Am I a rat?

I couldn’t resist that title, but the only rat I’ll write about here is me. Actually, Nasir Ghaemi didn’t call me a rat in his psychology today blog. He called me an “extremist psychologist.” I think I’d rather be a rat.’

Not that I mind the extremist part. But I am not a psychologist. I never claimed to be a psychologist. The psychologists own that word, and insist that only people licensed as psychologists can call themselves psychologists. Which is fine by me. I wouldn’t join a club that would have me as a member unless I needed to in order to make a living or get laid or something like that. This whole guild thing makes me a little nuts.

I’ll explain. Back in the 1990s, when I was getting my Ph.D. in psychology, the American Psychological Association, as if to prove that the American Psychiatric Association was not the only APA that could be power hungry, took over the licensure apparatus in as many states as possible. They created a model statute and regulatory scheme that required people who did not get their degree from an APA-approved program, which mine was not, to plead their case to the state, submitting course syllabi and other arcana for their review. I could have gone through that whole painful (and expensive; everyone I knew who succeeded did so only after lawyering up)  process, but I already had a license-=-as a Professional Counselor–and a full practice, so I figured, why bother. And I didn’t.

As to the extremist part. To my great surprise, neither Laura Miller nor Ben Nugent nor Dwight Garner seems to think so. One way or another they all make reference to my middle course. Miller goes out of her way to tell Scientologists that I am not on their side, and Nugent finds enough nuance in my argument to tease out the antipsychiatry from the propsychiatry strand. Actually, I don’t totally agree with this; my book is less dialectical than I would have wanted, but mostly because the APA (the psychiatrist one) didn’t do a very good job of creating narrative tension for me. Which is the biggest reason I was glad when Tom Insel called them out.

So I think Ghaemi is wrong to tag me as an antipsychiatrist; on the other hand, he;s a psychiatrist, so he is bound to diagnose what unsettles him. And I know he’s wrong to say that I believe “that no psychiatric condition can ever be a biological disease.” Of course I know that the brain can malfunction as surely as the liver can, without any prompting, for no particular reason other than that the body is a time bomb that will explode at some point or other, eventually lethally. Some of the mental disorder out there is undoubtedly as “medical” as the kidney disorder or the bacteriological disorder out there. But despite decades of effort, psychiatry has yet to tell us which mental disorder that is, and therefore which properly falls under its aegis. In the absence of limits the profession, largely through the DSM, has expanded to encompass all of it–an expansion that serves its interests in unsavory ways. When psychiatry can tell me what mental disorder is really a brain disease, and when it finally figures out the distinction between necessary and sufficient conditions, then maybe I will stop ratting it out.

6 Responses to “Am I a rat?”

  1. Bernard Carroll says:

    “When psychiatry can tell me what mental disorder is really a brain disease, and when it finally figures out the distinction between necessary and sufficient conditions, then maybe I will stop ratting it out.”

    Gary, this conversation is getting old. When you harp on laboratory tests before you accept the reality of psychiatric diseases then you signal that there are some things you don’t understand.

    You don’t understand that the existence of disease is not predicated on having a biological test. It’s nice when we do have one but there are many areas in medicine where there is no conclusive diagnostic test. Think migraine. Think multiple sclerosis. Think chronic pain.

    You don’t understand that clinical science correctly recognized many diseases long before lab tests came along for confirmatory diagnostic application. Think Parkinson’s disease, Huntington’s disease, epilepsy… it’s a long list.

    You don’t understand that in many areas diagnostic tests cause mischief. That’s what the whole debate around indiscriminate diagnostic screening is about. Laboratory measures are the servants of clinical science, not the other way around.

    You don’t understand that the great majority of laboratory tests are probabilistic rather than pathognomonic – which means that clinical judgment enters into their interpretation. A critical aspect of that process involves awareness of the prior probabilities of salient differential diagnoses for a given patient. It would be nice if you could sit down and chat with the Reverend Thomas Bayes.

