Combinatorics Revisited…

I critiqued a paper that purported to show that Diagnostic and Statistical Manual criteria produce an impossibly large number of possible combinations and that this somehow invalidates their use.  As a refresher, combinations are basically any pool of n elements combined k at a time.  For example, in the case of major depression, the diagnosis requires at least 5 (k ≥ 5) of 9 (n=9) elements.  That would lead to a calculation of C(n,k)  = C(9,5) + C(9,6) + C(9,7) + C(9,8) + C(9,9) or  126 + 84 +36 + 8 + 1 = 255     I have illustrated the total combinations for the first expression at the top of this post.  In each case the elements 1 – 9 are the DSM diagnostic criteria for depression.  Note that adhering to the diagnostic criteria eliminates the last column of combinations to the far right since elements 1, 2, or 1 and 2 are required for the diagnosis. 

Reading the actual diagnostic criteria illustrates that this is a crude measure because there are implicit unknowns – most significantly the total number of medical unknowns suggested by the criteria “The episode is not attributable to the physiological effects of a substance or to another medical disorder.” Historically reviews of those disorders suggest that they are in the 200 to 300 range with some being far more common than others. If all those conditions were included in the combinatoric expression it would be very large – but not necessarily that much more inclusive because of the low frequency of many conditions.  Additional exclusion criteria include psychiatric disorders with depressed mood as a feature and any previous episodes of mania.  Since they are exclusion criteria – it is reasonable to say that there may be only 255 combinations of rule in symptoms, but being able to make the calculation is no assurance that they exist in practice.  

Following the authors assumption about the combinatoric possibilities we can substitute short had for criteria 1-9.  In the following manner (as noted in their Table 1):

1. Depressed Mood

2. Loss of Interest or Pleasure

3. Appetite/Weight Disturbance

4. Sleep Disturbance

5. Psychomotor Change

6. Loss of Energy

7. Worthlessness/Excessive Guilt

8. Concentration/Indecision

9. Death/Suicidal Thoughts

A further restriction is included in criteria A: “…at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.”  That eliminates any combination that does not include 1, 2, or 1 and 2.  That changes the above expression to 105 + 77 + 35 + 9 + 1 = 227 possible combinations just based on the numbers.  The authors were interested in seeing how many of these possible combinations exist in the clinic and that was the goal of this paper.   

The sample for the paper was 1,566 subjects with a diagnosis of major depression out of a total sample of 3,800 evaluations.  All subjects were being seen on a clinical basis and the Structured Clinical Interview for DSM-IV (SCID) was administered by trained examiners and the interrater reliability was sampled and posted for all of the depressive symptoms.  The number of subjects in each group of combinations was determined and the results were interesting.

For starters – 57 of the 227 combinations or about 1/4 did not occur in a single patient. In the case of 5, 6, and 7 criteria the combinations that did not occur are listed in tables 3, 4, and 5.  The most common combination was all nine criteria and that occurred in 10% of the sample (N=157).  The authors were able to observe that 9 combinations from the 9,8,7, and 6 criteria categories accounted for 40% of all diagnoses. They suggest that these might be prototypical combinations in a field of diagnostic heterogeneity. Apart from diagnostic prototypes the authors suggest that it may facilitate the search for biological markers but they conceded that those would need to be very large and expensive studies. 

As I thought about that proposition, a few things came to mind.  First, Mayo Clinic multi-omics studies. Some of these studies have already identified biomarkers and possible genetic markers on heterogenous groups of subjects with major depression.  The subjects were all administered standardized DSM based interviews and the combinatorics could be determined.  This would be an efficient way to see if symptom combinatorics match the biomarkers.  Second, why would we expect there to be any correlation between symptoms and biomarkers?  Most medical illnesses would not have a  correlation and in fact the more complex illness can be expected to produce significant non-specific symptoms like fatigue and malaise.  Some authors have suggested that very specific subtypes of depression are more likely to produce reliable biomarkers.  Taylor and Fink (2) have written extensively about melancholia and biomarkers associated with that illness.  I also recall work done by Linkowski and Mendlewicz (3) that they published in the endocrine literature.  Their work was almost exclusively on subjects with very severe forms of depression (HAMD ratings > 30) and their neuroendocrine biomarkers were more robust.  Third, is there a time domain consideration with the combinatoric groups?  For example, do the people meeting 8 or 9 criteria have depression that has persisted for a longer period and does attempted treatment or not treatment affect that group?  Fourth are some of these symptoms complexes generated by others - are they secondary to sleep and appetite disruption?

Either way, the application of combinatorics to some of these situations is very interesting in the field.  As noted in my previous post, combinatorics reflects biological scaling at some point. That occurs at the molecular as well as the evolutionary level.  Large numbers of combinations should be expected when combining either molecular components of organisms, metabolic networks, or the organism wide effect.

Thinking about these combinations clinically is also an interesting exercise.  During my tenure as an acute care psychiatrist it was rare to see anyone without most of the symptoms in an inpatient setting.  Doing consults on medical and surgery wards there were often more novel symptom combinations.  Looking at the author’s tables and the combinations they did not see in their study is an interesting exercise.  One example would be the combination 1,2,3,4,5,7,9 from Table 3.  That would be a person with depressive symptoms except for loss of energy and concentration problems. According to this study that person does not exist.  And of course all of the combinations that lack depressed mood, anhedonia, or that combination have been eliminated by definition.

I hope to expand my look at combinatorics to the genetic, evolutionary, and molecular levels in subsequent posts as well as trying to see if there are mappings from one level to the other.  I am also interested in any books or papers that use similar analyses so please send those references my way,      

 

George Dawson, MD, DFAPA

 

References:

1:  Zimmerman M, Ellison W, Young D, Chelminski I, Dalrymple K. How many different ways do patients meet the diagnostic criteria for major depressive disorder? Compr Psychiatry. 2015 Jan;56:29-34. doi: 10.1016/j.comppsych.2014.09.007. Epub 2014 Sep 6. PMID: 25266848.

