DSM-5 R.I.P?

By Neuroskeptic | August 3, 2012 3:58 pm

Yesterday, the proposed new DSM-5 revision of the American Psychiatric Associations “Bible of Psychiatry” came under yet more criticism.

Aaron T. Beck, the father of currently-mega-popular cognitive behavioural therapy, started it off with an attack on the upcoming changes to one diagnosis, Generalized Anxiety Disorder; but many of the points also apply to the other DSM-5 proposals:

The lack of specific features, which is the primary issue for GAD, will not be addressed in DSM-5. The hallmark of the condition will remain pathological worry, although it also characterizes other disorders. Likewise, the proposed behavioral diagnostic criteria lack specificity for GAD, and it is not clear how these will be assessed. The proposed changes will lower the diagnostic threshold for GAD in DSM-5… many currently subthreshold cases will qualify for this diagnosis. The likely inclusion of many such “false-positives” will result in an artificial increase in the prevalence of GAD and will have further negative consequences.

Then from across the Atlantic, and also across the psychotherapy-vs-medication divide, came another piece of criticism. The authors are all associated with the European Medicines Agency (EMA, Europe’s equivalent of the FDA), or with national drug regulators. Although they’re writing in a personal capacity, this is still big news if you ask me.

These authors start out by saying that the EMA is broadly in favour of DSM reform, but they then attack one of the key DSM-5 innovations – the move towards ‘dimensional measures‘ of symptoms in addition to diagnoses:

One of our main concerns is related to potential future [drug] indications based on an effect on a dimension that is independent of diagnostic categories (although we acknowledge that non-specific claims are common in other areas, such as analgesics for pain). As an example, cognitive impairments are common in psychiatric disorders, but they do not have a unique clinical pattern or a unitary cause.

We therefore believe that, at present, such a cross-cutting approach may increase heterogeneity in patient populations and make the assessment of the benefit–risk balance more difficult. Similarly, the use of dimensions as key secondary end points in many different diagnostic categories may lead to pseudospecific indications and polypharmacy. As a general rule, a therapeutic indication should be a well-recognized clinical entity that is clearly distinguishable from other conditions...

They also echo Beck in warning of over-diagnosis and over-medicalization:

Current proposals to reclassify some conditions that were subthreshold or prodromal as distinct syndromes or disorders could have implications for clinical trials. The inclusion of milder or very early cases of psychiatric disorders may lead to an increase in the number of non-disordered (false-positive) patients in clinical trials, and to an increase in the placebo effect, as less severe cases are more likely to respond to placebo. It may therefore be difficult to show a statistically significant difference [of drug over placebo]…

This raises another highly controversial issue: the risk of medicalization of the normal population. In this respect, a strong concern comes from the proposal to remove bereavement exclusion from the criteria for major depressive disorder, implying that all individuals with ‘normal grief’ might be considered as patients in the future.

Regular readers will remember that I’ve covered both overdiagnosis screwing up clinical trials, and the bereavement debate.

Two and a half years ago, shortly after the first draft of the DSM-5 was made public, I predicted that the eventual release of DSM-5 would be a non-event because, by then, it would have been widely debated and criticized, destroying the illusion of expert consensus that any such document must have in order to succeed.

I think events have borne this out. An awful lot of professionals, patients, and their relatives, will reject the changes in favour of sticking with the DSM-IV or other criteria. Without swift and general acceptance, a document like the DSM is just paper. It seems increasingly likely that the DSM-5 is going to be dead on arrival.

ResearchBlogging.orgStarcevic V, Portman ME, & Beck AT (2012). Generalized anxiety disorder: between neglect and an epidemic. The Journal of nervous and mental disease, 200 (8), 664-7 PMID: 22850300

Florence Butlen-Ducuing et al (2012). DSM?5 and clinical trials in psychiatry: challenges to come? Nature Reviews: Drug Discovery DOI: 10.1038/nrd3811

  • http://trashbird1240.wordpress.com/ trashbird1240

    Is the DSM-IV as reliably used as its authority would suggest? When I worked in psychiatric research we were all concerned that our scientific criteria (which strictly followed the DSM-IV and DSM-III-R in the case of older data) were far stricter than the criteria used in practice. Perhaps the DSM-IV was also a “non-event” as you're predicting for DSM-V.

