The arbitrary and often absurd rhetorical attacks on psychiatry

 

I drew the above graphic (click on it to enlarge) to highlight a few things about popular psychiatric criticism, but mainly that it is absurd.  I have commented on antipsychiatry rhetoric many times in the past and how it has a predictable pattern.  But this goes beyond antipsychiatry to include critics in the press, authors selling books (or being paid for lectures or appearances), and even critics in the field. I thought it might be useful to try to crowd as much of this rhetoric into one diagram as possible for easy reference.

Why is rhetoric so important?  Rhetoric is all about winning an argument.  The strategies are all well documented and you can read about them and the common fallacious arguments in any standard rhetoric or logic text.  My goal is not to teach rhetoric.  For the purpose of this post, I want the reader to understand that there is more rhetoric leveled at psychiatry than any other medical specialty. There is always a lot of speculation about why that might be – but nobody ever seems to come out and say the most obvious reasons – gaining political advantage or financial renumeration. There is also dead silence on the questions of facts and expertise - since practically all of the literature out there including much of the rhetoric advanced by psychiatrists is an overreach in terms of psychiatric knowledge and expertise.  When absurd rhetoric about psychiatry makes the New York Times or even prominent medical journals it is simply accepted as a fact. There is no marketplace of ideas approach or even a single alternating viewpoint. Some of the statements in the graphic are taken directly out of newspaper articles and they are absurd. 

I happen to believe that the best critiques of the field come from people who are experts and usually do not deteriorate into ad hominem attacks against the field or other experts in the field. I was trained by many of those experts who consistently demonstrated that a lot of thought and work goes into becoming a psychiatrist and practicing psychiatry. I have known that for 35 years and continue to impressed by psychiatrists from around the world who contact me every day.     

I sought feedback from psychiatrists through several venues about absurd psychiatric criticism, by showing them a partially completed table and asking for suggestions.  One suggestion was making a grid to evaluate plausible, implausible, and unproveable. I do not think that is the best way to analyze these remarks. There seems to be a lot of confusion about rhetoric versus philosophy and a tendency to engage in lengthy philosophical analysis and discourse. It turns out that a lot of what passes for philosophical critique of psychiatry is really rhetoric.  That rhetoric generally hinges on controlling the premise and arguing from there. For example – the statement that the DSM is a “blueprint for living” is taken directly out of a New York Times article where the author – a philosophy professor was critiquing the 2015 release of the DSM-5 on that basis. Never mind that no psychiatrist ever made that claim or even had that fantasy – there it was in the paper written like the truth. A reading of the first 25 pages of the manual would dispel that notion but it is clear nobody ever seems to do that. 

I seriously considered modifying the diagram based on a division proposed by Ron Pies, MD (1).  That would have involved dividing the area of the graph into a zone of “legitimate criticisms focused on problematic areas in psychiatry” versus “fallacious and baseless attacks ... aimed at delegitimizing and ultimately destroying psychiatry.”  As I attempted to draw that graph – I realized that I could not include any of the current statements in a legitimate criticism zone.  In order to do that I will need to find an equivalent amount of legitimate criticism and include it in a new graph.

This rhetoric has much in common with misinformation, except it has been around for decades. It is not an invention of the Internet or social media. An important aspect of rhetoric is that since it does not depend on facts it can be continuously repeated. That is the difference between the truth and facts versus rhetoric. The classic modern-day example is the Big Lie of the last Presidential campaign. Former President Trump stated innumerable times that the election was stolen by election fraud and at one point suggested that there was enough proof that it allowed the Constitution to be suspended. All that rhetoric despite no independent corroboration by any judiciary or election officials from his own party.  Major news services began reporting his claim as a lie.  Recent news reports revealed that the stars of the news outlet that Trump was most closely affiliated with - did not believe the election was stolen. Many of the statements leveled at psychiatry in the table are equivalent to the Big Lie.

Rhetoric typically dies very hard and that is why it is an integral part of political strategy. A current popular strategy is to use the term woke as a more pejorative description of politically correct. It creates an emotional response in people “You may be politically correct but I am not.”  The term is used frequently to describe many things including the teaching of Critical Race Theory (CRT) in public schools. Repetition alone has many Americans believe that CRT is being taught in public schools and that is something that they should actively resist. The fact is – CRT is not taught in public schools and yet the effect of the rhetoric has been enough to leave many people outraged and susceptible to political manipulation. The rhetoric itself is difficult to correct by a long explanation about CRT.  That approach will not win any arguments. The best approach is to characterize it for what it is at the outset – absurd rhetoric that is not reality based. But there is a good chance that will also not have much impact.

When I talk with psychiatrists about the problem of not responding to rhetoric – I typically encounter either blank stares, the rejoinder that “there might be a grain of truth there”, or  the suggestion that we should just ignore it and it will go away. Physicians in general seem to be clueless about the effect of politics and rhetoric on medicine and psychiatrists are no exception.  When you are trained in science and medicine, there seems to be an assumption that the scientific method and rational discourse will carry the day.  That may be why we were all shocked when the American people seemed to be responding in an ideological way to public health advice during the pandemic and they were so easily affected by misinformation. 

