
The Evolution of Psychiatry - anarbadalov
https://www.worksinprogress.co/issue/the-evolution-of-psychiatry/
======
skissane
The article goes to great length to consider possible evolutionary
explanations of autism, but never considers another possibility – Lynn
Waterhouse's argument [1][2] that ASD does not exist. Waterhouse doesn't deny
the symptoms exist – indeed, she spent much of her career trying to help
children with those symptoms. She simply argues that the symptoms are caused
by numerous unknown diverse causes in the brain, and the concept of a single
disorder (ASD), or even a spectrum of related disorders (ASDs, the DSM-IV
PDDs, and more recent ASD sub-typing proposals), isn't helpful in
understanding those causes. Waterhouse argues that in order to have the best
chance of finding effective treatments for people impaired by those symptoms,
researchers should abandon the idea that ASD (or even ASDs/ASCs) is a useful
concept in understanding what causes them.

If Waterhouse's position is correct, then trying to find a single evolutionary
explanation for numerous diverse brain conditions (that people have lumped
together under a single label) is probably not a very useful approach.

[1]
[https://books.google.com/books?id=IaFY8r0rpn8C&printsec=fron...](https://books.google.com/books?id=IaFY8r0rpn8C&printsec=frontcover)

[2]
[https://link.springer.com/article/10.1007/s40489-016-0085-x](https://link.springer.com/article/10.1007/s40489-016-0085-x)

~~~
gwerbret
> She simply argues that the symptoms are caused by numerous unknown diverse
> causes in the brain, and the concept of a single disorder (ASD), or even a
> spectrum of related disorders (ASDs, the DSM-IV PDDs, and more recent ASD
> sub-typing proposals), isn't helpful in understanding those causes.

I think this is a dangerous misunderstanding of the reason for the grouping of
autism-spectrum disorders under a common umbrella. The danger lies in the
(all-too-common) tendency of people to think that the rejection of autism's
categories means "autism doesn't exist" or something similar. The purpose of
such categories is not to help understand the causes, but to help cement the
reality that autism is a group of very serious disorders with similar traits.

As an analogy, many cancers that are grouped under a single name -- such as
breast cancer -- are actually caused by very different genetic alterations. To
use these differences as a justification to reject the concept of breast
cancer would be ludicrous.

~~~
skissane
> I think this is a dangerous misunderstanding of the reason for the grouping
> of autism-spectrum disorders under a common umbrella

Who are you accusing of a "dangerous misunderstanding" here – her, or me? If
you haven't read her work, I don't know how you can fairly accuse her of
misunderstanding anything; likewise, I think having read at least some of her
work is a prerequisite to be able to fairly accuse _me_ of having
misunderstood her

If your accusation is that she doesn't understand "the reason for the
grouping" may I point out that she played a central role in the drafting of
the PDDs section in the DSM-III-R [1]. As a former member of the DSM working
group on autism, Waterhouse has a very good knowledge of the reasons and
history behind the development of the "ASD" diagnostic label. Waterhouse may
or may not be right, but her argument cannot be dismissed anywhere near as
easily as you seem to think it can.

[1]
[https://link.springer.com/article/10.1007/BF01046326](https://link.springer.com/article/10.1007/BF01046326)

~~~
gwerbret
> Who are you accusing of a "dangerous misunderstanding" here – her, or me?

I wasn't accusing anyone specifically, merely commenting on the idea you
shared. However, since you asked, I would say that the misunderstanding is on
both your parts -- yours, for interpreting her arguments to mean "ASD doesn't
exist" (as far as I can tell, she makes no such claim); and hers, for arguing
that the formal definitions and categorizations of ASD need to be biologically
valid (which they can't be, as we don't understand enough about the biology
for that to be possible).

It's common for many fields of research to start with "stamp-collecting",
where people just identify and group diseases and conditions and birds based
on shared characteristics; and later, as the field becomes more mature, to
develop more meaningful categories. I think this same concept applies to ASD.

~~~
skissane
> yours, for interpreting her arguments to mean "ASD doesn't exist" (as far as
> I can tell, she makes no such claim);

To quote page 431 of her book _Rethinking Autism_ (my emphasis):

> Taken together, these three claims and associated lines of evidence _argue
> against the existence of autism as a single disorder, spectrum, or set of
> autism subgroups_. If autism symptoms are not one disorder, and are not many
> disorders, what are they? The most parsimonious and least speculative view
> is that autism symptoms must be symptoms.

Her book is quite explicit in its claim that autism spectrum _disorder_ does
not exist. Her conclusion (p. 433) is given under the heading "AUTISM SYMPTOMS
WITHOUT A DISORDER". The whole point of her book is to argue that the disorder
"Autism Spectrum Disorder" does not exist, but the symptoms do. You might say
she rejects the "Spectrum" and the "Disorder" in "ASD", but keeps the "Autism"
as a reference to a set of symptoms – however, her "autism" is narrower than
the DSM-5's "autism", since it only includes social impairment, and considers
repetitive behaviours/restricted interests and sensory issues, to be distinct
symptom sets coequal with attention-deficit/hyperactive-impulsive symptoms,
intellectual disability, functional language impairment, seizures, see
p.434-435

To quote the blurb on the back cover "Rethinking Autism... draws the
potentially shocking conclusion that 'Autism' does not exist as a single
disorder. The conglomeration of symptoms exists, but like fever, those
symptoms aren't a disease in themselves..." (But, the book actually goes
further than the blurb says it does, because it not only rejects the idea that
autism exists as a single disorder, it also rejects the idea that autism
exists as multiple disorders or a spectrum of disorders, as my quote above
demonstrates.)

