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Should Mental Disorders Have Names? (scientificamerican.com)
126 points by LinuxBender 30 days ago | hide | past | web | favorite | 101 comments



Most researchers agree that mental disorders should not have names, as it is difficult or impossible to draw discrete boundaries in this complex and poorly-understood spectrum of symptoms. However, as a broad generalization, researchers are the only group who feel this way:

- Doctors like names because then they can provide a diagnosis and recommend action based on the diagnosis

- Patients and their loved ones (often) like names because it is easier to think/say "I have schizophrenia" than it is to describe their factor scores on a myriad of benchmarks

- Drug companies like names because they can develop drugs for specific disorders rather than for a combinatorially large number of factors

- Regulators like names because they can approve treatments and standards of care for a finite number of situations

- Insurance companies like names because it allows them to approve or deny claims in a more straightforward way.

While names are often times arbitrary, they make many things more convenient. I am not saying that I personally agree or disagree that there should or should not be names, only that this is a complex issue with many complexities besides the underlying science.

Also, I see nobody has mentioned RDoC yet, which is the taxonomy researchers are starting to use to classify mental disorders: https://www.nimh.nih.gov/research-priorities/rdoc/constructs...


We used to get drunk and debate the merits of the DSM as undergrads. Most of my friends who went on to get their PhDs still see it as a imperfect but necessary evil. As a researcher, you need a common language to discuss what you're researching. There is value to studying one particular group of symptoms vs another; different ones have different treatment guideless, medications, and potentially common biomarkers. But people don't always fit neatly in these boxes, as the article shows. It's entirely possible someday that we'll move past specific labels, but we don't have viable alternatives to the DSM right now.


I completely agree with your overall analysis, as well as the main point of the original article. The one thing I would add or clarify is that even the phrase "mental disorder" may not be the best way to refer to this class of symptoms/behaviors. I believe that "mental injury" would be both more accurate, and more conducive to healing.

A substantial portion of the things we refer to as "mental illness" are the after-effects of trauma. When you break your leg and you can't walk for 6 months afterwards, people don't say you have a "leg illness". It's not some unspecified thing which caused your leg to stop performing like most people's legs. It's a fracture. If set properly and given time to heal, it will resume normal functioning. If it's never set, or if it gets reinjured, it may lead to a permanent disability.

Minds can be broken as well. Any one who has ever experienced an abusive relationship knows this. Survivors of child abuse know this. A "mental fracture" isn't primarily physical, like a fracture of the leg, but it has a similar effect in terms of impairing the organ to perform its role correctly.

But mental injuries can be "set" and healed, just like physical ones. Perhaps not 100%, perhaps there will always be scar tissue or some version of impaired mobility where the injury occurred. But injuries heal with time, given proper care.

I am aware that this concept is fairly at odds with the western conception of mental health with its myriad disorders, all of which are unexplained and presumably lifelong diseases. I attribute this entire weird world of DSM pseudoscience with its gargantuan and ever-growing list of labels to the massive social pressure against dealing with the actual problem of trauma and abuse.

Correctly diagnosing someone with a "mental injury resulting from trauma/abuse" would lead to some extremely difficult conversations, which most people (even the ones experiencing the abuse) would prefer not to have.


How exactly would you "set" a mental injury?


It's like setting a physical injury, but significantly harder because usually you're not dealing with it at the time of injury, only much later.

You find the original source, some event or series of events that caused the psyche to fracture. By fracture I mean caused the mind to operate according to some models that were necessary to survive at the time of crisis, but are no longer adaptive in the normal/real/adult world. You then update your mental model to one that is more aligned with reality.

In other words: go to the source of the pain, unlearn whatever lesson you learned at the time to deal with the situation, learn a different/healthier way of looking at it, and then practice a lot until the new mental model is firmly in place.

This is hard. But it gets easier with practice. And it's much easier than trying to set an injury by taking lots of pain-killers.


> Most researchers agree that mental disorders should not have names, as it is difficult or impossible to draw discrete boundaries in this complex and poorly-understood spectrum of symptoms.

By that logic, we shouldn't name species either.


This is essentially it. The names are a fiction. You let somebody say that you or your dependant is "disordered" or what have you, even if functionally they're doing better than most people, and in exchange you get benefits. Insurance coverage, social assistance, access to specialized programs, certain social privledges.

I do wonder if we're absolutely fucking up the minds of a generation of people by giving more and more people the made up labels. They come hand in hand with stigma and insecurity. We've been loosening diagnostic criteria continually on the dubious grounds that we "better understand" mental illness in the past. When it gets down to brass tacks we just decided as society labelling more people as "different" and treating them differently was for the best. Beyond the concern I have for individuals more and more people are qualifying for disability assistance every year and its unsustainable financially.

I do wish we had a model of mental health that was more focused on addressing more granular individual strengths/weaknesses and one less prone to just saying a broad swathe of people who are nothing alike are part of the same "spectrum".


I do research on the topic of the article. I actually initially clicked on it because the title seems so uncannily similar in content to an article I wrote that I thought they might mention something about it. They did not but it's still really salient to me.

The article is sort of strange in that it brings up these issues and then fails to discuss the huge range of research in this area. The p-factor stuff is sort of hot lately but is just one subtopic in a vast area, somewhat controversial, and more of theoretical interest than clinical utility.

Part of the problem is that there are different purposes for classification systems. I think you're right in that categorical diagnoses have all the appeals you mention at least among some subgroups, but those are a little detached from (1) how many clinicians actually think about a lot of problems, and (2) how many researchers think about these things. Putting aside the "syndrome"-favoring clinicians, a lot of clinicians focus more on behavioral patterns, which tend to be very specific, more targetable, and far removed from broad categorical labels. Many researchers are moving away from these categorical labels also, for many reasons, but mostly generally because the patterns you see in behavior don't map onto the categories in the DSM in reality. Think blood pressure or height as analogies for depression or disorganized thinking, rather than Huntington's disease or malaria.