  • http://petrossa.wordpress.com/ petrossa

    There is only one way out. Restart form scratch. Too many overlapping symptoms of 'syndromes'. To frequent diagnosis of 'comorbid blabla syndrome'
    Syndromes which are actually the same thing but repeated in another form etc etc.

    By the sheer amount of misdiagnosis (and read any patients forum to find out how often that happens) you cna either conclude that most professionals are incompetent or that the manual they have to work with is faulty.

    Logically there will be as many incompetent psychiatrists as there are incompetents in any other profession so it has to be the manual.

    Redo the manual. Start with a true scientific baseline. Not observational studies, but actual empirical science.

    This is up to neurology. Do your job.

  • Anonymous

    I wish I could agree, but if insurance payment requires DSM 5 payment (and it will) that will be all that is necessary for the DSM 5 to have a permanent and large place in practice.

  • http://dxrevisionwatch.wordpress.com Suzy Chapman

    Don't like DSM? Don't use it – use ICD instead.

    For insurance reimbursement DSM-IV codes are converted to ICD codes.

    The mental and behavioral disorders chapter of the forthcoming ICD-10-CM is Chapter 5. ICD-10-CM can be accessed for free on the CDC website. The 2013 release of ICD-10-CM is now available for public viewing, though the codes are not currently valid for any purpose until ICD-10-CM has been implemented, currently proposed for October 2014.

    No-one needs DSM-5 except American Psychiatric Publishing.

  • http://www.blogger.com/profile/06647064768789308157 Neuroskeptic

    Anonymous: Maybe… but I don't think DSM-5 will catch on outside the USA, or in research anywhere. It might end up being used only for insurance purposes, reducing it (in the eyes of many) to a piece of bureaucratic paperwork.

  • Anonymous

    It is becoming increasingly obvious that psychiatry, like homeopathy, is a 'medical' pseudoscience. For any mental illness there is no etiology, no pathogenesis, no physical or biological markers, no agreement on diagnosis, no treatment and no cures. Despite the vast amounts of time and money expended on research. Dr Thomas Szasz is still correct.

  • http://www.blogger.com/profile/06832177812057826894 pj

    Well Szasz can come and treat all my patients then. Good luck to him.

  • julia

    Szasz could still help heal them, he just wouldn't call them patients. You don't need a diagnosis in order to be healed.

  • Ivana Fulli MD

    The USA is a country I admire for many things but health is not their forte:

    They spend more money than most countries- even rich countries- and their results are near the bottom.

    The American psychiatrists have become pills prescribers doomed by the greed of their Psychiatry academics for the Big Pharma money.

    Why should we use the Am Psy Ass DSM manuals?

    Easy answer: to treat people badly and spend more money at it!

    I wish the ICD11's makers were not trying as hard as they do -for the little I know- to produce a classification compatible with the DSM5.

  • http://dxrevisionwatch.wordpress.com Suzy Chapman

    APA participates with WHO in an “International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders” which is chaired by Steven Hyman, MD, a former Director of NIMH and a DSM-5 Task Force Member.

    There was a degree of concordance achieved between DSM-IV categories and Chapter V of ICD-10 (on which ICD-10-CM has been based). For DSM-5 and ICD-11, APA and WHO have committed as far as possible “To facilitate the achievement of the highest possible extent of uniformity and harmonization between ICD-11 mental and behavioural disorders and DSM-V disorders and their diagnostic criteria” with the objective that “The WHO and APA should make all attempts to ensure that in their core versions, the category names, glossary descriptions and criteria are identical for ICD and DSM.”

    WHO acknowledges there may be areas where congruency may not be achievable. The timelines for DSM-5 and ICD-11 are now running significantly out of synch: DSM-5 has completed its field trials and is finalizing its disorder descriptions, criteria sets and the manual texts, and is slated for publication next spring (May 2013).

    But ICD-11 is still at the Beta drafting stage with a considerable amount of content to generate and with a two year period scheduled for carrying out its own field trials and revisions – this may present barriers to “harmonization” with DSM-5.