> and hers, for arguing that the formal definitions and categorizations of ASD
> need to be biologically valid

Biologically valid categories would be a lot more useful than biologically
invalid categories, and one of her major points is that the research
community's fixation on the later is getting in the way of actually
discovering the former ([1], [2]). She argues that, in place of the current
widespread practice of doing research with ASD-defined samples (a confirmed
ASD diagnosis as a study inclusion criteria), samples should be based on all
individuals showing neurodevelopmental symptoms (mixing together ASD, ADHD,
epilepsy, intellectual disability, etc, into a single sample) and then trying
to study the variation in the sample in order to derive biologically valid
categories to replace the existing biologically invalid ones such as ASD. [3]
is an example of a study along the lines of what she recommends (indeed,
they've obviously read [1] since they reference it)

[1]
[https://link.springer.com/article/10.1007/s40489-016-0085-x](https://link.springer.com/article/10.1007/s40489-016-0085-x)

[2]
[https://pubmed.ncbi.nlm.nih.gov/28714261/](https://pubmed.ncbi.nlm.nih.gov/28714261/)

[3]
[https://www.nature.com/articles/s41398-019-0631-2](https://www.nature.com/articles/s41398-019-0631-2)

------
intuitionist
Is the history of psychiatry one of progress? Or is it one of damage and
partial repair? I very well might not be alive if not for my SSRI
prescription, but the side effects are brutal and lasting, and as a first-line
treatment for kids too young to drive it really leaves a ton to be desired.

~~~
nvrspyx
I'd say that it is one of progress, but one in which outdated or poor
practices overshadow that progress. I can't speak of the prevalence of such
practices, but rather I mean the result of mistreatment is apparent and rapid
while relative success is subtle and gradual.

It's generally understood that medication should be used as a backup after CBT
or other forms of therapy and if you do need medication, it should be
concurrent with that therapy. Psychiatric pharmacology is more complex and
opaque than others, but there is progress being made on that front as well.

The more apparent progression being made is in understanding the neural
mechanisms for these disorders and thus, determining alternative methods of
treatment as a result, such as transcranial magnetic stimulation targeting
individualized neural correlates (e.g. stimulating areas near the surface of
the brain that have functional connectivity with deeper parts of the brain to
activate/inhibit areas like DLPFC) and discovering relationships between
certain mechanisms and certain disorders to investigate other pharmacological
avenues (e.g. ketamine loses antidepressant effects when opioid receptors are
blocked with naltrexone).

Another issue is that this progress in research takes awhile before you see
results in practice and much longer for it to disseminate through the whole
psychiatric community.

~~~
konjin
>Another issue is that this progress in research takes awhile before you see
results in practice and much longer for it to disseminate through the whole
psychiatric community.

The problem is that when I was a teenager I could walk into any psychiatrists
office and leave with whatever drug I had decided I wanted to get high off for
that weekend. I memorized a list of symptoms, said I had them to a GP, got a
referral to a specialist and repeated them there again. If I started on Monday
I could get a prescription by Thursday. Having talked to "problem" kids of
friends it that's still the case today.

I never took the field seriously, and until I became an adult didn't realize
anyone else did either. I just thought of them as legal drug dealers with good
quality product, but not as fun as the unregulated product you could get on
the street.

Imagine my surprise when I found out people actually took prescriptions for
decades at a time, something that is as horrifying to me as drinking yourself
to sleep every night because someone told you to.

~~~
afarrell
So your problem with the field of psychiatry is that psychiatrists can be lied
to and they don't put more effort into second-guessing their patients'
experiences?

...

...

I think you might just be blaming other people for your unethical behaviour as
a teenager.

[https://slatestarcodex.com/2018/10/24/nominating-oneself-
for...](https://slatestarcodex.com/2018/10/24/nominating-oneself-for-the-
short-end-of-a-tradeoff/)

~~~
konjin
If a 14 year old can consistently outsmart multiple professionals then it's
not the 14 year old that's the problem.

If there no way to detect false positives then everyone is a false positive.

~~~
afarrell
> If there is no way to detect false positives, then everyone is a false
> positive.

That does not logically follow.

Proof by contradiction:

I have invented a dumb test for COVID-19: I look at a linkedin profile of
someone, then I lick a block of salt. If my tongue tastes salty, then I
conclude they have COVID-19. Trivially, my test has no way to check for false
positives. So, if ran this test on someone, your statement implies that they
would be a false positive and therefore they would _definitely_ be free of
COVID-19.

Unless you think my salty tongue has magical COVID-curing powers, then even a
broken clock is still right twice a day.