RDoC is important to mention but it's ending up to be about as controversial as the DSM for various reasons. First, it suffers from the same "names by committee fiat" as the DSM, which is problematic when you are dealing with something like neurobehavioral pathology, which can be examined at many levels and from many directions, which is fuzzy and complex, and about which we know very little. Second, despite its noble intents, was kind of developed by neuroscientists with little connection to actual clinical human behavior. I don't mean any offense to them, but when you get together a bunch of researchers, a substantial number of whom study rodent neurobiology, you're going to start losing touch with what clinicians are actually wrestling with in clinical settings. Look for psychosis or subdimensions of psychosis, for example, and it's missing from RDoC. I like to think of RDoC as "revenge of the neuroscientists," people who got tired of trying to connect their research to human public health, and decided to just redefine problems so it's closer to their own research. A similar initiative is HiTOP, which is more phenotypically focused, and uses statistical/quantitative models for classification rather than committee decisions (I'm not saying HiTOP is better, it just is a similar but different approach from RDoC).

I think the issue is not whether or not mental disorders should have names, it's whether or not there are mental disorders per se, or how to best describe mental-neural-behavioral patterns. You need to be able to quantify to study something scientifically, and quantifying implies labeling; the question is how.


> Drug companies like names because they can develop drugs for specific disorders rather than for a combinatorially large number of factors

Which then mysteriously only seem to work on a small fraction of people diagnosed with that disorder, no?


Came here hoping to see well-informed commentary -- was not disappointed. Thanks :)


Now that I think about it, this is the reason naming things in general is so hard, including computer science.


The root issue here is finding some path forward for helping people. Psychiatry, psychology etc aren't doing a great job with that.

He tries to determine what has happened historically but not why.

Why was this guy using drugs starting at age ten? What led up to that? Shouldn't it be classified as a parenting failure, not a "disorder" on his part?

What was the history with the father? Perhaps assaulting his father wasn't simply due to insanity. Some parents are really awful to their kids and it's a huge problem for the kid. That doesn't necessarily stop being true just because the kid became a legal adult.

Labels determine what mental models we use when trying to intercede in a problem. Different labels get very different reactions and treatment modes.

We need to up our game in myriad ways, but labels are a critical tool for this problem space. I hate labels, but they are a useful communication tool.


>He tries to determine what has happened historically but not why.

The biggest advance in the history of psychotherapy was to stop asking why and start asking what and how.

The psychoanalysts broadly believed that mental disorders could be treated by revealing and resolving unconscious conflicts and forgotten childhood memories. That's a very slow process, and eventually randomised controlled trials would demonstrate that it wasn't particularly effective.

Rational emotive and cognitive behavioural therapists essentially argued I don't care why you're nuts, I just want to teach you how to be less nuts. If you have habitually fearful or negative thoughts, you can learn to disregard those thoughts as unhelpful and consciously replace them with more useful thoughts. Knowing who to blame for your cognitive bugs doesn't really help you fix them. Aaron T. Beck had the good sense to subject his psychotherapeutic approach to randomised controlled trials, demonstrating that a relatively short course of cognitive behavioural therapy was at least as effective as several years of psychoanalysis.

Psychiatry, clinical psychology and psychotherapy undoubtedly has a lot of shortcomings and there are a lot of patients we don't yet know how to treat effectively. A far bigger problem however is lack of access - the vast majority of people who could benefit from psychiatric medicine simply don't get treated. In the developed world, it's usually fairly easy to get prescribed medication, but there are often long waits or financial barriers to access psychotherapy. In the developing world, most people can't even access SSRIs despite the cost being around $1 a month. Stigma and a lack of awareness are still a substantial barrier to accessing care.

We need better treatments, but the priority right now must be simply to get more people to try the treatments we do have. Trying a treatment with a 40% success rate is obviously better than doing nothing, but nothing is still the default and it's causing immense amounts of needless suffering.


> The biggest advance in the history of psychotherapy was to stop asking why and start asking what and how.

> Rational emotive and cognitive behavioural therapists essentially argued I don't care why you're nuts, I just want to teach you how to be less nuts.

This is part of why schema therapy is getting so much attention right now: it takes CBT but combines why, what and how into a cohesive whole. The success rates seems to be even better than CBT, a lot better in some cases.

[0] https://en.wikipedia.org/wiki/Schema_therapy


It's interesting that a lot of the 'hot new thing' therapies are around Personality Disorders or PTSD. I'm curious what the theory is to apply this to depression or anxiety. And what about dissociastive disorders, or oppositional defiant disorder, or autism?


> oppositional defiant disorder

Tangent: I have a lot of skepticism about that one being a proper disorder on its own, in the same sense that I wouldn't consider "fever" an illness in and of its own, but a symptom of other illnesses.


I agree, but even then, should the symptom be treated with the same treatment designed for personality disorders? What is the evidence of it? etc. I genuinely don't know these things.


From a Nursing perspective, which is a meld of sociology-psychology-medicine, it helps to ask the why to build compassion toward the individual in direct care situations. The overlap between mental health and what makes someone act like a jerk or insecure is almost 1:1 and hard to discern from the outset, but contextualization separates the two.


Psychiatry, psychology etc aren't doing a great job with that.

I'm not sure that's a fair criticism. They're certainly not doing a perfect job but the number of people who have a higher quality of life than a century ago is a real success.

There are people who are living fulfilling lives who would have been housed in mental institutions or who would have long since killed themselves, given the state of mental health care 50 or 60 years ago.


I believe its a perfectly fair criticism because honestly what has western psychiatry accomplished on a broad scale over the last two decades? Self-reported mental illess which correlates with poor health outcomes overall has shot up. Suicide rate is up. Resources dedicated to mental health and the mentally ill can't be dedicated elsewhere. There has been a pretty substantial stalling when it comes to developing truly innovative new drugs and therapies. Most of what's being developed are new takes on ssris, cbt, talk therapy etc. Most of the existing therapies are getting less effective over time which I would guess is due to saturation/diminishing returns.

The Mental Health field collectively doesn't know what the fuck it's doing. More time and money is spent on mental health every year and things are actually getting worse. People are not as skeptical of the mental health field as they should be. Either our current efforts are counterproductive or they're failing to address a bigger picture concern which outweighs any positives of increased mental health treatment.


I hail from the hard sciences and used give a all the psy* disciplines a considerable amount of flack. But then, what do you know, I found myself in need of their help, and now I live a much happier life thanks to a doctor who knew their way around the application of CBT. And I'll never talk sh*t again :)


>Labels determine what mental models we use when trying to intercede in a problem. Different labels get very different reactions and treatment modes.