2:  Taylor MA, Fink M.  Melancholia: The Diagnosis, Pathophysiology, and Treatment of Depressive Illness. 544 pp. New York, Cambridge University Press, 2006.

3:  Linkowski P, Mendlewicz J, Kerkhofs M, Leclercq R, Golstein J, Brasseur M, Copinschi G, Cuater EV. 24-hour profiles of adrenocorticotropin, cortisol, and growth hormone in major depressive illness: effect of antidepressant treatment. The Journal of Clinical Endocrinology & Metabolism. 1987 Jul 1;65(1):141-52.

 

Apps:

Very good apps are available for calculating combinations, permutations, and the varieties.  For example – if you think back to your probability and statistics course in college at one point the professor was talking about combinations occurring where elements could be used more than once (with repetition). That is typically demonstrated by taking numbered balls out of a container and replacing them in one situation and in the other cases leaving them out. Those are different calculations.  For the above calculations the assumption is that each k element can only be used once (no repetition).  There are apps that give you both calculations.

 

Coming to Love My Darkest Places: Poems by Jennifer Kelley

 

 

This is a review about this book of poems.  The author Jennifer Kelley has a brief biography in the book and she is listed as a writer (fiction and non-fiction) and poet with several accomplishments.   The book is autobiographical and written in free verse.  The physical structure of the poems is altered at times in the familiar manner of poets who use free verse. The overall structure of the book is interesting with 3 chapters of 11 poems each followed by a final chapter of 16 poems in the final chapter for a total of 49 poems over 107 pages.

The organizing theme of the collection is what she has endured and overcome in her life – including depression, bipolar disorder, psychosis, post-traumatic stress, grief, love and loss, and childhood epilepsy.  Like most important life experiences it is not a question of overcoming but recalling them over time and the changing relationship to those memories.  That can lead to different assessments and different emotions - experienced with age. 

The opening chapter is a clever James Bond metaphor (The James Bond Series) with childhood epilepsy as a equivalent of Bond’s martini.  She conveys her unique situation in 5 stanzas culminating in her observation that the only place she felt unique as a child was waking up in a hospital after a seizure.  It was the only place that she felt carefully attended to.  From my training as a physician this was interesting because it also parallels what I was told on both pediatric and child psychiatry rotations.  Some children with a lot of hospital exposure may prefer the setting because of the level of care that they receive.  The idea is developed that the only way she felt exceptional was due to the seizures, but later that same feeling could be recreated by drinking alcohol.

The poems raise questions for the reader and may lead to associations from the past. As I read her descriptions and imagery about her grandmother and the loss of her grandmother – I had the immediate association to remembering my grandparents earlier that day and the similar catastrophic circumstances. But more than that the hope that they knew the way I felt about them when they were alive.  It was perfectly captured in this phrasing:

“You were always a place as well as a woman

Did you know that?

I hope I told you.

One million times over the green polyester tablecloth,

I hope you knew.”

(p. 67-68)

There is an interesting element of timelessness in this experience. Many of us have conscious experiences each day where we are emotionally anchored in time even though the events occurred decades ago.

One of the tasks of poets is to pay close attention to the events of life as we pass through them and come out the other side.  What was it like?  What was learned? Is it a shared or more unique experience?   Many of the poems are universal experiences – like being with your grandparents when you are a kid and realizing there are problems but you are not quite sure what they are. And later driving down the road late at night and thinking of how that distance out past your lights closes far too slow – then thinking about that as a metaphor.

I noted a technique using lead off quotes with references to them in the body of the poem that I had not seen before.  The references are both to the original author and in some cases include stanzas written by that author.  As an example, she opens the poem Light using two lines by Fatima Ashgar and closes with two lines by Emily Dickinson.  Between that opening and closing was a poem about grief and the stark contrast between all the memories of that very real person and the hollowness of grieving them.  Rereading that poem many times it is clear the lines by Ashgar and Dickinson were perfectly used in the body of the poem written by Kelley.       

In the final analysis, this is a collection of unique but common experiences. The author does a good job of characterizing both. There is an implicit spirituality contained in many passages – her experience in 12-step recovery is one example.

I recently saw a presentation on the meaning of art and how it differs from other human endeavors. The presenter contended that any form of art is the perceptual and conscious experience of the artist as they go through life. Should it just be a description or there are rhetorical elements?  Is the author trying to persuade you to accept a certain viewpoint about life – or will you naturally come to a viewpoint based on the artistic expression.  I thought this book of poems was an excellent example of the latter.  Kelley describes vivid interpersonal and emotional experiences that may or may not resonate.  If not, it will increase your appreciation of the human experience.  

Read this book if you like poetry and free verse.  Read this book if you like stream of consciousness writing and can relate to it at any level. But aside from the technical aspects read this poetry if you are a student of human consciousness and spirituality and how both of those dimensions come into play when dealing with adverse experiences whether they reach the threshold of a diagnosis or not. Certainly read this book if you are a psychiatrist or psychiatric trainee – this is a glimpse into real human experience at the highest level.

 

George Dawson, MD, DFAPA  

Reference:

Jennifer Kelley.  Coming to Love My Darkest Places.  Kelsay Books, American Forks, Utah.  2023.  Kelsaybooks.com

 

Mass Shooters - The American Gun Extremist Superman

I had dinner the other night with a long-time friend and psychiatric colleague.  She and I ran an acute care unit for many years where we were charged with assessing and treating some of the most difficult problems in psychiatry. By definition, that also means the associated social problems.  That work included a significant number of civil commitments and in Minnesota associated hearings about medications.  The conversation turned to politics and then the recent attempted assassination of Trump.  Before I could say anything, she commented about how absurd it was that there was endless speculation in the media about “motive” and the fact that there was no motive. I agreed with her completely on that point.  What motive can you have for picking up a high-capacity military weapon and deciding to shoot and kill someone and anyone else who happens to be around?  And of course – why does it predominately happen in the US? 