    In a June 2011 presentation to the International Congress of the Royal College of Psychiatrists, then APA President, John M. Oldham, spoke of “Negotiations in progress to ‘harmonize’ DSM-5 with ICD-11 and to ‘retro-fit’ these codes into ICD-10-CM” and that DSM-5 would need “to include ICD-10-CM ‘F-codes’ in order to process all insurance claims beginning October 1, 2011.”

    So “harmonization” between the systems is a now a dog's breakfast.

    By shifting its publication date from May 2012 to May 2013, and giving themselves an extra year in which to complete DSM-5, APA missed the boat for submitting proposals for synchronizing ICD-10-CM Chapter 5 categories with DSM-5 categories.

    In 2010, APA sent Darrel Regier to an ICD-9-CM Coordination and Maintenance Committee to lobby for the proposed October 2011 code freeze on ICD-10-CM to be held off so that DSM-5 could potentially be harmonized with ICD-10-CM. But he didn't get what he wanted and the code freeze on ICD-10-CM was applied in October 2011. Other than some specific classes of proposal, ICD-10-CM code sets are now frozen until 2014, possible 2015+.

    So when when ICD-10-CM is implemented (let's assume HHS does issue a final rule for October 2014), DSM-5 categories, in some cases, are going to be quite out of whack with ICD-10-CM categories.

  • http://www.placebocontrol.com Paul Ivsin

    I cannot see how classification of “subthreshold or prodromal [conditions] as distinct syndromes or disorders” would plausibly lead to changes in clinical trial design. If anything, there might be a (slight) incentive to tighten up inclusion criteria, as protocol writers are often loathe to explicitly include multiple defined conditions.

    I'm not arguing that inclusion of subthreshold patients in treatment trials isn't often a bad thing — of course it is. However, trying to be a bit more specific in our definitions of that subthreshold population seems like a worthwhile endeavor, and there's no logical reason that increasing that specificity would alter clinical trial design.

  • Anonymous

    So PJ, what do you do to 'treat' your 'patients' that Szasz would not do?

  • http://www.blogger.com/profile/04330057648612438692 mount analogue

    ….and this is just the tip of the iceberg, unfortunately. Both the BPS and several sections of the APA have openly criticised DSM, both for failing to improve on the validity of DSM IV and, in some cases actually reducing it.

    It's certainly not realistic to equate the critics with anti-psychiatrists like Sasz either, as much of the criticism comes from within the field itself, even some of the framers of DSM III and IV have been highly critical of the methodology.

    In relation to the dimensional approach (which IMO is actually more scientifically valid, even if it is difficult to implement clinically) the only two non-American members of the personality task-force resigned in protest about a month ago.

    Lastly, it seems fairly certain that many of the changes will lead to a broadening of criteria, capturing more and more people into one psychopathology or another. It looks increasingly likely that this will lead to greater co-morbidity, greater heterogenity within classifications, and lower content validity (see Horwitz and Wakefield's criticisms for example).

    For scientific research, which often uses DSM classification as a basis for selecting participants, this is going to be a disatster. The search for neural correlates of a psychiatric disorder becomes impossible if the psychiatric disorder isn't a valid, natural kind in the first place. Garbage in, garbage out, as the old adage goes.

    I vaguely remember a Neuroskeptic post a couple of years ago, which suggested that psychiatry is in danger of disappearing – crushed between cognitive psychology on one side, and neuroscience on the other. In my view, psychiatry has become trapped into an uncomfortable alliance with insurance companies, penny-pinching governments, and big Pharma. The result is clinical practice that addresses needs so disparate from science that they are looking increasingly like corporate witch doctors.

    You gotta feel sorry for them really, and their unfortunate patients. How can we help to change this dysfunctional situation?

  • http://www.blogger.com/profile/06832177812057826894 pj

    “So PJ, what do you do to 'treat' your 'patients' that Szasz would not do?”

    'What' 'do' 'I' 'do' 'to' treat 'them'?

    Well, for a start, unlike Szasz, I don't work in private practice refusing to see people who are too ill to seek help and unable to pay for it. And, unlike Szasz, I don't blame the patients for their illness or their failure to get better.

  • http://survivingantidepressants.org Altostrata

    Just spoke to a US psychiatrist who said his researcher colleagues refused to take part in DSM-5 field trials because they would have had to mis-treat their patients.