I think he ever-so-briefly touched on a different angle of that problem: "The psychoanalysts don’t like it because it ignores the “unique milieu of individuality.” The more biologically-oriented clinicians don’t like it because it ignores biology. The DSM lacks “validity,” they say. A diagnosis based on a combination of symptoms is, they might argue, like a constellation of stars — sure, you could reliably identify the Big Dipper, but no one would argue that the Big Dipper is a valid interstellar system. It’s just a name."

The problem is that the label matches no defined model; which is why I think that everyone dislikes it.

>I hate labels, but they are a useful communication tool.

Agreed but without the matching underlying models, they're just added toil; especially, if they're only "valid" in niche use-cases (such as clinical settings).

For example, we have a general idea of what Schizophrenia is but when it comes to the classification, diagnosis, and/or treatment, that's when we lose context. Schizophrenia isn't - implicitly - the same classification, diagnosis, and treatments across the board for every patient. So, effectively, you're coupling a large group of individuals under a very generic label, which has no effective model applied to it.


I understand that cancer may have similar characteristics. All cancers are similar in that they are uncontrolled cell division, but the causes, symptoms, treatments, and characteristics of every cancer can be very different.


Exactly. It's often useful to have a label to describe a set of symptoms that you see occurring together over and over again, even if they don't always have the same root cause. The problem is when doctors mistake the existence of a label for understanding.


But we don't have that level of knowledge yet when it comes to schizophrenia. The closest I can get to such an absolute is "all schizophrenia cases are similar in that they manifest as sensory inputs uncorrelated to the outside world", but that isn't really a useful classification -- that description is based on symptoms, not on causes.


I think we only have a partial understanding of cancer as well. Uncontrolled cell division is something in between a symptom and a cause.


I was a homeschooling parent and had a role in a TAG/parenting/education organization to support that role. My feedback on very difficult kids, some of whom had been failed by multiple experts, was pretty popular, enough so that I de facto got "referrals," though I had no real formal credentials and charged no money. Parents would just talk to friends and say "Go talk to her" basically.

In many cases, these were Twice Exceptional kids who had started doing really strange things around the time they were toddlers or preschoolers. The strong negative reactions of adults around them then compounded the problem and made it an intractable issue.

I was often able to help parents back off from this dynamic so the family and child could get unstuck. I wrote an anecdote about that sort of process in January. It can be read here: https://raisingfutureadults.blogspot.com/2019/01/the-hand-li...

I'm a former military wife and homeschooling parent. People are quick to be dismissive and tell me I don't know anything about x, y or z, etc.

But my experiences suggest to me that a lot of mental health issues are rooted in relatively prosaic cases of "kids do weird and stupid things because they are kids, some kids do very weird and stupid things for various reasons, and parents often don't have effective tools for handling the situation, thereby compounding the problem." My experiences also suggest that a lot of this is fixable, without drugs or therapy, if you can help the family disengage from long-standing patterns of interaction and help the child in question understand where their dysfunctional behaviors came from in a non-blaming manner and give them some better answers and/or just breathing room to change on their own without interference.

I spent about two weeks writing the above piece and it's based on many years of education and experience. It got more than 60k page views and people are republishing it, some with my permission and giving me credit.

I would like to do more of that kind of writing, but it made me zero money. I am routinely told my writing has zero value and I should go get a real job. I'm not good at the self promotion thing etc.

I think I know some useful things that could help parents avoid becoming mired in the kinds of problems this man in the article has. But I have no audience and people who know what I used to do mostly are in my past or simply unwilling to vouch for me, including some prominent people on HN who knew of my work in that area at the time, to some degree or another.

I've largely made my peace with the fact that I can't afford to write for free and lots of people on the internet expect excellent content for free. They don't want ads and they don't want to pay anything for it either. No, they don't want to be a Patreon supporter.

So I content myself as best I can with leaving comments on the internet and generally being percieved as a blowhard and arm chair politician type who has an opinion on everything and zero credibility.

Que sera, sera.


> My experiences also suggest that a lot of this is fixable, without drugs or therapy, if you can help the family disengage from long-standing patterns of interaction and help the child in question understand where their dysfunctional behaviors came from in a non-blaming manner and give them some better answers and/or just breathing room to change on their own without interference.

Helping the family change how they interact with their children is therapy!


But it was often accomplished in one or a few emails, not months or years of intensive effort.

Someone would join the list and complain about the intractable, crazy making behavior of their impossible child. I would write a reply and say something like "That's a common issue with gifted kids. It's due to boredom and is easily solved by keeping them adequately occupied." They would go "Oh. My. God. That makes so much sense! Just before the last incident, he did actually say out loud 'I'm bored.'" and a long-standing, intractable pattern of problem behavior that had stubbornly resisted all prior intervention would largely disappear overnight once the parent made sure to keep their kid adequately occupied.

Or a parent of a particularly hard case would exchange a few emails with me for a week or two and then report back to me months later that all these terrible, intractable issues had magically changed and it had involved almost zero effort on the part of the parent who had spent years sinking enormous time, money and effort into resolving these problems, all to no avail until they spent a little time talking to me.

If it was therapy, it was like an *easy button" version of it, very unlike the roughly 3.5 years of intensive therapy I pursued in my youth to get my personal issues to simmer down to a dull roar before really resolving things around the age of forty when I got divorced and yadda.


> Why was this guy using drugs starting at age ten? What led up to that? Shouldn't it be classified as a parenting failure, not a "disorder" on his part?

"So you say your father broke your arm.... This isn't a bone fracture! It's bad parenting, now go home, no medical attention for you".

You are looking to see if some mental/physiological process is in disorder, so it's not about whether you caused it or your father caused it. The question to ask is does the patient fit in box X, because we have scientific studies saying that a large number of patients in box X when given treatment Y move to box Z, which is classified as being better than X.


You're missing his point. A doctor can treat you every time your father breaks your arm but the problem you have doesn't lie with your body or your brain. Yet the first line approach to mental health is treating the patients as the problem, assuming their brains are malufunctioning, and giving them behavioral therapy and drugs. If your depressed because your father keeps breaking your arm no amount of ssris and therapy will fix that...

I'm not saying the mental health field doesn't take into account external factors. It does especially psychology. I still think psychology overestimates how sick people are and underestimates how sick society is.