As I pondered our conversation over the past couple of days and what I have written here about it – I came up with the idea of the American Gun Extremist Superman. This is not a traditional superman role or even the antihero role.  It is a superman role that can occur only in a culture of gun extremism.  I have written in the past about how this is quite definitely a cultural problem and the people who have been the source of the culture – extremist politicians, judges, and other gun extremist advocates largely blame everything else.  Incredibly they blame the lack of an armed staff in schools, a shortage of firearms in the most heavily armed country in the world, and more recently law enforcement and parents. They never examine the fall out of gun extremist policies that have been accumulating over the past 40 years.

Here are the features of the gun extremist superman that I have so far.  They are not diagnostic criteria by any means.  This is a societal and cultural problem more than anything.  It obviously exists only in the US.  There are undoubtedly people with psychiatric disorders who acquire these traits – just like people with psychiatric disorders assimilate other social and cultural traits.  But a psychiatric disorder does not explain most of these shootings.  I am using the pronoun he in these cases for the obvious reason that practically all of the shooters are men and boys.   

He is disgruntled and dissatisfied:  This is a common nonexplanation for mass homicide. It is basically a marker for what causes an unexplainable behavior.  When you study human behavior, these changes can occur from internally driven psychological states, external states, and all points in between.  To what extent is their insight, judgment, and decision making affected? To what extent does their moral decision making have an impact on what is occurring?  It is complicated by what is known about a person’s baseline.  For example, are they quiet and non-disclosing about their internal states or are they more demonstrative?

He has no problem at all attributing his state to the actions of others even when that is completely displaced.  In other words, displaced onto completely innocent coworkers, bystanders, school children, etc.  In psychiatry we call this projection and historically it is listed as a defense mechanism.  It is typically seen in persons with psychotic disorders and moderate to severe personality disorders.  It is a common experience to feel like you are being unjustly blamed during interactions with people using this mechanism or in the extreme case where that person is reacting to you as though their accusations are true.  Even though it is difficult to research this mechanism in mass murders – it seems intuitive that it has to exist at some level given the discrepancy between their real victims and the purported abusers (if any).

He knows that there is a burst of fame associated with each shooting and endless speculation about his motivations.  Although there is little information about the Trump shooter – it is known that he had details about a previous mass shooter on his electronic devices and this has also occurred with previous mass shooters. Anybody experiencing the news cycle in the US following a mass shooting notices a flood of information and speculation about that shooter that can go on for weeks followed by other bursts from associated court cases, documents, computers, web sites documenting mass shootings, legislation, and scientific literature.  Mass shooters seem to be guaranteed immediate and sustained notoriety – despite some concerns expressed in the literature that this is reinforcing the behavior.  The psychology of mass shooters is difficult to investigate, but I would not be shocked to learn that revenge fantasies go hand-in-hand with the expectation of notoriety from the act. 

He feels some justification by identification with previous mass shooters and cultural revenge themes.  As noted above many aspiring mass shooters have immediate access to the mass shooter literature as well as a wealth of revenge-based video games and movies.  The preponderance of this information depicts the shooter as the good guy meting out justice and revenging either his own victimhood (real or imagined) or that of his loved ones.  A secondary theme is that the usual channels of justice – law enforcement and the courts are too weak, do not apply to him, are too slow, or too negligent to be useful.

He sees it as a singularly masculine activity – especially with the use of firearms.

Most of the cultural figures engaged in this activity are men.  Armed men are typically the graphic elements of disaffected groups of society but their rhetoric has creeped into the political mainstream.  You don’t have to look too hard to find opinion that in the battle over “gun rights” – the correct interpretation of the Second Amendment will go to the winners of an armed insurrection or that the more heavily armed political party will “win.”  In that atmosphere was it an accident that we witnessed an insurrection on January 6^th?  Nobody steps back to point out that gun rights are there in the Second Amendment and the real battle is between gun extremism and common-sense guns laws.  In the common discussion nobody has advocated to take guns away from law abiding and responsible citizens.  At this point the US is awash in guns to the point that collecting all of those guns or buying them back is impractical.

Societal reinforcement of the Gun Extremist Superman. 

At first that seems like an extreme idea.  How can American culture and society reinforce this behavior? I have touched on the very real aspects of gun extremism and the cultural aspects that are reinforcing but there are others. Whenever mass shootings occur – politicians show up make the typical statements about “sick individuals”, offer “hopes and prayers”, and in some extreme cases have encouraged the affected communities to “move on.”  Mental health becomes a distraction, when politicians use it as a cause for the incident but never do anything constructive to address it.   The condemnation of the shooter is trivial compared with what has occurred. And no effective measures are ever suggested or accomplished. If anything, many politicians come up with a series of rationalizations about why the shooter was not stopped – the teachers were not armed, law enforcement response was inadequate, the only way to stop a bad man with a gun is a good guy with a gun, etc. Specifically, no measures to counter gun extremist laws are ever suggested and we are supposed to pretend that getting as many guns out on the street is a remote problem from the problem of mass shootings.  The real message to mass shooters is that “we are not going to do anything to stop or interfere with you.”

There is an additional message that is the direct result of gun extremism and that is – shoot first and ask questions later. Stand your ground and castle doctrines or statutes are a relatively recent development in the gun extremism landscape.  Stand your ground statutes basically say that there is no duty to retreat before using deadly force. Before these laws self-defense laws included the provision that the person who is unlawfully attacked needs to exercise judgment to try to avoid the use of deadly force by retreating if necessary.  Stand your ground laws were passed initially in 2005 in Florida and since then these laws exist in 38 states. The details are available at this site, including references to the fact that it probably increases the crime and homicide rate.  Although these laws were passed primarily in the past 20 years, they are the culmination of gun extremist rhetoric that has emphasized the need for people to be armed and dispense justice with firearms.  My conceptualization of the mass shooter is that he likely believes he is dispensing justice, even though nobody would agree with that premise.

