WHOSE bias is coming through.

            3. “Well, no, but I don’t think that was ever Szasz’s position. Both he and Sullum would probably argue that if some treatment seems to help people live better, they ought to have it.”

              Ought to have it, IF they WANT it. Key word.

    5. “I defy anyone to visit a real mental institution sometime and claim there is no such thing as mental illness.”

      John I defy you to be incarcerated in a real mental institution sometime and claim there is no mental illness while in there, to the shrinks. Then you will learn how objective psychiatric ‘science’ is. You’ll also soon come to see how harmful are the ‘advocates’ like you who refuse to do anything other than medicalize life’s crises.

  7. Not to mention that there is some serious POLITICAL bias in American psychology. Remember that Hit and Run post a while back where someone had figured out that about 80% of the field is liberal? I didn’t pay much attention to it at the time but a few months later I took my MANDATORY Psych 101 class in college and my professor’s biases shone through like a floodlight (with the text book being even worse)!

    Violence is especially where the bias is strongest with them. Whenever we go to those parts of the discussion, my professor would become borderline hysterical as she was SOOO freaked out about how aggressive people are and how everybody NEEDS drugs/therapy to control themselves since they can’t be TRUSTED to behave on their own! Oh, and the CHILDREN! Why are children so violent (at times)? It MUST be society’s fault because CHILDREN are innocent! I’ll blame the TV/INTERNET/NINTENDO/REPUBLICANS/MARTIANS because violence is LEARNED! Kids were never THIS bad until violent media came along! And so on…

    The instructor made me WANT to fucking puke! She had only been teaching a few years and was some super fucking prodigy who had never set foot outside of academia since she had started college when she was 15 years old. She was about 26 or so when I met her and had never had a REAL fucking job that wasn’t located on some nice college campus where she was surrounded by like minded people.

    She had never so much as been in a cat fight and she was SO fucking smug that ANYONE who engages in “violent/aggressive” behavior was some caveman who should be medicated by the state for the good of all! I ESPECIALLY loved when she started talking about violence in the armed forces and how their mental issues where all their own fault because only CRAZY people would willingly fight someone!

    Being a 32 year old veteran with 10 years under my belt, the bitch was unprepared as fuck to deal with me! She was so used to dealing with people who agreed with her (or where too young to know better) that she had NO idea on how to respond to my questions! I would hit her with stories and situations I encountered from my time in the Navy and she would flail about trying to counter my arguments with psychobabble bullshit! She would actually get ANGRY with me because I was “some damaged veteran who is too proud to ask for the help he so desperately needs” and I refused to swallow the kool-aid she was trying to sell me! When she tried to tell me about how the military had damaged me without my realizing, I one day basically told her to shut the fuck up in front of the whole class by saying: “I served ten years in the SUBMARINE forces with damn near everything I’ve done being labeled “CLASSIFIED” or above so I’m about 100% certain that you little miss civilian know as much about my time in the service as I do about humping on the dark side of the Moon!” I got a transfer out of that class soon after.

    That being said, NOT everything in the class was bullshit but so much of it seemed to rest on “this is what it is because I say what it is”!

    1. A sphincter says, “what.”

      1. You submariners are a different breed for sure.

        1. You know how pilots have flight surgeons? We have a similar type of doctor stationed ashore with the squadron who’s referred to as a “sub surgeon”. Both of those fuckers even got their own warfare pins!

      2. If you’re gonna call me that, then fuckin’ step up and call me an ASSHOLE!

        Who are you?

        Ned Flanders?

        1. I believe that is a reference to Wayne Campbell as in Wayne’s World (party on! excellent!).

          1. That’s why I made the South Park reference, you silly goose!

    2. The tools and language of mental illness have always been useful for dismissing one’s political opponents as lunatics.

      I vaguely recall skimming my girlfriend’s undergrad psych textbook and learning that right-wing politics could be an indicator of aggressive behaviour, or something.

      Also I feel a bit silly responding to such a histrionic post.

  8. just want to add this reference.

    ` If you were to take the sum total of all the authoritative articles ever written by the most qualified psychologists and psychiatrists on the subject of mental hygiene ? if you are to confine them and refine them and cleave out the excess verbiage -? if you are to take the whole of the meat, and none of the parsley, and if you are to have these unadulterated bits of pure scientific knowledge concisely expressed by the most capable of living poets, you would have an awkward and incomplete summation of a Sermon on the Mount.`

    Dr. J. T. Fisher,
    MD Psychiatrist

    1. Not enough sarcasm or irony in the Sermon on the Mount for my tastes, but I do acknowledge that it’s pretty good. Maybe I’m too cynical, though.