"So you say your father broke your arm.... This isn't a bone fracture! It's bad parenting, now go home, no medical attention for you"

So your father broke your arm at age ten. And broke your arm annually every year thereafter because he's an abusive asshat. And doctors decided to label you with some bizarre form of osteoporosis that must be the underlying cause of your frequent and mysterious fractures. And when you finally smack dad in the head with a hammer as an adult in self defense, it goes in your file that you are not only crazy but also dangerous and violent, even though you've never been violent with anyone else ever.

Better solution: You need a restraining order on your father who should not see you without court supervision while he finishes up his jail sentence for assault and battery and child abuse. He goes to therapy. You get put in a safe environment with adults who don't break your arm annually while claiming it's you that's defective.


Definitions are much too narrow, there is so much overlap, ultimately though therapeutic methods don't differ quite so wildly. The handful of conditions he was displaying are common differential diagnoses with very similar treatments.

However, there are stigmas attached to certain diagnoses and not their differentials so some people prefer less negative labels.

In my experience with world class psychiatrists your views are a little outdated, generally the more academic practitioners are much more like Dr Barron.


This is different situation here. He is not doing therapy nor treatment for this guy just evaluating for the study.


I realize that. I don't think it's pertinent to my point.

It matters very, very much whether we label someone as "a victim of a crime suffering PTSD" or "crazy" by some fancier term for crazy. If the diagnostic tools he is using make no effort to make such distinctions, they won't make that distinction for purposes of clinical treatment either.


Don't you think it's pretty damning for psychiatry if this guy is the first one who figured out he's actually ill from taking drugs, after decades when he was treated as mentally ill?


Just imagine a doctor telling you what ICD code you have. There's nothing wrong with classification and labeling things. I think society is getting a little carried away with such topics. Personally, I think it's a phase that collectively we'll pass and reflect on how extreme we took things in order to try and obtain balance.

There's a difference in calling someone "crazy" vs saying they have a mental disorder. The meaning of "crazy" has changed over the years due to the abusive context it's been used in more and more. A lot of words got redefined over the years, so this isn't new, but the idea of dropping labels or trying to eliminate well established scientific and testable classifications is new.

To future generations, I hope you don't create a culture in which you're continuously stressed out about how others will label you publicly. When I was younger, a kid that was bullied in school could escape it by coming home. These days, you have no escape because of social media. I hope you learn to adjust and navigate these new times. Even older folks struggle with how things are currently.


For me one of the issue of the current names is that their definition change too much depending on the context and the person interpreting them.

For instance if you say someone your arm is 'broken', they understand something is deeply damaged (not just fissured). They might not know the specifics on how it broke, where exactly, how you are healing it or how it impacts you, but they know the basic criticality of it.

If you say you have "depression", they don't know if you'll take your week off to recover or actually need extensive professional follow up with a long term medication. There is no common sense of how bad it is 'broken'.

From there people all have their anecdotes, visions of how they solved "depression" and come with a very personal idea of what your issue is that most of the time will have nothing to do with your actual diagnosed issue.

In that sense the word doesn't work that much as a conveyor of information, they'll just know you have "something". I see the reasoning behind getting rid of a word in medical context if it doesn't bring any viable information with it.


This is a total tangent, but I find it funny, everyone uses bone breaking as an example, but a broken bone is a unique injury. It can totally disable your limb. If you don't immobilize it, it won't heal properly. If you immobilize it, it'll heal back stronger than ever in a few weeks. Mental illness seems more similar to a soft tissue injury. There's a much wider range of severity, it can be asymptomatic, cause instability, or be completely disabling. There's much debate over the right treatment in many cases (surgery isn't always the best option, but sometimes it is). People disagree on whether certain ligaments and tendons can heal.


>If you say you have "depression", they don't know if you'll take your week off to recover or actually need extensive professional follow up with a long term medication. There is no common sense of how bad it is 'broken'.

I think that's primarily because severe and enduring mental illness is still strongly stigmatised.

The public conversation about mental health is dominated by what I call "the narrative". We see a succession of successful and healthy people talking about how they had depression or anxiety, they plucked up the courage to ask for help but now they're OK. Our conversations about mental health are dominated by brief episodes of illness in the past tense.

That's not a terrible narrative and I'm sure it has encouraged a lot of people to seek treatment, but it's a very selective image of mental illness. We don't hear from people in the throes of severe illness. We don't hear from people who have struggled for years or decades and haven't found an effective treatment. We don't hear from people whose lives have been blighted by unmanaged schizophrenia or bipolar disorder. We don't hear from people who know they need treatment, but can't access it for financial reasons.

"There are effective treatments and you don't have to suffer in silence" is an important message, but so is "some people can't access treatment, some people don't benefit from treatment, so we need to work as a society to improve the quality and availability of treatment and help people with unresolved mental illness to live fulfilling lives".


I think what you're doing is comparing medical vs layman usage. A doctor will tell his patient they have a "broken arm" due to past experiences in speaking with patients using medical terms. e.g, fracture or distal radius fracture in the case of a broken wrist.

When it comes to mental disorders, it can be very difficult to accurately classify the severity. It reminds me of how doctors prescribe blood pressure medication; it's guess work. e.g, They will prescribe what they think will work and have you come back later to see if it's working properly. In my mom's case, the first prescription made things worse.

Depression can be rooted in chemical imbalances, diet, sudden loss of a job or family member, etc,. It's not like taking a walk will solve everyone's depression. In most cases, it's much more complex than that. That's why there's psychologist and psychiatrist. In some cases cognitive therapy works, some a good diet + workout routine works, and other cases medication is required. There are different levels of depression and they are properly classified by professionals. The word "depression" is like a doctor telling you that you're arm/wrist is broken. e.g, Bipolar Disorder is a type of depression that's treated with medication.

It's a terribly complex thing we're talking about and telling professionals how to define their own vernacular is pretty foolish. It would be like my mom telling me that engineers should drop the phrase "eventually consistent" and just say "consistent". :)


I'm afraid you are giving the psychiatric profession way too much credit.

Most DSM disorder categories don't perform well on measures of inter-rater reliability. (https://en.wikipedia.org/wiki/Inter-rater_reliability). One implication of this is that the categories can't be assumed to be well-defined scientific entities. Now, the DSM could be a shadow of some more complete, correct taxonomy of mental disfunction—certainly it's based on observation of genuine distress, so it's not completely arbitrary—but by scientific or medical standards, it's very shaky.

