I thought I would do a quick post on this because I am interested
in rhetoric and this is mind-numbingly simple rhetoric. It goes like this:
Being depressed means that you have major depression and
you are depressed because you have major depression…..
Having motor restlessness means that you have
attention-deficit hyperactivity disorder (ADHD) and having ADHD means that you
have motor restlessness
This has been presented as though it is an indictment of
psychiatric descriptive diagnosis – but you don’t have to think about it too
long to figure out why this is a fallacy.
By analogy
Having a cough means that you have COVID and having COVID
means that you have a cough.
The circular logic fallacy obviously does not consider the
biological complexity of medical and psychiatric diagnoses. We can rewrite them more accurately using
that knowledge. For example:
Being depressed means that you may have one of hundreds of medical, neurological or psychiatric conditions causing depression or that you
may have completely normal mood reactivity or you may have one of thousands of
pluralistic causes and having any one of hundreds of medical, neurological and
psychiatric conditions or normal mood reactivity or one of thousands of
pluralistic causes means that you have depression.
In other words – there is no 1:1 mapping of clinical depression onto the symptom of depression.
The diagnostic process returns a hypothesis about a condition that may be responsible for depressive
symptoms. I hope that illustrates how
fallacious this argument is. The problem with rhetorical arguments like this is
that they are generally advanced by people who have not gone to psychiatry
school or who may have done it but poorly. It is reinforced by business
practices and what I would call the necessity of low-quality research.
Starting with the research issue first. Practically all studies of depression in the literature
do not consist of psychiatric diagnoses of depression. Large GWAS studies
typically use a ratings scale like the PHQ-9 as the depressive phenotype of interest. There is no assurance that the patient would
be diagnosed with depression by a psychiatrist or have had any of the other thousands
of causes of depression considered. In
some of those studies there is a more general diagnostic screen administered to
research subjects by non-psychiatrists and if screening criteria are met – the inclusion
criteria for the study are met. None of this is assurance that the subjects’
studied would be diagnosed with depression (and not something else) by a
psychiatrist. The low-quality diagnosis
in this case is necessitated by massive databases. For example, the UK Biobank has data on a
half million individuals and that would require at least a million hours of
interviews by research psychiatrists to make a clinical diagnosis of
depression. That would probably require
several hundred full-time psychiatrists working their entire 35 year career to
complete.
The business practice of treating depression has similar
problems. It is almost a universal
experience today to take anxiety and depression rating scales in primary care
clinics. The primary care experience may
be even more crude than the research experience because the PHQ-2 may be administered
instead of the PHQ-9. The PHQ-2 consists
of the following 2 ratings over the past 2 weeks:
1: Little interest or pleasure in doing things
2: Feeling down, depressed, or hopeless
These screening methods were initiated to show that managed care plans were interested in treating depression. Since there will never be enough psychiatrists to assess and treat depression, these proxy screenings were felt to be an adequate replacement for psychiatry and they generally result in a diagnosis and treatment of depression even though (once again) there is no guarantee that a psychiatrist would have made that diagnosis. Just from a purely rhetorical standpoint – it is a syllogistic fallacy to conclude that 1 and 2 above are adequate premises to establish a diagnosis of depression. The debate at that point may be: “Well the clinician seeing the score will engage in a more elaborate diagnostic interview to make the diagnosis.” If that is the case – what prevented them from doing that in the first place? There is an expected paucity of data related to this practice – but I suspect there are many cases of antidepressant overprescription and “treatment resistant depression” based on the wrong diagnosis. I recently offered to analyze the data from a large health plan for free and they were not interested in looking at it.
The most recent commentary on circular reasoning apparently
came from a paper (1) claiming that causal language about psychiatric disorders
is the result of a logical error and leads to a confused public and intellectual dishonesty. The authors make several errors along the way
as they develop this argument including:
Ideally, a medical diagnosis both provides a precise term
for a given condition and identifies its etiological mechanism
This is a rhetorical construct that ignores what has been known for decades and that is according to Merskey (2): “Medical classification lacks the rigor of either the telephone directory or the periodic table. It is exceptionally untidy but it is taken to reflect in some way “the absolute truth” or at least the wonderful truth as it is known to its best practitioners.” Merskey elaborates on how the medical classification system has several conceptual parameters – most independent of etiological mechanism. In fact, if etiological mechanisms were known – all categories would be mutually exclusive and that is another property that does not exist in medical classifications. The medical terms "diagnosis" and "disease" are anything but precise and that leaves them open to attack by anyone providing a restricted definition.