    Which may explain why the field trials did not have the projected enrollment and were sparse in numbers.

  • Ivana Fulli MD


    Interesting bit of information.

    Still, even powerful voices in the USA- some belonging to psychiatrists- have been heard publicly against the DSM5 's proposals.

    This was USA at its best, to my mind, when some British academic would dare to use the DSM5's proposals as an argument of authority against a fellow academic publishing the e-mails conversation on her blog…

    Still, unless the persons involved in creating the ICD 11 find the will to break free from any obligation to be compatible with the DSMs, how would the Neuroskeptic's vision (Neuroskeptic 4 August 2012 11:30 // I don't think DSM-5 will catch on outside the USA, or in research anywhere ///.) come true?

  • Ivana Fulli MD

    Suzy Chapman,

    ///So “harmonization” between the systems is a now a dog's breakfast.///

    Is it not about time that the ICD11 makers skip their dog's breakfast and put their brains and wills energy into making the ICD11 sexier to use?

    You can say anything against the DSM's but not that it is not easy to read material and very easy to use in practice-the more so if you are very ignorant in psychiatry and clinical psychology but still handy if you want to save time and make money or research protocols.

  • ivana fulli MD


    After such a direct attack on their ultimate antipsychiatry weapon, I hope you will not complain if you do not reach worldwide notoriety for your thinking thanks to the scientologists.

  • http://dxrevisionwatch.wordpress.com Suzy Chapman

    Ivana wrote:

    “You can say anything against the DSM's but not that it is not easy to read material and very easy to use in practice-the more so if you are very ignorant in psychiatry and clinical psychology but still handy if you want to save time and make money or research protocols.”

    Ivana, you don't say which country you practice in, so I don't know which version of ICD your country currently uses.

    Which version of the ICD chapter for Mental and behavioural disorders are you comparing DSM's utility with?

    The internationally used version of ICD-10 Chapter V, which has two Volumes:

    “ICD-10 for Mental and Behavioural Disorders Clinical Descriptions and Diagnostic Guidelines” and

    “ICD-10 for Mental and Behavioural Disorders Diagnostic Criteria for Research”

    There is also a chapter for mental health disorders within the Primary Care version of the main ICD-10 classification (ICD-10-PHC).

    Or the US specific ICD-9-CM.

    Or the forthcoming US specific ICD-10-CM.

    Or Chapter 5 of ICD-11, for which only the public version of the Beta drafting platform is viewable.

    ICD-11 is a work in progress over the next couple of years and is far from complete. There will be both electronic versions (which will be accessed free of charge) and print versions for ICD-11 (which will be low cost) and also separate print volumes for Chapter 5.

    So which version of ICD are you comparing DSM with?

  • Ivana Fulli MD


    I am on your side (as once Altostrata had to remaind me elsewhere) but with my fingers crossed thinking of the dog's breakfast you mentionned.

    I just fail to understand how the ICD could replace the DSM -as it should for many reasons- as long as the dog's breakfast is attended to and as long as the APA will sell neat books beautifully marketed.

    The International Classification of Diseases 11th Revision is due by 2015 and it is really obvious that the DSM5's proposals- plus the Obama administration admirable work against Big Pharma fraudulent marketing technics – is giving the ICD11 makers the one generation opportunity to break free from the DSMs.

    Just the other day I heard a very quiet and composed professor of endocrinology arguing with the utmost passion against the DSM5 's proposals of “removing amenorrhea” in anorexia nervosa. you can go on forever on that line.

    PS: I am based in France and believe me you do not want to know how the psychoanalysts still very powerful here use any international classification or neuroscience

  • http://dxrevisionwatch.wordpress.com Suzy Chapman

    Ivana wrote:

    “The International Classification of Diseases 11th Revision is due by 2015…”

    The most recent schedule has presentation of ICD-11 for approval to WHA timelined for 2015 (previously 2014) but Chris Chute, MD, who chairs the ICD-11 Revision Steering Group, has warned that it may be 2016 before ICD-11 is ready for dissemination. The 110+ countries that use ICD-10 may not be ready to move onto ICD-11 for several years, post release.