The additional cultural change that preceded stand your ground was the idea of the armed citizen.  In the 1960s, the people who owned guns were predominately hunters.  The focus of the National Rifle Association (NRA) was hunter safety. When I took that course one of the mainstays was never pointing a gun at a person and always assuming a gun was loaded.  As firearms become more important as political rhetoric there was a sudden shift to the idea that there needed to be more guns out there for personal protection.  Since then there has been a steady escalation in gun extremist rhetoric and the idea that there are defined preconditions for shooting someone.

Psychosis is not an exclusion from societal or cultural factors:  Although the majority of these shooters are not mentally ill there is a lot of confusion over whether mental illness excludes the person from societal and cultural factors - making the psychosis in itself an explanation for the behavior.  It does not.  Just as computer chips, microwaves, and surveillance satellites were incorporated into delusions as they became incorporated into society - gun extremism has the same effects.  There is no reason that they and the folklore of mass shooters cannot be incorporated into a delusional system of thinking and acted upon.  In other words - there is no de novo psychosis of mass shooting - it happens in a gun extremist society.

All of the above elements are more important to him than self-preservation.  Many mass shooter incidents occur with the death of the shooter by homicide or suicide.  The high mortality rate suggests that mass shooters are unconcerned about their own life in carrying out their actions. This information is readily available to potential mass shooters and I would argue is part of the Gun Extremist Superman stereotype.  

He has easy access to high-capacity firearms – both handguns and rifles. Easy access to legally purchased firearms is well documented in many of these cases.  In some cases the firearms are borrowed and in other cases they are purchased from licensed firearms dealers.  One of the common gun extremist slogans is “if guns are criminalized only the criminals will have them.”  It is obvious that firearms are legally available at this point to anyone who wants to commit a serious crime like a mass shooting. It is also obvious that there are loopholes that allow gun purchasers to bypass existing laws.

What I have described here is a Nietzschean superman who clearly rejects traditional moral values of society and adopts his own – even though they are morally reprehensible to almost everyone else.  There are currently numerous patterns in American culture and society that reinforce this pattern of activity.  We are on a course for that to continue unabated.  It may worsen as the pattern of gun extremism worsens.  There are two potential solutions as far as I can see.  Reverse gun extremism back to the gun rights laws of the 1960s or preferably the 19^th century.  If the 19th century seems  too radical - see the Tombstone ordinance at the bottom of this post.  A second more public health focused measure would be on mass homicide prevention – by identifying the problem and trying to intervene while researching it.  

At the time I am writing this - neither intervention seems likely.

 

George Dawson, MD, DFAPA  

Supplementary:  If you have any doubt about the lack of motive for most firearm related homicides - I suggest watching crime TV like The First 48.  These shows typically have investigations by experienced homicide detectives that include interrogations of  suspects, witnesses, and family members.  In some cases court proceedings are included. The majority of cases are attributed to senseless violence and that typically means somebody got angry, there was a firearm available, and it was used to commit homicide.  Mass homicides can be viewed as taking the senseless violence theme to the next level.  Senseless violence is a predictable outcome of widespread gun availability and gun extremism. 

The Map Is Not The Territory

 

I ran into a quote this week that I must have read and forgotten from the past – because it was referenced in Bateson’s Steps to an Ecology of the Mind.  That was a book I read back in the hippie era after seeing it referenced in the Whole Earth Catalogue.  It happens at a time when I was writing about the usual philosophical rhetoric used to criticize psychiatry.  The circular logic argument I have encountered frequently by philosophers seeking to either destroy the profession or portray psychiatrists as unthinking buffoons.  That quote was “A map is not the territory” and it is attributed to Alfred Korzybski.

When I saw it – I associated immediately to the map I know the best and that is Hwy US2 running across northern Wisconsin between Minnesota and Upper Michigan.  I have travelled that road hundreds of times.  In fact, in 1988 I drove it over 200 times that year to keep a small inpatient psychiatric unit open. Maps these days are much better than they used to be.  For the old road maps to have the same scale and sufficient detail meant a large size that had to be folded and refolded to get it back into the glove compartment.  The above map is a clip from Google Maps and it can be scaled down to the individual house level and from there a street view that is regularly updated.

Thinking about old maps and new maps it is easy to see Korzybski’s argument. Driving US 2 late at night it is common to encounter characteristics of the territory that are not listed or even included in your GPS updates. The territory at night is much different than the territory during the day.  A major difference is deer on the highway.  There are the occasional deer crossing signs but I have suddenly found myself driving among a herd of 30 or 40 deer running next to my car and alongside the road.  The Google camera cars fail to update the video information fast enough to account for social and cultural changes that happen in the small towns along the way.  Am I going to encounter a large influx of out-of-staters for the Blueberry Festival in Iron River or the Strawberry Festival in Bayfield?  Is that small general store still there or is it finally gone? Is the posted or suggested speed limit accurate or do I have to correct for the weather?  

In the era of climate change even modern maps have uncertainty.  Highway 2 has been washed out and under water – both events that have never happened at any other point in my lifetime.  Using modern GPS guidance – I ended up on what appeared to be a dirt wagon trail that eventually got me back to Minnesota.  Every inch of that terrain looked like it had been seen by very few people in the last 50 years and no Google camera cars.  Most people unconsciously adapt to the terrain on the drive home – that sunken manhole cover or pothole to avoid.  We automatically adjust to the hazards even though they are not indicated on any map.  

Korzybski’s argument is basically twofold. First – no matter how far you drill down with a map – even a much-detailed map you will not find what you are experiencing – what your perceptions tell you is there. The map after all is an abstraction by someone and that is not a perfect representation of geography but also not your reality.  From consciousness science - your reality or experience of it is not my reality.   From information theory – the human brain is acquiring much more information going forward than you can get from one derived across a series of finite dimensions and time.  Second – this has clear implications for the ideas of subjectivity and objectivity.  In medicine we construct clinical trials – with exclusion and inclusion criteria that eliminate large real populations and at this point cannot account for the heterogeneity in the remaining research subjects. That does not preclude progress but it should introduce humility into the eventual results. No matter how broad or narrow those selection criteria are – they are only an approximation of the real population who will be treated.