Here's an article about the situation in relation to the DSM:

https://www.madinamerica.com/2013/03/the-dsm-5-field-trials-...

It's not uncommon for people who haven't looked seriously at the mental health field to assume that the so-called medical model of mental illness meets the same high standards of intellectual rigour as other areas of medicine, or other endeavours such as engineering. I put it to you that you are in exactly that position: the very basic point you are making ("This is as complex as engineering! Leave it to the experts!) indicates that you are unaware of the unique flakiness of psychiatry. This is contested territory, and many professionals are invested in a certain dubious framing of the situation.


Could the same not be said of a broken arm? - for instance, an incomplete fracture may heal on its own after being immobilised for a few weeks, whereas a severely comminuted fracture may require surgical intervention.

https://en.wikipedia.org/wiki/Bone_fracture#Classification


ICD is not a public facing label, I use them every day for healthcare analysis but they'd never be intelligible to lay people.


From a technical standpoint, ICD codes are intended primarily for financial and reporting purposes. When you need more nuanced clinical data a different coding system such as SNOMED CT might be more appropriate. It allows for multiple post-coordinated qualifiers including severity and other dimensions.


If past technological advances are any indication, the kids will adapt to this new world much better than we will.


The danger of naming mental disorders (or any other abstract concept) is when you confuse the map for the territory.

The map (the name) should serve as the best possible mental model of the territory (the actual, descriptive physiological condition) - not as the thing-in-itself.


It is tempting to stare at the map when the territory is obscured by the fog of war. The rigor of the SCID very much hides the fact that several places on the territory have similar features but are miles apart. And then every observer loves certain places and hates working in others.

As bad as the state of diagnosis is (some say >50% for certain conditions) there is no way around a diagnosis for treatment as one needs to make decisions and these need to be based in whatever tenuous grasp one has on reality. At this point imho. we can only try to make sure all sources of bias, tendency to defend previous decisions, treatment capacity and financial considerations (diagnosis is key to insurance payments) are as far isolated from decision making as possible. There is lots to be done. SCID is only the symptom.


The name of a disorder mental or physical is a map or model in the same way that the name of a town or street is. Which is to say, it's not, though it's necessary for identification of a component of a model.

“Diabetes mellitus” isn’t any kind of a model. It's a symptom description dressed up in Latin. We've since attached a useful model to it, but the name long predates the model and has little to do with it.


I am of the opinion the worst part about naming disorders is the holy hell some groups will have if what they suffer from is described as a mental disorder. Then you will get the other side of the coin where people self diagnose and that sets off a different chain of issues.

So it become six of one and a half dozen of another. For the benefit of the medical community yes we should name them or slot them into broad categories. For the public its best to probably just use broad categories


I personally think this is a great sort of walk-through of the pitfalls of the strictly DSM-based approach. I don’t necessarily see it as something that particularly reflects this guy. If he wanted to create a new diagnostic approach to include people who are, in a sense, indistinguishable from the patient population of strictly DSM-V bipolar that would be its own study. In addition to the above, and a host of other matters, this article does demonstrate something about how diagnosis and diagnostic approaches greatly influence how we understand, classify, and teach psychiatry, psychology, medicine, and other clinical fields. Plus, it presents some things about practitioners understanding of patients and clinical priorities in patient visits can be so structured by these approaches, research based on them, even conventional clinical wisdom structured by them, and so on. They cause a ripple effect, and one that influences clinical and academic practice in a sufficiently complex and opaque way. So, even clinical providers, academics who try to radically depart from these approaches are still quite effected by it.

That said, the point I really want to reach is that it’s my opinion—and there is a body of academic work within and about many clinical fields on this matter— that the longevity of these diagnostic approaches and their bases, the categorization of disorders, how clinical fields themself are taught, how priorities are set in the clinic is owed and hugely influenced by the necessity (and the hegemony) of US insurance coding, especially as it relates to prescription drugs. I’m not insisting that prescriptions, or necessarily any of this is inherently negative in it’s effects, just that insurance coding as it is, health insurance in the US as it is, has (sometimes quite extreme) far reaching influence over essentially every aspect of clinical practice, research practices. At least that’s my opinion/conclusion/interest in this article.


The neurological field has grappled, over the last few decades, with an increasing understanding of the interconnectedness and pliability of the brain and the rest of the body. We've gone from categorical localization of function to neuroplasticity for example, and likewise we've seen how distinct disorders can involve a number of different physiological differences and deficits (comorbidites are rife, e.g. see atopy + neurological sensitivities). The brain is especially complex. Our grappling with the terminology around its disorders is entirely ok IMHO. It's important to not get tied down in dogmatic categorical thinking. It's also important to let people explore different treatment paths, and find what works for them. There is never going to be a canonical "cure" for depression, just as there won't be for IBS.


I tell people I have Tourette's. I don't have Tourette's. I'm missing one of the required criteria

- must have tics that begin before he or she is 18 years of age.

In a medical standpoint that makes it different, but in any practical sense the name conveys all of the information people need, it is perhaps unusual in that it is also a condition that occasionally requires rapid explanation.


> I'm missing one of the required criteria

Are you sure about that? Tics don't always manifest in obvious ways. You may well have had them in a very mild form but never noticed.


Us humans certainly prefer to put boundaries and names on things. And indeed, it is often unwise i.e. with (one of our) species definitions: A can procreate with B, B can with C but A cannot with C, meaning A==B, B==C but A!=C, a paradox because of our tendencies.

Could it be a cultural thing? While I grow older I find it more natural to think of things as continuous or to assign uncertainty to "facts", but perhaps our educational system does not give much attention to this. Perhaps it's too much about facts and names and boundaries.

In this articles' case though, of course mental disorders are a continuum but the drugs and methods for treatment we have are not. So perhaps in this case a label is nice. One should always keep the continuous nature in the back of one's mind though.


I agree with much of what you say. I've heard it said that education is a series of increasingly small lies. If you started teaching the whole truth and nothing but, from a young age, the student would fail to grasp the big picture and the broad connections in the way the world works. When you let something go, it drops. Well, unless it's lighter than air. And it doesn't drop, it attracts to the Earth. And actually, it attracts the Earth back to itself. And it doesn't simply "drop", it accelerates. And gravitational forces and air friction determine the acceleration and the jerk. If you don't omit anything, you can't communicate anything.