    From the status of the Beta draft and other project difficulties, I predict further delays or a scaling back of the project if the target of 2015/16 is to be met. But even if ICD-11 schedules are reached by 2016, a Clinical Modification of ICD-11 isn't anticipated to be implemented in the US until 2020+.

  • http://dxrevisionwatch.wordpress.com Suzy Chapman

    @ Ivana

    On compatibility between ICD-10 and DSM-IV:

    From the ICD-10 Chapter V “Green Book” (Diagnosic Criteria for Research, 1993):

    “Among the agencies whose help was of vital importance were the Alcohol, Drug Abuse and Mental Health Administration in the USA, which provided generous support to the activities preparatory to the drafting of ICD-10, and which ensured effective and productive consultation between groups working on ICD-10 and those working on the fourth revision of the American Psychiatric Association's Diagnostic Statistical Manual (DSM-IV) classification. Close direct collaboration with the chairmen and the work groups of the APA task force in DSMIV chaired by Dr A. Frances allowed an extensive exchange of views and helped in ensuring compatibility between the texts.”

    You might find this document of interest. The “APA” referred to throughout the letter is the American Psychological Association. American Psychiatric Association, where referenced, is spelled out in full. This document dates from 2007, at which point it was envisaged that ICD-11 would be ready for dissemination by 2011/12, which was then shifted to 2014/15, now 2015+.

    The letter is authored by Pierre L.-J Ritchie, PhD, C.Psych. Secretary-General, International Union of Psychological Science (IUPsyS):


    From Page 6:

    “…The first meeting of the Advisory Group was held at WHO headquarters in Geneva 11 – 12 January, 2007. Geoff [Reed] served as rapporteur for the meeting and drafted the meeting report in collaboration with Dr. Saxeena. That report is attached. Again, Geoff’s extensive involvement in the preparation of the report ensured the prominent representation of a psychology perspective. One example of this is the manner in which the report deals with the relationship between the ICD and DSM revision processes. The report notes that the overall timeframes for the development of ICD- 11 and DSM-V are similar, with a potential to harmonize the two revision processes and work towards possible uniformity between ICD-11 and DSM V. In balance, such harmonization would be advantageous to psychology as well as to other mental health clinicians and researchers. Nonetheless, the report also explicitly notes that there are important differences between the two systems based on their different purposes and constituencies.

    “Other differences that may be relevant include ownership, range of participation, and financial interests. ICD is owned by an international organization with a recognized charter to work on behalf of the public good in global health and health care. It is made available by WHO to its intended users at no cost. The report points out that DSM is a commercial product owned by a national association representing a single profession, which derives a significant portion of its revenues from the sale of DSM and its related products. The report concludes that although the Advisory Group considers harmonization to be a useful goal, the revision process for ICD-10 Mental and Behavioural Disorders will not consist of adapting DSM. Given the history of psychiatry’s dominance in WHO, it is difficult to imagine that this perspective would have been reflected in the final report, or that other language related to the role of psychiatry and the importance of a multidisciplinary approach, would have been included if Geoff had not had a substantial role in writing it. Beyond his recognized substantive expertise, Geoff has established a high level of credibility for his excellent process skills. Geoff’s contribution has built very nicely on the relationship I have been building with WHO on behalf of our profession.”

  • http://dxrevisionwatch.wordpress.com Suzy Chapman

    Continued from previous comment:

    “Largely as a measure of Geoff’s success in working with WHO, we have been presented with another opportunity. WHO has requested that IUPsyS make Geoff available full time as an integral part of the WHO directorate working on the ICD revision. The formal request from WHO to IUPsyS is attached. The request indicates that WHO’s intention that Geoff function as the primary coordinating person for the work of the Advisory Group (a role he has already begun to occupy), and that he be integrally involved in the drafting and redrafting of categories and criteria and in the development and implementation of field trials. In our respective “staff” roles, I know that you and I both understand the importance and potential influence over the process that someone in this position can have. In the context of WHO, I cannot stress too strongly what an opportunity this represents. Heretofore, such a role would have been reserved for psychiatry. If we do not meet the challenge, this will surely be the outcome. This as a significant opportunity for psychology in several ways.