~~~
konjin
I've never seen anyone use false negatives to argue that we should accept
false positives as reasonable. I guess there's a first time for everything.

But to answer your question, yes, it would be statistically prudent to assume
that everyone who passed your test is free of covid because the proportion of
the general population who have it is less than 1% currently and your test
produces a 100% positive rate.

This is a specific case of
[https://en.wikipedia.org/wiki/Prosecutor%27s_fallacy](https://en.wikipedia.org/wiki/Prosecutor%27s_fallacy)

------
JackFr
The main stumbling block of evolutionary psychiatry (psychology?) is that one
is always in danger of coming up with ever more clever just-so stories that
can never be proven or rejected by experiment but rely on who has the most
compelling argument.

The author also makes a grave but subtle misstep when he says “the eye evolved
to see” - the eye most decidedly DID NOT evolve to see. The eye evolved and
does see but importantly evolution has no intent, it has no goal and it has no
purpose. I might sound pedantic but there is an important distinction between
“the eye sees” and “the eye was meant to see”.

------
amelius
What remained the same: healthy people still can't relate very well to people
with a mental disorder. That's probably why cancer research gets a multiple in
funding of what research into mental disorders gets.

~~~
TeaDrunk
People with mental disorders cannot relate very well to people with very
different mental disorders as well. Someone with a mood disorder may still be
bigoted towards someone with a developmental condition like ADHD.

~~~
watwut
It is not just issue of feeling related. Some mental health issues have
massive impact on those around and on their mental health.

For example, mood disorder may mean you get yelled at and insulted or put down
a lot, unpredictably and for no own fault. It may be result of sickness, but
verbal abuse consequence is same.

------
trabant00
Everything I know about psychiatry and therapy has me believe we are in the
alchemy phase of mental health practice.

We have a huge number of theories and arguments that all sound reasonable but
are contradictory and fail horribly when applied to everybody with the same
disfunction label.

We are not without success examples but I don't know if overall we are at net
possitive.

What I dislike mostly about the situation is pacients and families rarely
being made aware of the gamble that is treatment. If the situation is bad
enough you have basically nothing to lose, so sure, try anything at your
disposal. But medicating young boys for being unruly for example...

~~~
enkid
There are certainly treatments that are based on evidence and capable of
helping individuals in a variety of circumstances. From what I've read,
Cognitivr Behavioral Therapy and some of its spin offs really do help people
recover from trauma. The problem, as far as I can tell, is that not all
practicing psychiatrist choose to use them.

------
PaulAJ
Yes, but....

The trouble with evolutionary explanations of human psychology is that they
are "just so stories". Actual tests of these hypotheses are extremely
difficult. Sometimes you can get somewhere with experiments on other mammals,
but for the most part its high piles of speculation. The little story about
the possibly autistic reindeer herdsman is a case in point. Nice anecdote, but
the plural of anecdote is not evidence.

Then you mix in speculation about primitive tribes with considerations of
supernormal stimulii and possible actual disease or genetic damage, and you
wind up with exactly the same morass that the article complains about in
current psychiatry.

And even when you have a tested theory it provides very little guidance about
how to help afflicted individuals live in modern society.

------
jackcosgrove
> Social oddities could be forgiven when your mind is spectacularly useful

Or simply when one's mind is not a threat to others. Perhaps those who see
abnormality as a threat are themselves disordered?

------
lquist
This article is fascinating. It proposes an evolutionary theory of mental
illness (e.g., "Psychopathy...as a cheating strategy which is game
theoretically optimal for some portion of a group."). What might be the
evolutionary reasons for Depression and Anxiety?

~~~
inportb
Enhanced analytic capacity and avoidance of distractions, apparently.
[https://www.scientificamerican.com/article/depressions-
evolu...](https://www.scientificamerican.com/article/depressions-
evolutionary/)

------
outlace
For those interested in a history of psychiatry, see “Mind Fixers” by Ann
Harrington (Harvard historian).

------
abellerose
Psychiatry as a profession is very dark. Even today if someone is wronged by
it. They will receive little to no remedy unless very financially well off, or
public outcry, and or the psychiatrist admitted wrong to his or her actions.

I frequent a website where most people are seeking to end their life from an
assortment of mental illnesses. Majority of them have tried multiple
psychiatrists as well as therapists and with little to no success in curing
their suffering. I find it egregious that people may think psychiatrists
actually seek the benefit of the patient's wishes because I know personally
the request for MAiD falls on deaf ears. Instead these patients continue to
experience involuntary treatment if they live in less civil countries or
advised to try different medication.

I've known someone labeled schizophrenic where it costed their insurance well
over 60k and in less than a year from involuntary hospitalization while being
drugged & observed. I know other psychological illnesses like Gender Dysphoria
where a person went through the wrong puberty never get that funded for their
quality of life to improve (fixing voice & appearance). Anyway I think the
whole field is very questionable if psychiatrists have a sincere interest in
the person their treating that's basically their customer that keeps coming
back.