The broader point I'm getting at is, first you need to learn about the artificial distinctions so you can "from" the subject. Then, once you know all the rules by heart, you can feel free to break them.


Nice way of putting it. Yesterday morning my son asked how humans came to be and I ended up stuttering that perhaps at some point some molecule of unspecified complexity gained the ability to replicate at which point it became subject to natural selection based on descent with modification... You get the problem. Better say: It started with simple life and the best ones (sometimes more complex ones) ended up in the next generation. FFWD 3.5 billion years and voila. It's a bit of a lie because "what's life, what's before that, what's best, what's fitness" etc. But it works. I keep having problems with this though, but yeah, what to say to someone without any grasp of cells or DNA or "1 billion years", do even grasp it "correctly"??... Man, speak about rabbit holes. I didn't even start on evolution on the population level.. I see my son loosing interest during my explanation, while I get more and more enthusiastic. It's a hard problem.


I think the analogy to species is misleading. While there are interesting edge cases, the basic idea that there are different kinds of animals is really obvious & clear: Sparrows don't try to mate with owls, seagulls, pigeons, let alone mice, earthworms & cockroaches. Instead with other sparrows, and produce more sparrows, which we can really confidently distinguish from owls, knowing just one of size/food/color/call would be enough. Nature is extremely clumpy here. Lots of points in the size/food/color/call space simply aren't occupied.

Maybe a better analogy would be to the informally defined neighbourhoods which exist in many cities. Everyone knows there's a Little Italy and a China Town, and could point out the main street of each. But whether or not an apartment three blocks away is or isn't in that neighbourhood gets pretty fuzzy, and depends a lot on what the realtor thinks you are looking for.


True, but do definitions not encourage a more thorough analysis?

If A is a male, B is a female, C is a male, your operator definition is even troublesome within a species.

What kind of mathematical object comes closer to this abstraction of a species? Maybe it's not about names and boundaries, but about getting to understand things for which you need abstractions.

I always appreciate when people do not fuss about definitions and easily change them but reason consistently after indicating their interpretation of those concepts.


I don’t think your example really applies, because no one expects the definition of “species” to imply that the “individual A can mate with individual B” relation to be transitive.


Agreed, of course we need definition to discuss, and indeed we should be fluent about them. This is difficult to explain to a child or indeed to some adults.


>> Could it be a cultural thing? While I grow older I find it more natural to think of things as continuous or to assign uncertainty to "facts"....

Yay! You've overcome splitting! Now if the profession could achieve what they want from patients...


If you don't have multiple names, you'll have a single name ('insane', or some new euphemism.) People with any sort of disorder would all get lumped together, and human nature being what it is, others would tend to assume the worst of all of them. I find it hard to believe this would be an improvement over the status quo, as imperfect as it may be.


The thing that unsettles me is that the diagnosis is all self reported. If I'm already going in to see a doctor because I think my mind isn't right, how can I trust that I am answering the questions correctly with respect to how they are intending them. You're trusting me to answer your questions when I don't feel confident in my ability to answer them and in a couple of hours you've handed down a diagnosis which basically amounts to 'here take these drugs and we'll see you again in a month' Good luck navigating the side effects as well as the problems you originally came in here with by yourself.


Most of the neurological diseases have no conclusive and unique biomarkers or tests, and symptoms often not unique. There is not much can do to without scales with current knowledge


I'm skeptical as hell of the entire field of psychotherapy, psychology, psychiatry, and cog sci. I think we're doing better than before, sure, but it's all such a shit show from my perspective as a participant.

Rambles:

Back in highschool we had a massively depressed friend. They tried it all with her: cognitive behavioral therapy, drugs (ALL OF THEM), weed, religion. Tough love. Exercise. Diet. Nothing cured her and her depression killed her via suicide. What's the psych tell me after? Sometimes there's nothing we can do? That sucks. Human genome, done. Prevent HIV from killing someone. Can't do shit about depression sometimes.

And if you get depression - do you take the ssris? Fuck knows? http://www.healthtalk.org/peoples-experiences/mental-health/... and the "next page." Sometimes they make you numb to the world or feel like you're being controlled. Sometimes they make you have suicidal thoughts. Sometimes they take a weight off your shoulders. Sometimes they make you feel like you actually have a chance. None of my psychs were able to describe any of this. I had to research it on my own.

And Lord forbid you've got multiple. Is it ADHD still? Newest psych has the idea that it's all ADD now - so, my memories of wildcat behavior that I'd be ashamed of in seconds as a kid, what was that? When shit bubbles up out of my mouth without me thinking, is that not the H anymore but just something else? And why did nobody tell me in 2 decades that a common symptom of ADD is shit memory? I had to find out on Reddit. Is it actually? Who knows!

Does Adderall help? Well, I suppose! Hard to say. Technically, I could work without it. I am more productive with. But, also more robotic. And, it's nearly impossible to track the subtle personality changes that come with medicating via Adderall, no matter how hard I journal. Ask the psychs and they shrug and say "keep a journal." Ask what dosage and they say "higher until the side effects are unbearable, then one dosage down," instead of "lower until the medicine is ineffective, then one dose up." And as for those personality changes - perhaps that's a "better" me anyway? It's certainly a smarter one.

Don't get me started on what fresh hell you find yourself in if the State discovers someone is suicidal and locks them in a psych ward. Came damn close to ruining my life by performing a full on jail break to get my friend out of that psuedo science nightmare.

I welcome all thoughts on my rambles and I apologize if no helpful meaning was able to be extracted, on this subject I can think of no other way to get my thoughts on paper.


> Human genome, done.

The main takeaway from the Human Genome Project was that we understand less about DNA now than we thought we did in 1999.


I read another article yesterday that even our most basic assumption, that all cells in a body share the same DNA, may not even be true: https://www.sciencedaily.com/releases/2019/02/190215135835.h...


Financial interests, publish or perish, p value abuse, reproducibility crisis...you're right to be skeptical of any soft, non experimental science.


I think the big problem is that all those fields are still very new and the thing they're studying is extremely complex and hard to directly study.

I'd argue that chemistry really began with Lavoisier in the late 1700s. Physics? Late 1600s with Galileo and Newton. What about psychiatry? I'd argue that it really got going in the latter half of the 20th century. Freud and lobotomies? They were the equivalent of alchemy. Other fields have been around in a recognizably modern fashion for hundreds of years. The same cannot be said of psychiatry and psychology.