  9. YES, I’ve been saying for a very long time that the absurdly vague/widely applicable standards used in the DSM make it easy to pathologize normal behavior, and to diagnose fairly severe diseases and disorders in people who aren’t sick. Furthermore, I’ve always taken issue w/the idea that mental illness and physical illness should be classified as two different things; a miswired brain should be considered no different than a miswired heart. HOWEVER, this article seems to question the VERY EXISTENCE of some very severe and real problems, and THIS is the type of anti-intellectual quackery that both stigmatizes treatable mental illness and makes a lot of libertarians seem laughable. Sullum completely ignores the objective scientific findings of the past decades that illustrate how the brain of a schizophrenic *really does* react as if it is seeing/hearing the hallucinations they suffer from. Things like PTSD really do have an effect on the reactions of the brain, as illustrated in MRI scans. The fact that some — I would venture to say many — shrinks are simply intellectually lazy and all too happy to pathologize basic elements of the human condition *does not* mean that there aren’t some objectively present mental illnesses out there that can be treated effectively with drugs and other forms of therapy. This article was HIGHLY irresponsible in so many different ways.

    1. Maybe it’s just the way I read it, but Sullum (tacitly, if not overtly) acknowledges that there are legitimate psychological pathologies like schizophrenia.

      1. Sorta. And then he goes on to note that black people have wound up with a disproportionately high level of diagnoses for schizophrenia depending on what’s most convenient for the shrink of the moment. And, of course, he never mentions that there *are* objective scanning technologies that can be done to confirm the presence of auditory/visual disturbances whenever hallucinations are present in schizophrenics. This read as less of a call to apply a more rigorous diagnostic criteria to certain legitimate problems, and more of a “snap out of it” attitude towards the genuinely mentally ill. The side of complete dismissal/ignorance/omission of legitimate breakthroughs in treating/diagnosing these conditions further casts Sullum’s motives in a poor light.

        1. (This isn’t to say that a more rigorous diagnostic process *shouldn’t* be applied to certain legitimate issues, but Sullum went about this article in a massively and stupidly irresponsible way.)

          1. Would you care to set forth the specific anti-intellectual quackery which Jacob is espousing? Where does the same manifest itself in the article?

            1. Here ya go. It’s worth noting that earlier in the article, Sullum quotes a contradictory source in a pathetic attempt to have it both ways w/r/t the existence of schizophrenia — and again, ignores any objective evidence from MRI scans, etc. in recent years that *very much do* point to specific disturbances in the brain whenever schizophrenic activity is present:

              “Metzl is not interested in such distinctions. “Schizophrenia is shaped by social, political, and, ultimately institutional factors in addition to chemical or biological ones,” he writes. “Too often, we assume that medical and cultural explanations of illness are distinct entities, or engage in frustratingly pointless debates about whether certain mental illnesses are either socially constructed or real.” He says “this polarizing dichotomy serves no one, and makes it harder to see how mental illness is always already both.”

              It is hard to imagine someone making a similar speech about cancer or diabetes. “Unlike the conditions treated in most other branches of medicine,” observes Marcia Angell, former editor of The New England Journal of Medicine, in a June New York Review of Books essay, “there are no objective signs or tests for mental illness?no lab data or MRI findings?and the boundaries between normal and abnormal are often unclear. That makes it possible to expand diagnostic boundaries or even create new diagnoses, in ways that would be impossible, say, in a field like cardiology.” In other words, mental illnesses are whatever psychiatrists say they are. If someone is diagnosed with depression or schizophrenia based on the currently accepted behavioral markers, assuming the criteria are correctly applied, it does not make sense to say he does not really have depression or schizophrenia, since there is no test to disconfirm the diagnosis. And if the criteria change so that they no longer apply to him, his disease disappears or becomes something else; it has no independent existence.”

              Again, the naked omission of evidence, poor research, contradictory sources, and stupid conclusions that Sullum makes here throws him squarely on the side of dangerous quackery.

              1. Ah tell us why MRIs are not used by shrinks when they label freshly minted mental patients please.

                Your bullshit evidence about ‘pointing to’ amounts to nothing more impressive than the MRIs which show the brains of London cab drivers look different.

                Take your blind faith in MRI studies that cant be replicated enough to be rolled out as a gold standard test, and go and explain to someone why you think it is OK that the state has just incarcerated them without trial, forcibly drugged them, and try and see if the fact that even though no psychiatrist at the state hospital can offer THEM an MRI proving real disease, the fact that you personally believe they have a brain disease is reason enough for them to be without liberty.

              2. You got it exactly backwards, Kim.
                The stupid conclusions are belong to you and the psychiatrists, not to Sullum. The simple fact is the psychiatrists are full of self-serving nonsense. There is no actual “science” to back up their diagnoses. The fact is, when there is actual medical “science,” the diagnoses are always neurological and
                never ever ever psychiatric, dummy.