Rhetoric in science predates the pandemic by at least a century.  It has been suggested that Charles Darwin used natural selection as a metaphor for domestic animal breeding (1) in order to convince the predominately religious people and scientists of the day.  He had to argue the position that unpleasant natural states were intermediate steps leading to a more advanced organic state.  Without that convincing argument Darwin’s theory may not have received such widespread acceptance in the scientific community. It is useful to keep in mind that just presenting the facts is not necessarily enough to win an argument especially in the post truth environment that exists in the US today.

The “grain of truth” rhetoric is typically used to classify, generalize, and stereotype and may be more difficult to decipher than straightforward ad hominem attacks. A typical “grain of truth” argument in the graphic concerns pharmaceutical money being paid to psychiatrists and other physicians. Some psychiatrists are employed by pharmaceutical companies to conduct clinical trials and other business, some provide educational lectures, and more are passive recipients of free continuing medical education courses.  All of this activity is reported to a database where anyone can search how much reimbursement is occurring. From this activity it is typical to hear that psychiatrists are on the pay roll of, get kickbacks from, or are brainwashed by Big Pharma and KOLs (Key Opinion Leaders).  The reality is most psychiatrists have no financial conflict of interest and they are not free to prescribe new expensive medications because those prescriptions are controlled by for-profit PBMs (pharmacy benefit managers). Further – the entire issue was highlighted by a No Free Lunch movement that provided essentially rhetorical information about conflict of interest and how it affected prescription patterns.  Those arguments have a very weak empirical basis. 

What about just ignoring this rhetoric? Ignoring it has clearly not been a successful strategy.  Any quantitative look at antipsychiatry rhetoric and literature would clearly show that it has increased significantly over the past 20 years – to the point that papers written from this standpoint are now included in psychiatric journals and you can make money doing it.  Recent cultural phenomena including the Big Lie rhetoric of the last Presidential election, the partial recognition of climate change (despite firsthand experience with increasingly severe weather most do not believe it is due to human activity), and the multilayered problematic response to the coronavirus pandemic sends a clear signal that rhetoric must be responded to and not ignored. 

The American public has been fed a steady diet of absurd criticisms about psychiatry for decades. If you do not believe that – study the table and compare it to what you see in the papers and across the Internet.  And never take anything you read about psychiatry at face value.

 

George Dawson, MD, DFAPA

Supplementary 1:  As noted in the above post I am interested in graphing legitimate psychiatric criticism in the same format used in the above graphic. If you have critiques and references - feel free to post them here.  I have some favorites from Kendler, Ghaemi, and others. 

 

References:

1:  Pies R.  Four dogmas of antipsychiatry.  Psychiatric Times May 5, 2022:  https://www.psychiatrictimes.com/view/four-dogmas-of-antipsychiatry

2:  Herrick JA. The History and Theory of Rhetoric. 7^th ed. New York, NY: Taylor and Francis, 2021: 221-223.  – I highly recommend this book on the historical and current importance of rhetoric. A lot of what passes for philosophical criticism of psychiatry is really rhetoric.

The Real Role of Biological Tests in Psychiatry

The idea of a "biological test" in psychiatry has appeared on the internet recently, primarily as a way to deny that psychiatric disorders exist.  The contention is that because there is no medical test for a psychiatric disorder - it must not exist.   Time to add a balanced view.

As a backdrop, most people do not understand the concept of "tests" in medicine until they have a problem and realize that the problem is not reflected in the tests ordered by their doctor.  That is a very common experience.  Some studies show that up to 30% of patients presenting to a clinic for investigation of a symptom never find out what the cause of that symptom was.  That is true even after they were given the usual panel of blood tests, imaging studies, and electrophysiological studies.  The assumption that symptoms and disorders in medicine are all diagnosable by a "test" is incorrect.

The second problem occurs at the level of test interpretation.  When a doctor orders a test they have to interpret it correctly and in many cases the idea of an "abnormal" test is blurred by biological variation.  The evaluation of back pain using imaging studies like MRI scans is a good case in point.  As people age there is a greater likelihood that an abnormal MRI scan of the spine is not necessarily the cause of their back pain.  That has very important implications for treatment and the physician interpreting the test may will definitely be influenced by their specialty training, their own personal experience, their knowledge and examination of the patient, and possibly treatment guidelines that they may be mandated to follow.  There is also the question of false positive and false negative testing.  The recent controversy about the utility of prostate specific antigen (PSA) testing for prostate cancer is another good example.  The current guideline says that this test has too many false positive results to use for treatment planning and further invasive procedures.  Even in the case where the diagnosis is made by a specific number there is always the question of whether the test number is accurate or not.  I have frequently repeated thyroid function tests that seemed to show hyperthyroidism only to see them in the normal range on repeat testing.  It is obvious to physicians that the so-called biological tests in medicine have their limitations and  always need to be interpreted in the context of a comprehensive evaluation of the patient.