    You don’t understand that clinical medicine is a pragmatic field that operates always under uncertainty. Diagnoses are probability statements and treatments are N = 1 experiments. I agree that the DSMs fail to convey these aspects of psychiatry. If you want diagnostic certainty with clear cut necessary and sufficient conditions, then don’t allow your surgeon to perform exploratory laparotomy next time you arrive in the ER with an acute abdomen. If you want diagnostic certainty with clear cut necessary and sufficient conditions, then by all means refuse your physician’s prescription of corticosteroids for your arthritis that is probably, but only probably, systemic lupus erythematosus or SLE.

    You don’t understand that clinical science operates through a process of convergent validation. That is how disease constructs take form, through iterative attention to signs, symptoms, course of illness, response to treatments, family history, and laboratory data. This is an area where DSM-III and DSM-IV failed us by limiting their focus to signs and symptoms. Most of the time these disease constructs are accurate. Occasionally they are flat out wrong – as with the psychosomatic narrative of peptic ulcer in the days before Barry Marshall demonstrated the role of H. pylori bacteria.

    You don’t understand that this process of convergent validity has already given us an A-list of psychiatric diagnoses that are candidate brain diseases. Here is the list: psychosis, mania, melancholia, vascular depression, crippling anxiety, panic disorder, dementia, autism, obsessive-compulsive disorder, delirium, catatonia, and more. If you want diagnostic certainty with clear cut necessary and sufficient conditions, then by all means tell the magistrate at your next commitment hearing that you were serious when you commandeered an airliner, prevented the scheduled passengers from boarding it, declared yourself the owner of the airline, announced that you were going to fly your entire extended family to London to meet with Margaret Thatcher, and that the psychiatrist who said you suffer from mania must be wrong because he hasn’t shown the court a laboratory diagnostic test for mania.

    Do you get it now? When you say psychiatric diagnosis is closer to fiction than to fact you expose a lot of things that you don’t understand.

  2. Dr G says:

    Very well stated, Bernard Carroll. It’s astonishing how this self serving pompous self promoter continues to argue against things he clearly has little understanding. Bravo, sir.

  3. don klein says:

    To the point as usual. Additional thought-those syndromes you mention have the interesting validator that they come and go in recognizable form. Odd behavior for social misperceptions.

  4. […] I was going to post this as a reply to a comment left by Barney Carroll, but then I realized–hey, it’s my blog. i can make a new post if I want. The original comment is here […]

  5. Glenn Silverstein says:

    Mr. Caroll,

    I think Mr. Greenberg understands the point you make and his response would probably be thus…while there certainly are medical conditions that we do not currently know the biological causes and tests that contain interpretations, but though the same scientific methods that have worked thus far those causes will be found and the tests will improve, but if and when that occurs it will not improve the psychology’s position. Medicine does not claim that it knows every cause and can trace every symptom to its biological source, but it can make those claims about an ever growing number of maladies. Where is a similarly impressive list for psychology? In other words, name three mental conditions that you KNOW the biological causes? Where are the scientific (not statistical) discoveries of causality that would warrant the moniker of a “science.” If you stake your claim to that moniker, you should be able to support it, and if not, create you own, but dont whine when people rightfully scream that the emperor has no clothes.

  6. NodisorderDisorder says:

    Mr. Carroll, you are misleading. Most actual medical diseases have tests to verify they are such. The case with Psychiatry is most don’t. I notice you interchange the terms ‘condition’ and ‘disease’. In fact Psychiatrists interchange the terms ‘disease’ ‘disorder’ ‘illness’ and ‘condition’ all the time. Covers all the bases. Chronic pain is not a disease. It’s a symptom. Same with migraines.
    Re your cute scenario of a plane hijacker, what else do you do but view the hijacker’s behavior from an entirely Psychiatric diagnostic viewpoint. You load the dice then defend your loaded dice. To the Psychiatrist the world and every human in it is a psychiatric construct.
    Would you believe Psychiatry is not an authority on the human mind? Nor is it regarding human behavior or feelings or emotions. It just proclaims itself as being so.

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