Lest these connections be seen as speculative – here is what map makers and geographers have to say about the situation.  Basic geographic data is a space-time location. In addition, there is other relational data that contextualizes a location.  Data and relationships are discussed in terms of model and how the model is a simplified representation of reality but not reality itself.  A good example was John Snow’s map of cholera during the 1854 epidemic in London and how he used that to determine the source and isolate it. Cartographers are aware of these relational loops to space-time location as well as the limitations that are due to the large number of contextual features.  The map cannot account for them all.  

What does it say about philosophy and rhetoric applied to psychiatry?   

It says a lot about classification systems.  Much research today is preoccupied with ideal classifications.  The DSM for example is criticized for not being a perfect diagnostic system when in fact (like all medical classifications) it is a crude system with additional landmarks.  The graphic below illustrates the problem and how the assumptions made for the diagram on the left do not reflect the reality of the diagram on the right. That diagram is more complex – but not nearly as complex as the real clinical situation. After all – if the clinical situation was accurately reflected in the diagram on the left everyone with schizophrenia would be the same.  Psychiatrists would not have to concern themselves with a developmental history, a social history and life narrative, a medical history, and a family history.  They would not have to consider critical psychological events in a person’s life and putting all that together in a formulation about what is unique about that person.  The territory of that person would include supportive people and important contacts. Like the map of Highway 2 – the DSM gets us into the ballpark but it is not specific about what we will find. 

Korzybski has been described as an independent scholar.  He is credited with inventing the field general semantics.  There is a research institute founded on his ideas. There are not a lot of scholars taking his work forward.  There is an excellent online biography of Korzybski that describes the controversies associated with his writings and varying degrees of acceptance.  Interestingly he wrote about psychiatry and in his biography, there was apparently a group of psychiatrists interested in his work.  He referenced “neuropsychiatry” as a field that had generally been ignored by the rest of medicine.

 

Irrespective of the complexity and controversy of general semantics – I am still focused on the map is not the territory concept for several reasons.  First it reflects what is going on in the DSM classification system.  Second, it describes limitations of any classification system and how that abstraction differs from reality. That is probably the reason that medical diagnostic systems die hard, especially after decades or centuries of the same observations.  Is there any reason to suspect a dimensional or sub phenotyping system would be any better?  Probably not at least until very detailed observations can be made.  A classic paper (4) suggested that hundreds of true/false questions identified psychological traits and that this was an actuarial method superior to clinical judgment.  Despite that alleged superiority many of the methods suggested in that review like the Minnesota Multiphasic Inventory or MMPI have fallen out of use and are no longer used for screening purposes or making diagnoses.  Machine learning and artificial intelligence can produce these results faster and on a larger database but continue to have limited applications.   Third, it reflects expert opinion by at least one of the top theorists in the field (5).  Fourth it reflects good clinical practice that includes a formulation with additional commentary on psychopathology, associated observations and theories. 

At the minimum I hope that you find Korybski’s observation as interesting as I do.  I probably will not read his voluminous works – but I am always aware of the fact that no matter what classification system you are using it is always an abstraction with various degrees of precision.  Further it is an abstraction by one person or a group of people.  The way the DSM (and all of medicine) is structured the precision of both the diagnosis and treatment of a particular patient depends on what occurs during the encounter and the experiences and abstractions of that physician.   

George Dawson, MD, DFAPA

 

Supplementary: Doing research for this post, I encountered another quote that expresses a similar idea:  "The menu is not the meal".  Alan Watts is credited with that quote. 

References:

1:  Korzybski: A Biography (Free Online Edition) Copyright © 2014 (2011) by Bruce I. Kodish.  See chapter 30 for Korzybski’s contact with psychiatry including Harry Stack Sullivan and William Alanson White:  https://korzybskifiles.blogspot.com/2014/06/korzybski-biography-free-online-edition.html?spref=tw

2: Doerr E. General Semantics. Science. 1958 Jul 18;128(3316):156.

3: Gardener M. General Semantics. Science. 1958 Jul 18;128(3316):156.

4:  Dawes RM, Faust D, Meehl PE. Clinical versus actuarial judgment. Science. 1989 Mar 31;243(4899):1668-74

5: Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi: 10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PMID: 27138588.

.

What Do Readers of This Blog Want To See?

 

I thought I would ask basically to see if I can be more helpful.  My interest in writing this blog came about because I had many people ask me what I was reading.  They seemed to find my information sources to be interesting. A secondary interest of mine is making sure that the best possible information is available to clinicians who are on the front lines making decisions each day.  Thirdly, the analysis of research whether it is basic science or clinical research is also an interest - both the scientific measures but also the rhetorical aspects.  Many people don't think that rhetoric enters into medicine and science. If you are a psychiatrist we have been contending with rhetoric for decades whether we want to or not and it has extended into literature that most would consider to be scientific.  There are a lot of posts about that rhetoric on this blog.  Fourth - I post about society, culture, and politics and how that impacts us.  I have frequent posts on the cultural effects on behavior - with many posts on my hypotheses about how gun extremism affects us all and is associated with the American mass shooter phenomenon.  Fifth - I have posts on diagnostic reasoning and taught a course to medical students about this for a decade in the past.  I try to tie in diagnostic thinking in psychiatry as a comparison.  Sixth - I have done book reviews on poetry with psychiatric themes and consciousness  and am currently reviewing another poetry book, Keith Rasmussen's book on ketamine, and a book on spirituality where I hope to illustrate a path to connecting that to psychiatry.