    “First, it will cement and advance the relationship as well as increase the standing of organized psychology with WHO. This is important in itself and will have implications for how WHO considers expertise, constitutes groups, and represents the clinical and research perspectives of psychology in its future work.”

    “Second, it will do much to put psychology on an equal footing with psychiatry in relationship to mental health diagnosis. Indeed, there is no current or foreseeable activity that can do more to achieve this particular goal. I believe that without Geoff’s enhanced participation as proposed by WHO in consultation with us, the process is likely to revert to one that predominantly and perhaps exclusively reflects the perspective of psychiatry. You will notice in WHO’s request that two senior positions are envisioned, one for Geoff and one for an unnamed psychiatrist. It is clear that psychiatry will support the active involvement of their representatives in this process. I think the implications of psychology failing to do the same are obvious. I have no doubt that psychiatry will gladly fund both positions for which WHO is seeking funding.

    “Third, I think this is a powerful opportunity to influence the development of the DSM. The American Psychiatric Association is in a difficult position in this regard. It is not to their benefit that there be two competing systems. At the same time, if ICD and DSM are more fully equivalent, they risk a loss of market position given that ICD is made available as a public good and not as a commercial product. They appear to have adopted the goal of minimizing the discordance between the two systems, in spite of the risks involved. To this extent, aspects of the ICD revision process have the potential to drive the development of the DSM. Clearly, the DSM developers recognize the content expertise of psychologists given their strong representation on their various committees. However, the enhanced psychology participation in the ICD revision process offers a much more over-arching and strategic opportunity for influence…”

  • Ivana Fulli MD


    I am sincerely out of my depth with all the material you offer.

    It reminds me of something I made an”electronic note” from reading Bob Fancher PhD(a psychologist)'s blog on “Mad in America” though.

    It reads like this

    ///Once medical insurance began paying for mental health care, psychologists and social workers began seeing themselves as treating mental illness after all. Now that medical insurance would pay, the talk therapists’ trade associations spent lots of money convincing state legislatures to “mandate” that medical insurance had to cover their services, just as they covered psychiatrists.

    One thing everyone in mental health agreed on was that mental illness should be insured “just like”—at parity with—demonstrably physical illness. As mental health parity laws gained traction through the 1990s, any idea that talk therapists were not treating mental disorders just vanished from their professional rhetoric.///

  • Ivana Fulli MD


    Here more from the same Dr Bob Fancher – a very discerning mind with a superb intelligence at work together with a soul and also a link to his blog-very worth reading- I had no time to look for yesterday:


    ///Psychology and social work, and literally hundreds of other movements—from the “New Thought” of the late nineteenth century to many different schools of psychotherapy in the mid-twentieth century to the “New Age” of the late twentieth century—tried to offer alternate ways of understanding mental suffering. None had medicine’s big advantage: an existing profession, with the attendant institutional support, cultural status, and financial resources.

    Psychology had the best opportunity to provide an alternate, with its growing institutional basis in schools, and with government imprimatur and protection—by 1977, psychologists had gained licensure in all states. But as I’ve explained before, the lure of money was too great, and psychology made itself subservient to the medical model.///

    Ps: Suzy, please accept my assurances : No offense intended against the politics you are into or the clinical psychologists in general.

    I appreciate greatly a priori any clinical psychologists ( when they are not French since so many psychologists in France are just badly taught and selected even more badly ) when they do not ask to participate in overprescription of dangerous Big Pharma drugs-which drugs should be reserved for patients receiving more benefits that side effects from it and then prescribed by medical qualified persons be it only because of the very medical nature of many side-effects.

  • http://www.blogger.com/profile/03474899831557543486 George Dawson, MD, DFAPA
  • Ivana Fulli MD


    Thank you so much for your point of view and the link to your interesting blog. You wrote a nice basis for discussion:

    ///The DSM5 is clearly about rearranging criteria based on recent studies with the sole exception of including valid biological markers for the sleep disorders section.///

    To my mind, those DSM's psychiatric disorders are now elected by people suffering from a phenomenal egohypertrophia and anosognosia as a defense wall against the reality which is that big pharma money and the therapists 'greed for income talk louder and louder with time and biological psychiatry has not deliver.