“By contrast, diagnostic categories in psychiatry are
currently defined only by symptoms.”
The DSM classification has a significant number of disorders where the precipitating and etiological factors are known. The hundreds of causes of organic mental disorders are a case in point as well as an entire section of neurocognitive disorders where the pathology is at least as precise as examples that the authors give. There is a universe of medical and neurological disorders that are polygenic quantitative disorders with no specific etiology like psychiatric disorders. Psychiatric disorders are also comprised of clear reproducible signs including sleep and appetite disorders and motor disorders that produce measurable results.
“While it would be entirely correct to say that the human
experiences that the diagnostic criteria describe can feel like an illness, it
is different from claiming that an identified external biomedical pathological
entity is really causing the symptoms.”
The authors trivialize depression as a mere feeling. I have
never seen a person who came in for an assessment based on a mere feeling. They
are typically experiencing a disruption in many aspects of their life and have difficulty
functioning on a day-to-day basis. Most
patients seeing psychiatrists also have considerable medical comorbidity.
“By contrast, psychiatric diagnoses are not conceptually
independent of their respective symptom lists.”
The authors contrast psychiatric
disorders and their symptoms with a lung tumor and a cough and suggest that
because psychiatric diagnoses “cannot exist” without symptoms and this is proof
that a purely descriptive syndrome cannot be a “cause” of the symptoms. They also make the error in suggesting that a
person must “meet criteria” for depression to be diagnosed with
depression. The problem is that
depression, mania, and psychosis existed for centuries before there was a
DSM. These conditions existed long
before there were psychiatrists. They
are obvious to non-psychiatrists (the authors apparently excepted). The only reason psychiatry exists today is to
treat syndromes that have been systematically observed and recorded by both
psychiatrists and non-psychiatrists. The
medical side of things is described well by DeGowin and DeGowin in their physical
diagnosis text (3).
"For several thousand years physicians have recorded
observations and studies about their patients.
In the accumulating facts they have recognized patterns of disordered
bodily functions and structures as well as forms of mental aberration. When such categories were sufficiently
distinctive, they were termed diseases and given specific names.”
To this day – medical practice is largely based on
recognizing sufficiently distinctive categories and not pathophysiology. There is always a lot of speculative
pathophysiology and I have witnessed that all changing over the course of my
career. The pathophysiology learned in
medical school – even if based on Nobel Prize work – is not the pathophysiology
that applies today. These diagnoses were
independent of symptom lists for centuries and to this day they still are - in
that no experienced psychiatrist is treating depression based on symptom lists
or “meeting criteria”.
“Some authors therefore emphasize that depression can be
described as an adaptive response or a functional signal to adverse
circumstances. Contrary to the erroneous
causal beliefs that circular claims promote, this approach underlines that low
mood and/or loss of pleasure are often meaningful reactions to life events, and
that they can be meaningfully understood.”
This is a potentially erroneous causal belief and the
authors apparently have no problem with circularity in this case or the
potential lack of investigation of associated causes. They also seem to misunderstand the idea that
to have a disorder – there has to be some form of altered functioning beyond
what would be expected. Most people have
that knowledge. This is also a naive
statement from the perspective of assessment and treatment of suicide risk. Can
suicidal thinking associated with loss be explained away as a “meaningful reaction
to life events” or does something more definitive need to be done? Before anyone dismisses the idea as rhetorical - some of these same authors have suggested that psychosis is an adaptive response. Finally – they include a quote from authors
on the adaptive response theory as if psychiatrists have not been involved in
theories, clinical observations, and developing therapies of these phenomena
for decades (4-11).
Rather than continuing a point-by-point analysis – a look at
the rhetoric is probably a better summary.