How are biological tests currently used in psychiatry?  It turns out that there are a lot of applications similar to the rest of medicine.

1.  To detect a medical cause of a psychiatric disorder.  The DSM classification has an entire set of disorders that are caused by underlying neurological illnesses, endocrine disorders, and infectious diseases that need to be recognized and treated.  They often present as psychiatric disorders.  In my experience of treating people with severe problems, up to 15% of the psychiatric presentations had an underlying medical illness that either was a direct cause of the "psychiatric" symptoms or it made a psychiatric disorder worse.  In that case the psychiatrist has to be trained to order the appropriate tests, make the diagnosis and refer the patient for treatment of the underlying disorder.

2.  To screen for medical illnesses that complicate the psychiatric disorder or its treatment.  A good example here is screening blood tests and electrocardiograms based on the clinical assessment of the patient and the likelihood that a disease is present.  At times patients present with significant problems that require urgent treatment that they are unaware of.  A good example would be detecting complete heart block on an ECG because of a patient's responses to the cardiovascular review of systems and the fact that an antidepressant was going to be prescribed.

3.  To monitor the safety of biological treatments.  There is probably no better example than the FDA focus on cardiac conduction and how that can be affected by medications.  The most recent warning occurred with citalopram.  This antidepressant has been used for over a decade by psychiatrists and was widely considered to be a very safe medication. Both the FDA and the Mayo Clinic have guidelines about how this problem needs to be assessed and that is a combination of clinical assessment and electrocardiograms.  In some cases electrocardiograms and referrals to electrophysiologists are required.  In light of this information psychiatrists need to have access to these ECGs and a plan to address any abnormalities.  As specialists, it is common to see patients who are referred taking doses of citalopram that exceed current FDA guidelines and that may involve testing and a plan to modify the dose of antidepressant.

4.  To identify medical emergencies in patients who are being followed for a psychiatric disorder.  Many patients who see psychiatrists either do not have primary care physicians or are very reluctant to see them.  A psychiatrist in this position needs to make every effort possible to encourage the patient to establish primary care, but even then medical emergencies need to be recognized and appropriately triaged.  That can happen more quickly if testing is available to facilitate the referral.  If a patient presents with jaundice, medical consultants are more likely to see him quickly if some basic testing is done that can be discussed with the consultant.

5.  To identify neurobiological correlates of psychiatric disorders.  A common example is an abnormal brain imaging or electrophysiological study that was ordered because of an acute or progressive behavioral change.

6.  For heuristic purposes.  The classic example of a test done for heuristic purposes was the dexamethasone suppression test.  At various times it was suggested as a test for various forms of severe depression and suicide risk.  The test is rarely done today because of the false positive errors but it helped generate a couple of decades of research on the neuroendocrinology associated with psychiatric disorders.

Some of the articles currently out there on the internet deny the existence of psychiatric disorders because there is no biological test for these disorders like depression or schizophrenia.  That really does not differentiate psychiatric disorders from neurological or rheumatic disorders that may have some supporting markers but that in general depend more on pattern recognition and less on a gold standard or pathognomonic test.   From a paper that addresses that subject (1):

"Although the results are often useful, they can be misleading. Few tests yield results that are pathognomonic for particular diseases. For these reasons, test results for autoantibodies alone are insufficient to establish the diagnosis of a systemic rheumatic disease; they must always be interpreted in the clinical context. Positive results for tests such as the ANA test are seen quite commonly in patients with nonrheumatic diseases and even among normal, healthy persons..."

The key sentence here is:  "Few tests yield results that are pathognomonic for particular diseases."  That would mean that in fact there are few so-called gold standard medical tests that confirm or deny the existence of a diagnosis.  Up to 30% of people presenting to a medical clinic for an evaluation of symptoms will never have a diagnosis to explain their symptoms no matter how many tests they have.  People with real illnesses often are frustrated by the fact that the test results they get are often equivocal.  Obvious conditions that have no biomarkers range from migraine headaches to Alzheimer's Disease.  I don't think that any rational person would suggest that neither of these conditions exist.  People who have first hand experience with severe mental disorders know that the profound emotional and cognitive changes that they see in their friend of family member is real - whether there is a biomarker or not.

George Dawson, MD, DFAPA

Reference:

1:  Arthur Kavanaugh, Russell Tomar, John Reveille, Daniel H. Solomon, Henry A. Homburger; Guidelines for Clinical Use of the Antinuclear Antibody Test and Tests for Specific Autoantibodies to Nuclear Antigens. Arch Pathol Lab Med 1 January 2000; 124 (1): 71–81. doi: https://doi.org/10.5858/2000-124-0071-GFCUOT