    Do you not need quite an egohypertrophia to invent a disorder like bipolar for children telling the world it is so spread and anosognosia to spare for being happy when your work is the causation for so many American children suffering brain shrinkage'risks , tardive dyskinesia, diabetis, intelectual stupor etc…from neuroleptic use plus the conviction that their brain is defective?

    I wonder when it will be that some conspirationists will “discover” that psychiatrists shorten people 's lifespan and produce numb adults full of tics using neuroleptics ' side-effects in order to take control of the world's economy.

  • Michael

    I'm a scientist who can't understand why the concept of mental illness is still around. It seems totally unscientific and incompatible with modern neuroscience. Is there anyone here who can correct my logic? My colleagues, both medical and scientific can't find any fault in it. I'd love to be proven wrong, if I am wrong, as that's how one learns…

    1. If we have a brain illness, it's called a “neurological illness”.
    2. Mental illnesses are not classified as neurological illnesses. These categories are mutually exclusive.
    3. So what is a “mental illness”? If it's not a neurological illness it must be a non-physical brain illness? How's that for an oxymoron!
    4. The mind is the emergent property of the brain, much like walking is an emergent property of the legs, circulatory system, respiratory system, brain etc. There are no walking illnesses, only leg injuries, heart problems etc… so why is mental illnesses as a concept considered to be (A) real and (B) scientific!?

    My belief is that the evidence shows this…
    1. Our brains have a huge amount of plasticity built in thanks to evolutionary pressure to be adaptive, learn and have flexibility. This is especially true when it comes to (A) when to feel an emotion… (B) our cognitive interpretations / beliefs about life events & who we are (identity) etc
    2. We have genetic variation – which is an asset in any evolutionary system – and so some people LEARN to feel depressed more easily than others (If depression is caused organically, then it is a neurological illness, not a mental illness). In other words… a change in the connectome.
    3. Much of this “learning” is from social situations, and almost all of it imllic (conditioning – both operant and classical… and a lot more)
    4. Learning produces changes in the brain, so the so called chemical and structural neuroanatomical markers of any psychological “problem” are NOT necessarily a sign of disease, but also can result from learning. So any shrinking of the hippocampus in PTSD is not a sign of an illness… it could well be a sign of an evolutionary stress response in response to learning without a refined enough context (hippocampal involvement). This could well have been a very adaptive survival enhancer in evolutionary conditions… again not a disease or illness!
    5. Following on from 4… many problems may be due to adaptive processes that don't match the current life context, but beautifully matched the context that had evolutionary pressures. For example, exercise helps depressed people a lot… and hunter-gather tribes certainly exercise much more than people do now. Hunter-gather tribes have vastly more social interactions… loneliness and time for extensive rumination alone were probably very rare. Again, these could well be adaptive responses that should urge us not to pathologise them, but do our best to recreate more of the context we evolved to be in.

    I am well aware psychology pain is very real and is often driven by non-conscious processes… but neither pain nor unconscious processes, alone, qualifies something to be categorised as an illness.

    I'd LOVE any intelligent criticism of my current way of seeing this issue as I'm open to being shown I'm wrong… and I, of course, love to learn and improve my understanding if I'm missing something. I've shared my views with colleagues for over a decade and no one has come up with any argument other than “you're right, but I can't explain why” or “you must be wrong because this is the consensus”

    Thanks for constructive criticism, if you have any. I do question myself when I seem to be the only person with this belief… but I also can't find any errors in my logic.

  • Michael

    PS – I don't agree with Thomas Szasz… people with serious psychological problems don't just have “problems with living”… they often have neuroplastic changes, but I contend these changes are not an illness, but rather down to the fact that our brains have an evolutionary benefit from learning so well, a negativity bias which is very protective in the evolutionary scheme of things (eg: associative conditioning that works better from learning the occasional bad thing rather than miss it and die), and the fact that we are living lives that are quite different from our hunter-gather history.

    Thanks for your input as I'm sure there are some very smart people here!



No brain. No gain.

About Neuroskeptic

Neuroskeptic is a British neuroscientist who takes a skeptical look at his own field, and beyond. His blog offers a look at the latest developments in neuroscience, psychiatry and psychology through a critical lens.


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