From the diagram, the authors argue using a typical biomedical
psychiatry conflation combined with controlling the premise. The top of the
diagram illustrates that when all of psychiatry (in this case depression) is
condensed or conflated into a monolithic nondescript biomedical model - it is easy to demonstrate not only circularity
but also how clueless psychiatrists are.
This should come as a surprise to no psychiatrist since this is really a
longstanding rhetorical approach to the deconstructive criticism of the field.
A more realistic assessment can be seen in the lower
graphic. I labelled it clinical depression since in this case the authors’ use
of biomedical psychiatry is largely pejorative. Every psychiatrist I worked with in acute care
would not consider it to be a problem – since we were confronted with hundreds
of conditions that had depressive symptoms that we had to figure out. We were good at it and looked forward to it. The emphasis is on multiple etiologies. Numerous psychiatric disorders have
depressive symptoms as well as medical and neurological disorders that
psychiatrists need to be able to diagnose. There are known biological causes as noted in
the DSM, but many psychiatric disorders are complex polygenic disorders with no
specific etiology. With rule out
diagnoses – that means that depression can cause depressive symptoms that can
be addressed at the pluralistic level.
The authors suggest that “guild issues” may be a reason that biomedical
psychiatry is defended as causal of depressive symptoms. Psychiatry in fact has
produced a solid literature (4-11) of various etiologies of depression and how
to treat them that easily encompass the authors’ suggestion that meaningful
events may have a role to play. That theme has been present in psychiatry for decades
prior to this paper.
Anyone reading a paper like this one needs to have an awareness
of biology and human biology as a subset. As I tried to point out in previous posts –
for many reasons biological classifications will be imperfect. That is true for biology without human
constraints like speciation in all living organisms. It is also true for disease classifications
and I hope to have more on this soon. Any argument that there exists a standard
for categories, diagnoses, or disorders in medicine or psychiatry that is
perfect or even unidimensional should be considered rhetorical.
George Dawson, MD, DFAPA
1: Kajanoja J,
Valtonen J. A Descriptive Diagnosis or a Causal Explanation? Accuracy of
Depictions of Depression on Authoritative Health Organization Websites.
Psychopathology. 2024 Jun 12:1-10. doi: 10.1159/000538458. Epub ahead of print.
PMID: 38865990.
2: Merskey H. The
taxonomy of pain. Med Clin North Am. 2007 Jan;91(1):13-20, vii. doi:
10.1016/j.mcna.2006.10.009. PMID: 17164101.
3: DeGowin, EL, DeGowin, RL. Bedside
Diagnostic Examination. United Kingdom: Macmillan, 1976.
4: Sifenos PE. Short-term Dynamic Psychotherapy. New York.
Plenum Medical Book Company, 1979.
5: Klerman GL,
Weissman MM, Rounsaville BJ, Chevron ES.
Interpersonal Psychotherapy of Depression, New York: Basic Books, 1984.
6: Yalom ID. Existential Psychotherapy. New York: Basic Books, 1980.
7: Beck AT, Rush JA,
Shaw BF, Emery G. Cognitive Therapy of
Depression. New York: Guilford Press,
1979.
8: Bennett D. Social and community approaches. In: Paykel ES (ed).
Handbook of Affective Disorders.
New York: Guilford Press,
1982: pp. 346-357.
9: Arieti S. Individual psychotherapy. In: Paykel ES (ed). Handbook of Affective Disorders. New York:
Guilford Press, 1982: pp. 298-305.
10: Stein A. Group therapy. Paykel ES (ed). Handbook of Affective Disorders. New York:
Guilford Press, 1982: pp. 307-317.
11: Viederman M. The
psychodynamic life narrative: a psychotherapeutic intervention useful in crisis
situations. Psychiatry. 1983 Aug;46(3):236-46.
Explanatory Note: When I use the terms psychiatric, neurological, and medical diagnoses - I am referring to medical as including all internal medicine specialties (Infectious Disease, Endocrinology, Nephrology, Cardiology, Rheumatology, Allergy and Immunology) as well as general Internal Medicine and Family Medicine. Neurology and Psychiatry generally have non-overlapping conditions but there is a considerable amount of comorbidity from the medical fields.