My most viewed page recently has been the updated review of systems for psychiatrists.  This is actually a tool I use in clinical practice and there are several other pages like it.  It has recently been viewed over 31,000 times - but I think at some point Blogger (the Google interface that this is published in) - stopped counting page views from virtual private networks (VPNs) by the page and only counts them in aggregate - where there are about 2.1 million views.   Additional highly viewed pages about clinical psychiatry include 2000 Words About the Last Ten Minutes of a Psychiatric Evaluation and Additional Work on the Review of Systems for Psychiatrists.  

Posts that are currently pending include:

1:  Updated post on Neanderthals and why they disappeared.  Paleogenetics is a fascinating read and it has implications for human illnesses, evolutionary aspects of psychiatry, and the evolution of man. 

2:  Review of the poetry book Coming to Love My Darkest Places by Jennifer Kelly. 

3:  Review of The Varieties of Spiritual Experience by David B. Yaden and Andrew B. Newberg.

4:  Review of Ketamine: The Story of Modern Psychiatry's Most Fascinating Molecule by Keith Rasmussen.

5:  Continued posts on the rhetoric of medicine and psychiatry including the theory of that rhetoric.

6:  Continued posts on the importance of biological theory to psychiatry.  I am referring to theory that originates in biology rather than the usual biological hypotheses in psychiatry although they are not mutually exclusive. I hope that I give the impression that I am not very impressed with the proliferation of purely philosophical ideas about the field, especially from people who have never been trained in psychiatry or medicine.  

7:  A musculoskeletal case including images (CT, MRI, bone) with a discussion of complex misdiagnosis and how all of that applies to psychiatry.  

I will avoid a top ten list of what is coming, but that is what is percolating right now. I tend to work better when I am thinking (and writing) about many things at once.  My motivation for this brief post is too see if there are any topics that readers would either like to see or like to see elaborated on.  They can be clinical or theoretical - medical or psychiatric. Feel free to send me your ideas either posted here or to my direct email address. 

I would also like to address two related topics.  The first is the use of these blog posts.  I think most people read them for their own interest, but some have been incorporated into books.  Everything on this blog is Creative Commons licensed.  That means it can be shared for no charge in just about any medium that you want it to be.  The only stipulation is that you cite me and this blog as a source.  I have found myself in the awkward situation of being at a conference and seeing my blog pages projected by a prominent researcher without referencing my work. I do not make any money writing this blog.  I have no paid subscribers or advertisers and pay all of the expenses out of my own pocket.  I think one line of 12 point font referencing my work in the bottom corner of a PowerPoint slide is not too much to ask. 

Even better, I am happy to collaborate.  I am willing to research, cowrite, or make graphics for your project for co-authorship credit and nothing else.  In fact, I recently offered to analyze the utilization of psychiatric medications for a large healthcare plan for free.  They declined the offered but I remain very interested in the analysis of real world data in health care setting.  Send me an email if you are interested.

George Dawson, MD, DFAPA

Supplementary 1:  Requests for topics:

 The request for topics has gone well so far.  The following is a list by topic and/or specific question.  If this leads to any other ideas – feel free to send them to me.  I am also interested in learning about any graphics that people would find useful. 

 

1:  ADHD – rates of diagnosis, how people present for assessment, missed diagnoses and other associated problems, diagnosing adults, and neurodevelopmental diagnoses in general.  (see comment below).

2:  ADHD – stimulant treatment and cannabis use.

3:  Antidepressant withdrawal with a focus on gastrointestinal symptoms.

4:  The models of mental functioning that are helpful in psychiatry.

5:  Indications/guidelines for antipsychotic use in children and teenagers.  Data on long term use.

6:  Memory and cognitive problems associated with POTS (Postural orthostatic tachycardia syndrome) – and recommended medical treatment.

7:  How psychiatry was practiced and the current transition – implications for the future of the field.

8:  Dementias associated with Lyme Disease and other infectious diseases

9:  More biological psychiatry!

10: Pharmacology and psychiatric applications of alpha-1 and alpha-2 adrenergic receptor agonists and antagonists.

11:  Pharmacology and psychiatric applications of beta adrenergic antagonists in psychiatry.

12:  What are inverse agonists in 10 and 11 above?

13:  Post Finasteride Syndrome (PFS) – I continue to get treatment requests for this syndrome.  Some of the people sending me emails explain that I am listed on web sites as a treatment resource, even though I have never personally assessed or treated the disorder.  I will probably post a review on PFS in the next year.

14:  Post SSRI Sexual Dysfunction (PSSD)/Persistent Genital Arousal Disorder (PGAD) – I have posted a review of this disorder and I am listed on web sites as a treatment resource. I have also had at least one person try to convince me to remove my post or modify it to their liking.

https://real-psychiatry.blogspot.com/2023/07/post-ssri-sexual-dysfunction-pssd.html

15:  Antidepressant withdrawal/discontinuation:  I have posted on this and my opinions are all consistent with a recent major review.  I am always interested in medication side effects – no matter the medication and how they can be mitigated. I have also had treatment requests to assist with this problem. I will probably add a post on the major review and also continue to comment on the politicization and the associated rhetoric. As well as placebo/nocebo responses.   

https://real-psychiatry.blogspot.com/2018/06/the-problem-of-antidepressant.html

16:  Supportive psychotherapy:  Throughout my career I practiced supportive psychotherapy in practically every clinical encounter and across every diagnostic category.  I consider it to be a necessary skill for psychiatrists – but it is difficult to write about in terms of both observations and techniques.  At some point I will be posting about this.

17:  How to walk down stairs and minimize the risk of falling:  That's right - I am a psychiatrist and old speedskater with an interest in biomechanics. I will post this as soon as I can figure out how to draw stick figures walking up and down stairs.  Let me know if there is software out there that might help with this type of drawing. 

That should keep me going for a while.  Do not hesitate to send more ideas or questions.