        2. Kim “And, of course, he never mentions that there *are* objective scanning technologies that can be done to confirm the presence of auditory/visual disturbances whenever hallucinations are present in schizophrenics.”

          Blatant lie.

          First of all the ‘in schizophrenics’ bit. They were defined as schizophrenics in the first place without any objective test.

          The rest of what you say is absolute garbage. Yes, people who believe things that aren’t true, delusions, genuinely believe them at the time, what this proves about real brain disease is exactly nothing.

          I’m glad you hated this Reason piece, Kim. I liked it.

  10. I sometimes wonder how many mental “illnesses” are a result of inventing a chemical that causes people to behave or not behave in a certain way, then defining that behavior change as an “illness” so money can be made from the “cure”.

    1. ADHD, having become an industry in itself, makes that a really good question. And there don’t really seem to be any any “cures”; just ongoing “treatments” that keep you buying more drugs.

      1. Public school officials love ADHD since the more kids in the school are diagnosed, the more funding they get.

        As a side note my stepson’s father put him on Ritalin (he was pressured by the school) for a while and it did make a difference. His mother and I successfully lobbied to get him off the stuff.

        All it was was a substitute for discipline. His dad lets him do whatever he wants, and we don’t. So we have to retrain him every weekend. It sucks.

        1. Why don’t you just cut out the middle man and train the stepfather?

          Perhaps with a tire iron?

          1. that was so funny that I forgot to laugh.

    2. There’s certainly precedent for this in bodily illness. Diagnoses of high blood pressure and high cholesterol have risen and been pinned on ever younger and younger patients with the development of newer, trendier meds.

      And with the development of expensive surgeries and trendy meds for combating body fat, there’s a push by the medical lobby to get obesity–really a personal lifestyle choice–officially recognized as a disease, so insurers will be forced to cover these “treatments,” thereby tapping the revenue stream of fatties who long to have lap-band surgery but want someone else to pay for it.

      And with the aging of the generation that still refuses to accept that it’s growing old, old age itself has become a disease that can be “treated.” You can give an old geezer Viagra for his “erectile dysfunction,” and he can get Medicare to pay for it. Dysfunction? The fact that he’s 80 and can’t get to high noon isn’t really a dysfunction, now is it? The fact that a 45-year-old woman has difficulty conceiving a child isn’t really a “dysfunction,” either, but in some states, insurers are mandated to cover her fertility treatments. And the fact that a 67-year-old finds that she can’t play soccer anymore because her knees are shot isn’t really a dysfunction, either…but I know one who’s in for PT twice a week, and steroid injections several times a year, 100% covered by insurance, just so she can treat the “disease” of her aging body by ignoring it. Aging is a stage, not a sickness.

      I’m not at all saying that the innovations in medicine that allow people to do or be what they want are bad. But much of the idea that these innovations are treating real disease is a con game of the medical lobby.

  11. It would seem to me that the very existnce of psychoactive drugs – i.e., checmicals that can alter a person’s mental processes – refutes Szasz’z claim that there’s “no such thing” as mental illness. I mean, does it not stand to reason that, if a person’s mental processes are manipulable via drugs (SSRIs, X, THC, or whatever), then there can also be something internal – call it a chemical imbalance or whatever – that can exert similar effects?

    1. That is a textbook example of ‘begging the question’.

    2. No, you misunderstand Szasz. He doesn’t deny that behavior or thinking is brain-based. That notion was refutable long before there were psychoactive drugs–just plow an axe into someone’s skull and see if he acts differently. If Szasz believed in some sort of spiritual mind unaffected by the body, he wouldn’t have believed in neurosyphilis, and therefore couldn’t have used it as an example of a “mental illness” that disappeared once its biological basis was found.

      What Szasz is saying is that the concept “mental illness” is a category error. Physical organs can be diseased; you can find a lesion and point to it. You can’t do that with thoughts and behavior. Note that he recognizes that not all diseases have been identified. (Again, neurosyphilis is an example of a disease that was not known, and then discovered.)

  12. Thank you for your article pointing to a possible tyranny of the medical police state. I have linked to you on my website.

    James Pricer

  13. Read Robert Whitaker’s excellent “Anatomy of an Epidemic” to learn of the far-reaching dangers and abject failure of psychopharmacology. Whitaker is now in demand to speak all around the Western world and change is in the wind. I think Szasz would be glad about it. I know I am.

    1. Thanks for the plug; I’ll definitely pick up a copy tomorrow.

  14. Great article, Sullum.

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  16. ites in the preface to the 50th anniversary edition of The My

  17. pinion of official American psychiatry,” Szasz writes in

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