And that's not surprising. The brain and mind are incredibly difficult to study directly. Until the advent of EEC, fMRI, and other modern tools, the only real way to do it was by studying behavior. Similarly, the brain is very complex. We didn't have, what could be considered, a modern picture of the atom until the early 1900s and that was after several major discoveries spread over a few decades. It's not surprising that we're still struggling with the brain.

>Back in highschool we had a massively depressed friend. They tried it all with her: cognitive behavioral therapy, drugs (ALL OF THEM), weed, religion. Tough love. Exercise. Diet. Nothing cured her and her depression killed her via suicide. What's the psych tell me after? Sometimes there's nothing we can do? That sucks. Human genome, done. Prevent HIV from killing someone. Can't do shit about depression sometimes.

That's still the case for a lot of things. You have ALS? On average, you'll be dead in two to four years. 90% of people die within 10 years. Treatment is mainly supportive. Likewise, it's the 1800s and you contract a bacterial disease? Can't do anything about that, antibiotics won't be invented for decades. Drain the pus and hope that you survive.

On ADHD, it turns out that Concerta and Adderall are indistinguishable to me. I take a low dosage and the side effects are basically non-existent and it also gets rid of my anxiety and depression. But it also happens that exercise reduces the intensity of all my symptoms. I only found this out when I stopped going to the gym for two weeks and noticed that my medication doesn't seem to be as effective.

It's quite possible that, if I hadn't been in the habit of exercising regularly, I would've required a higher dosage that would give me severe side effects. It's also possible that I would be fine. How is my psychiatrist supposed to know that? Maybe exercise doesn't work for some people, maybe diet is critical, maybe it's getting enough sunlight. The entire web of interactions is extremely complex and we don't currently have the ability to examine it at a fine level.

Speaking of complex interactions, ADHD is predominantly genetic and there are a number of genes that can contribute to it. For example, a variant of the gene that codes the protein Latrophilin 3 is estimated to be responsible for roughly 10% of ADHD cases. People with this variant are also very responsive to stimulant medication. Given the way that I respond to medication, it wouldn't be surprising if that's responsible for my ADHD.

But other people might have multiple gene variants, each contributing to a portion of the severity of their ADHD. Adequately treating them might require a very specific combination of drugs. The current process is trial and error, but it's possible that you'll never hit that magic combination. Likewise, maybe there is no magic combination in existing drugs or maybe the ideal dose is 6mg, but it only comes in 5mg and 10mg doses.

The medication situation is getting better. There are services that will run a genetic analysis to determine which medications might be most effective. But it's still in its infancy and that's only a portion of the picture.

The brain is complex and our current tools for examining and treating it are still blunt. Don't get me wrong, there are definitely systemic issues in those fields that need to be corrected. But a lot of criticisms seem to boil down to the equivalent of "It's 1819, why haven't chemists invented acrylic to replace the glass in my glasses?"


Sorry to hear about your friend. I swear psychiatrists are exempt from observing the Hippocratic oath.

"I need help. My life is falling apart. I'm struggling with work and school. I might have a learning disability."

"You sound depressed. Here's a prescription for some obscure variant of an SSRI not covered by your insurance."

"These meds you put me on make me feel sick."

"Let's increase your dose."

"I want to hurt other people. I want to die."

"It takes 4-6 weeks for it to take full effect."

"This just isn't working."

"Let's add another variable to the equation. Here's a second prescription. Take both and see what happens."

The experiment must continue. It always ends the same way.

I know psychiatry helps some people (especially where sedatives are involved), but for the rest of us who slip through the cracks it's just the new Nazi science.


I can only imagine the frustration you are describing, but I still wonder if the blame is really on the doctors or the branch of medicine. Is there a better alternative?


The first thing you need to ask is are we, collectively, seeing an improvement or a deterioration of aggregate mental health? And how does this compare and contrast against nations where pharmacological treatment of illness is less and, if such a thing exists, more common? In other words is what we are doing better than nothing? The answer to this question is not always yes, because it's entirely possible that in the process of trying to do something you end up going backwards.

This also cannot be answered with isolated consideration such as the effectiveness of drug 'x' since there are externalities involved. What happens to these individuals in the longrun? The treatment of ADHD with amphetamines is a great one for this question. For those who showed no response to the treatment, are their outcomes better or worse than if they had never pursued treatment? What is the false positive rate and what is the affect of medication on these individuals?

The answer to this question should be obvious, but I'm not so sure it is anymore.


I don't disagree with your basic point, but that's a huge correlation bias. Why would a country with little mental illness introduce these medications?


It's not countries introducing drugs, but companies. And companies are driven primarily by a profit motive. This is not a bad thing in and of itself since it creates a private incentive for the research and development of drugs. However, when the money starts to become prioritized more heavily than the product being made, it creates a severe conflict of interest. The recent issue with opioids being an obvious example of this. Quoting this [1] great article from the Houston Chronicle:

----

"The trigger of the opioid crisis was a misrepresentation of a 1980 letter published in the New England Journal of Medicine, reporting on 11,000 hospitalized patients receiving opioids. It concluded that “despite widespread use of narcotic drugs in hospitals… addiction is rare in medical patients with no history of addiction.” This became a landmark study, cited more than 600 times, particularly after Purdue Pharma introduced OxyContin (extended-release oxycodone) in 1995.

Large opioids manufacturers began funding nonprofit groups such as the American Pain Society; and pain experts advocated for pain to become an important “fifth vital sign” to be queried in every doctor’s visit when checking blood pressure, heart rate, respiration and temperature.

Caught in the trend, the Federation of American Medical Boards encouraged punishing physicians for under-treating pain. This policy was drafted by individuals with ties to opioids manufacturers. Some were members of industry speakers’ bureaus, and later became company executives.

Purdue funded more than 20,000 educational programs between 1996 and 2002 to influence physician prescription habits nationwide, and developed a misleading advertising campaign that claimed that the risk of addiction from prescription opioids was “much less than 1%.” OxyContin sales grew from $48 million in 1996, to over $1.5 billion in 2002. With increased sales came increased abuse and addiction. By 2004, OxyContin was the leading drug of abuse in the United States.

In 2007, Purdue (and three executives) pleaded guilty to misrepresenting the risks of OxyContin addiction and paid $634 million in penalties, a fraction of the $35 billion in sales in two decades."