A final note on treatment requests.  I have received these requests as noted on #13, #14, and #15 above from many different states.  My response is always that I am retired from clinical practice and no longer provide active treatment since 1/19/2021.  That also means that I do not have access to what is required to provide medical care and meet licensing requirements (records, malpractice insurance, support staff, etc.).  And even if I did – treating people across state lines remains somewhat of a logistic nightmare.  As a result, I cannot provide telepsychiatry services or casual advice.  What I write on the blog has always been educational and for a large part directed at physicians and more specifically psychiatrists.  It is not medical advice and I hope I have always emphasized that the best treatment with continuity is available from your local physicians and specialists.  Proper medical care requires a formal doctor-patient relationship and that cannot be casual advice.  And for the physicians out there I hope I come across as an interested colleague.  Another intent in writing this blog is not to suggest that my knowledge or practice is superior to anyone else.  Life, biology, and medicine are too complicated for that.

Supplementary 2:

Elements of a dynamic textbook:  In my spare time I will be arranging my blog posts from the past 12 years in the general form of a book.   The intention is not to create a book but an outline for a book.  Not all of the posts will translate well but most will.  I would like it to be dynamic - not psychodynamic but useful to all psychiatrists.  Typical texts waste too much space on just technical details and I would prefer to focus on key concepts and approaches including how that evolves. I will post the outline here when I have it - in the meantime feel free to suggest chapters. 

The American Gun Protection Fantasy and the Secret Service....

 

Ten days ago, a lone shooter attempted to kill former President Trump at a rally in Pennsylvania. About 6 minutes after he began speaking, Trump is noticed to turn his head to the right and then grab his right ear and drop to the ground. He is swarmed by Secret Service agents and after a period that seems too long is escorted off the stage and taken to a local hospital for assessment and treatment.  Three people in the audience are shot – one dead and two seriously wounded.  They were all in the line of fire seated behind Trump.  About one minute later the Secret Services Counter Assault team returns fire fatally wounding the shooter.  Weeks later it is learned that the shooter may have fired as many as 8 rounds based on shell casings found near his body on the roof.

There is immediate speculation and controversy about the incident. Quite incredibly several members of the Republican party blame the incident on Democrats even though they are the party that has been espousing political violence and gun extremism. Preliminary reports suggest that although the shooter is a registered Republican – he donated $15 to a liberal cause a few years earlier.  The shooter was using an AR-15 rifle that he borrowed from his father and he had purchased 50 rounds of ammunition.  At the time of this post there is no information on whether he was using a high-capacity magazine or not.  The state of Pennsylvania has no prohibition on assault rifles or high-capacity magazines.

We subsequently learn that the shooter did not make the cut for his high school shooting team, but did belong to a local shooting club.  He was described as a loner who was bullied in school. Some people described him as bright and eccentric.  All agreed that there was no suggestion that he was a potentially violent individual and nobody ever heard him make any threats. It was later learned that he did some drone surveillance of the site and had saved materials on several people from both parties.  To at least one analyst this data suggested that his goal was a mass shooting rather than an assassination.  Others speculated that it may have been a “suicide by cop” scenario.  Some information leaked from the preliminary investigation suggested he was searching “major depression” on the Internet. 

We also learn that the shooter had a picture of a recent mass school shooter whose parents were also convicted for allowing him access to firearms.  The shooter in this case places his father in the same predicament, although there have not been any statements from the parents.

At this point there are signs that there were significant security lapses.  That led to Congressional testimony by the Director of the Secret Service on July 22.  Several members of Congress demanded an immediate resignation and she subsequently resigned on July 23. She did accept full responsibility for the security lapse, an administrative maneuver that is apparently expected only in the government.  She resigned at a time when the results of the investigation of the incident are still pending.

The public has been presented with interviews of people who saw the shooter on the roof and tried to get the attention of law enforcement including the counter assault team without success.  The shooter was approached on the roof by a police officer who apparently had to back down because the rifle was pointed at him and he was not able to draw his weapon in defense.  There was a story today that Secret Service agents were located at the roof level on the interior of the same building that the shooter was on but did not see him.  The shooter was identified as a “suspicious person” but not a threat because his rifle was not seen initially. If he had been identified as a threat – Trump would have been sequestered in a safe area until the threat was neutralized.

I have not heard any information about the perimeters established for security.  I heard initially that there was a Secret Service perimeter closest to Trump and extending out for 200 yards.  The meant that Secret Service was responsible for anything inside that perimeter and local law enforcement was responsible for the next tier beyond 200 yards.  That may explain the aborted attempt by the police officer to intervene moments before the shots were fired at Trump. 

Most significant to me as a psychiatrist is the continued “search for a motive” or that “no motive has been found.”  That is a routine finding in these events.  There really are no rational motives for picking up a gun and trying to kill the former President or anyone else.  There is no motive for essentially firing into the crowd beyond Trump and killing a spectator and seriously injuring two more.  Most firearm related homicides are irrational acts – related to angry disagreements and firearm accessibility.  The fact that motives are lacking is probably the reason mental illness is often considered to be a factor in firearm homicides. 

That takes me back to my hypothesis of mass shooters that can probably also be related to lone shooters in this case.  The United States has a long history of cultural memes related to firearms.  Film and television is a rich source of revenge stories where the hero/antihero is wronged and proceeds over the next 90 minutes to kill everyone who wronged him.  That has extended in the media to include mass shooters and school shooters. Many are described as “bullied”, loners, or mentally ill.  The overriding story is the revenge meme – whether it is accurate or not.  For several decades the meme involved postal workers "going postal" due to workplace stress and mismanagement although a subsequent investigation showed the incidence of post office violence was not greater than other workplaces.   All it takes is a marginal person without self-control ability to decide to project their problems onto an available individual or group and extract their revenge.  The method of choice in the US is a firearm.

There is another group and cultural factor that may be important in these cases and that is the American sniper.  There are thousands of snipers in the US military.  They typically operate at a range of 600-1200 meters, although several shots have occurred at much greater distances. The IMDB database lists 18 sniper movies dating back to 1963. Just inspecting that list suggests to me that there are many more. And of course there are constant real-life stories about mass shooters.

My point about snipers is fourfold.  First, it reinforces the shooter meme in that a sniper is generally seen as a very competent person who is shooting people for the right reason.  Even the cinematic revenge version often has the audience primed to see the shooter's viewpoint.  Second, snipers are generally portrayed as cool and professional.  Third, there are any number of weapons that can be used to become a self-styled sniper.  The first mass shooting I became aware of was the Texas Tower mass shooting of 1966.  The incident occurred at the University of Texas and the shooter fired from the same clock tower position.    Snipers are generally portrayed as possessing some special talent to shoot well – but the reality is that anyone can shoot well – even at a distance if they have enough practice. Fourth, gun access in the US is easy.  The problem of how long mass shooters experience thoughts about shooting people is unknown and probably an impossible study.  That leads to a certain politics of explaining the motives.  To gun extremists the shooter is just “a bad guy with a gun.” who needs to be stopped by a “good guy with a gun.”  Many of these same gun extremists tend to blame the behavior either on mental illness or the treatment of mental illness even though most incidents are not related to either.  This group rigidly avoids acknowledging their possible role due to cultural changes and the widespread availability of guns.  They are joined by some mental illness advocates for not treating mental illness who suggest the behavior is due to medical treatment.  In the past, I have suggested going after the problem directly and approaching it as a public health problem.  That is – if you have homicidal thinking call an emergency number for intervention.  Acute care psychiatrists intervene in the problem when it is precipitated by severe psychopathology, but in most cases that is not the issue.  It is safe to say, the problem and successful interventions cannot be well studied in the current landscape.

Getting back to the shots fired at the Trump rally, Trump was speaking 430 ft away from the shooter or about 131 meters.  That is well within typical sniper range.  Further – given the military sniper range suggests that the Secret Service would need to secure the entire area out to 10 times the distance to that rooftop and even then, that may not be far enough.  If there are two important lessons from this event it should be that guns are inadequate protection from a shooter with an element of surprise and a long-range weapon.  You can make the argument that the Secret Service snipers may have stopped a mass shooting event, but at this point that seems to be highly speculative.  Secondly, the perimeter is very significant.  If the initial descriptions of a 200-yard perimeter are accurate – new strategies are required and even then, I would question the likelihood of stopping catastrophic results from single shot fired by a sniper who was trained in evasive action.  These are important considerations when the political solution at this point appears to be an investigation focused on who to blame for security lapses.  Members of Congress are saying all that is needed is a thorough and transparent investigation.  So far – very few details of the investigation are available.

It is doubtful that the obvious cultural factors like gun extremism, widespread availability of weapons and military style weapons, and the cultural phenomena of the lone wolf shooter will be addressed. It is doubtful that public health approaches to the problem will be discussed. I expect a final report several hundred pages long focused on what law enforcement and the Secret Service should have done.  I look forward to reading that report to see what perimeters and measures are considered and anticipate that they will be woefully inadequate compared with any determined shooter from a long range. 

And then there are the legal considerations. After the Reagan assassination attempt, the Brady Bill – a modest modification of existing gun control laws was eventually passed 12 years later.  Since that time there have been decades of gun extremism put into the law, basically because one of the major parties needs the issue for political purposes.  This has made the United States less safe for everyone including Presidential candidates.  The most striking example is that the city of Milwaukee was not able to ban firearms outside of the hard security perimeter at the Republican National Convention that occurred 2 days after Trump was shot at.  Wisconsin law prohibits local municipalities from banning firearms.

Over the past 30 years we have gone from a nation of common-sense gun laws – to a nation of gun extremism.  That is almost entirely due to the actions of the Republican party and its politicians.  There has been a clear association with increased firearm deaths and there has been no resulting retracing of the path to gun extremism.  Gun extremism puts everyone at risk including Presidential candidates. I will refrain from the usual political platitudes about how I hope everyone will be safe out there. Hopes and prayers for the victims of firearm violence have not changed anything so far and I expect more of the same until the party of gun extremism decides to change their mind or they are voted out. 

These are my observations about this Trump rally. It was a shocking event, but probably not shocking enough to change any gun laws or the steady march towards gun extremism that is oddly enough in the hands of the party whose candidate was targeted. 

George Dawson, MD, DFAPA

References:

1:  Update on the FBI Investigation of the Attempted Assassination of Former President Donald Trump Update: July 15, 2024, 3:05 p.m. EDT:

https://www.fbi.gov/news/press-releases/update-on-the-fbi-investigation-of-the-attempted-assassination-of-former-president-donald-trump

2:  Neuman S, Westervelt E.  Trump's close call: A detailed time line.  NPR:  https://www.npr.org/2024/07/19/nx-s1-5041734/trump-shooting-assassination-crooks-bulter-secret-service 

 

Supplementary 1:

I decided to write this essay ahead of any investigation results because it appears that will be a very slow process. I will read those reports as they become available.

Supplementary 2:  This article became available after I completed the above post.  It is based on testimony by the FBI Director Christopher Wray.  He states the AR-15 used by the shooter had a collapsible stock and therefore was easier to conceal.  He also said the shooter flew a drone for 11 minutes over the site about 2 hours before the event.  And in terms of the motivation:   

"Wray said investigators haven’t found a manifesto or obvious motive for the shooting. He said pictures were saved in the cache of Crooks' electronics from news searches, rather than necessarily because of a specific search for a public official."

https://www.yahoo.com/news/fbi-director-wray-set-house-143641332.html

Supplementary 3:  Additional fragments of information today in the news. There were 8 expended cartridges next to the shooter's body.  No word on the location of the other 42 rounds or whether there was a high capacity magazine.  Some data from the shooters laptop showed that he did a Google search on the JFK assassination searching on both Kennedy and Lee Harvey Oswald. 

Graphics Credit:

Click on graphic to get full information and CC license on Wikimedia Commons.

 

 

 

 

The Circular Logic Argument

 

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.