----

It's pretty sick stuff, but extremely clear evidence that these comes have come to see profit as the sole point of their existence. And these companies have extensive reach. And opioids are obviously not the only example here. This is a typical pattern, even if a rather extreme case. For instance the nonprofit industry tool used to push medicating and diagnosing of ADD is CHADD - Children and Adults with ADD.

[1] - https://www.houstonchronicle.com/opinion/outlook/article/Opi...


Hard to say.

I think the branch itself is too immature to have as much clout as it does, but we'd make a lot of progress if they'd start listening to their patients more than they listen to their drug reps.


>better alternative

I don't know what they're teaching at psych school but it should include a single class on "researching all the shit your ADHD and depression patients, who will be your most common patients, have to look up on their own."

So, knowledge of all the treatments to depression, from ssris (and what they do to you) through diet and exercise, meditation, mindfulness, etc. Basically Try Harder.

Maybe I was just unlucky?


Would you rather: "This just isn't working." "Okay, well we tried."

Once you're in the "this isn't working" phase of your story, shit is pretty dire. Hard to blame the caregiver for trying something else.


Honestly, yes. The solution to something not working is seldom to increase its complexity and/or double or triple down on it.

Bad treatments often exacerbate or inflict the symptoms they're supposed to correct.


It's a difficult one because sometimes it _does_ help people. 50mg of sertraline does nothing (other than making me sleep less, thus aggravating the base symptoms), 200mg made me feel sick for a week, but after that I'm noticeably better (OCD).


The thing is, when there are so many people who insist it isn't working, or even makes things worse, (while nobody has much of idea why the drugs should work in the first place, and there seems to be a growing movement to try treating people with currently illicit drugs instead), maybe the drugs are actually not working and the "experts" actually have no idea what they are doing.


Pretty great article. This characteristic that many patients have multiple disorders is an interesting point. Reminded me of my real world PCA applications which were never satisfying. In such a case you'd take the attributes of answers to questions in a population, and then get principle components (PCs) to these vectors of examples. Who says that each example in a population has to be dominated by 1 principle component? Many people have the view that PCs are just whatever linear combinations of attributes that explain your data, and I've seen many people try to name them in ways that encapsulate the attributes that each PC selects for, but it always seems like an awkward exercise after you get past the first few PCs.

And of course, I'm not literally saying this SCID is the attributes to the DSM "PCA," or any other subspace method. I don't work with subspace methods often, so if anyone wants to fill me in on what is done in the medical world (or other high stakes domains) in practice, much appreciated.

In cases of segmenting customers and then targeting each one differently, I have found that subspace methods work well for raising typical startup metrics. But the interpretability was not cut and dry in my experience, something that obviously is needed when you work with individuals like Doctors, not populations like many companies.

My guess is that the DSM segments patients to different treatments though. If this is the case then it does't really matter what the name of the constellation is as long as after they send the patient there, everything is hunky dory.


Person comes to conclusion that objective tool doesn't work because it doesn't give him the results he wants. I'm glad he didn't get to just subjectively call people bipolar or not based on what he wants, it would just bias his research and make it all scientifically useless. Whether you like skid or not, at least "According to skid patient is in box X" has a definite meaning, and can be scientifically trusted to mean something. Opposite to that "This one specific doctor based on this one single interaction decided that the person fits in box Y" is just completely useless.


Why is the author is so troubled? They’re just using an instrument to transform qualitative data into quantitative data. Such methods are used pretty much anywhere there’s subjectivity in observation. To do science, you have to have a standard way of measuring.


Are names quantities?


Yes, categories are as long as they’re well-defined. Measurement instruments get better over time.


The conclusion of the article raises a great question. Wouldn't it be more valuable to diagnose based on quantitative criteria instead of binary answers to extremely complex questions? I'd love to hear an opinion from a SCID practitioner.


Something like the SCID is useful as a structured way of measuring or assessing behavior. A binary output is probably not helpful though.

What's interesting is that the people who developed the SCID (and the DSM and its predecessor, the RDC) actually developed a very similar tool in the 60s, but instead of it producing binary diagnoses, it produced scale scores more like test scores. It actually had better statistical properties and provided fairly detailed information. It's always been a mystery why they moved away from that, except that the DSM as a whole moved away from that.


That's interesting. It reminds of the BMI, a metric intended only for use at the population level. It's been adopted (some would say misappropriated) as a yardstick for individual health, because... reasons?


I have been diagnosed with bipolar disorder, schizophrenia, depression, anxiety, and autism. All caused by chronic mercury toxicity. The name of the disorder should be "mercury toxicity" in my case.


Sure, we can label and categorize human behavior, but first you need to define what is normal.


Jordan Peterson, is that you? Pretty sure we can ballpark it. I had a cup of coffee this morning - normal, a woman in the news kept her dead sister in a freezer for almost 20 years - not normal.


>I had a cup of coffee this morning - normal

You casually drank a psychoactive drug. Is "normal" just another word for common?

If your culture demanded that you keep your dead refrigerated, and everyone around you did exactly that, would that behavior be promoted to normality?


Now you're just playing semantics.


how about "i had a cup of coffee and felt like the world was ending but i got over it with some anti-depressants"? have i been normalized?


"It's seven am on a frosty Wednesday morning" Oh my God, not another one of these articles that starts with a goddamn novel before it gets to the point.


[flagged]


tl;dr: He needs subjects with a particular mental illness, so he needs to recheck the diagnosis. Turns out this person is actually ill from using drugs since he was 10, so he can't use him in his study, and he wonders how meaningful the diagnoses are.


Thank you very much.


Should anything have a name?

It seems that people are just running out of shit to write about at this point.

And from Scientific American! I trusted you as a kid!


I not sure if you are just trolling here, but reading the article it seems clear that the author has a point beyond the usual signifier-signified semiotic crisis.

The author ends by musing about mental diseases being described by coordinates in several dimensions. Sure, perhaps connected regions of that space can be given their own names, but in general, the author believes that our vocabulary lacks the granularity to identify the fingerprint of individual diseases.

I know a lot of hands have already been wrung over the ineffectiveness of natural language in describing the phenomena of the inner world, but in a clinical setting this takes on a new meaning, and the essay is, in my opinion, poignant.


Sure they should, they have a life of their own. Mine are called Alice and Edward... Sorry, we could not resist.




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