Sisyphean Arguments with Anti-psychiatry Proponents…
In response to the previous article discussing OCD and Involuntary Psychiatric Care, S. P. has decided to post a reply on his blog. He also used different proxies to comment on this blog, despite the fact that his comment privileges were removed several weeks ago because of his constant abusive behavior and unwillingness to address arguments. Unsurprisingly, S. P. engages in multiple personal attacks (calling me a zealot, claiming that I must be mentally retarded, a fascist and a pathetic useful idiot) and rehashing of the same old assertions that have been debunked before. Unlike S. P. I am going to be the bigger person and just address the arguments.
Details are not irrelevant!
It is clear that the personal story of S.P. was an important influence for the origin of his animosity towards psychiatry. In my previous post, I made a provisional conclusion that the story lacked crucial details. The major details S. P. gives us is that he has an exaggerated fear of contracting HIV through usual contact, that he was diagnosed with OCD and that he underwent involuntary psychiatric care in an unnamed European country. However, to investigate whether the decision to commit S. P. for involuntary psychiatric care was justified (an by extension the emotional underpinnings of his position), one needs to know the precise details of the conditions, such as severity and the level of functional impairment, as well as the identity of the European country (to be able to check the laws regulating it).
My general argument was that it seemed implausible that he was subjected to involuntary psychiatric care just because an exaggerated fear. I assume most people have more or less irrational fears: wasps, dogs, clowns, heights, spiders, snakes, lightning and thunder, flying and of course germs. But obviously the majority of people with irrational fears are not subjected to involuntary psychiatric care. The conclusion I drew was that there is more to the story that S. P. has shared. Now, I certainly realize that anxiety issues (as well as other issues related to mental health) are sensitive things and I obviously cannot force S. P. to share if S. P. does not want to. However, this does not change the fact that these questions are very relevant. How severe is the condition? How much functional impairment was there? What are the laws regulating involuntary psychiatric care in the unnamed European country?
Individual freedoms and laws regarding involuntary psychiatric care (Sweden v.s. the U. S.)
S. P. dislikes the Swedish laws that regulates involuntary psychiatric care. To summarize, Sweden require that the patient has a severe psychiatric condition, refuses voluntary care and cannot be taken care of in any other way that around-the-cloak psychiatric care. According to S. P., the U. S. requires that the life of the patient or a third person needs to be threatened. What S. P. fails to grasp is that the third condition in the Swedish law is related to whether or not the life of the patient is threatened, but is more specific and focuses on not being able to take care of him or her self, or by other people. This highlights an important difference between Sweden and the U. S. Sweden has a generous welfare system, but the U. S. generally does not. It boils down to how much do we think that the government should have to care about people.
I find it peculiar that S. P. considers the U. S. to value freedom. Is S. P. aware that the FBI regularly abuses the Patriot Act?
Accuracy of medical testing
I confronted S. P. on his belief that medical tests are generally 100% accurate. S. P. then says that he clearly did not mean 100%, but used a metaphor. I find this hard to believe because the argument is often used by opponents of science-based medicine and metaphor is really a form of analogy, so S. P. is using the term incorrectly. The general message of my argument was that medical tests that are not 100% accurate does not undermine the existence of the condition, or the biological basis of the condition.
Misunderstanding consensus
S. P. clearly misunderstood my transition from medical testing to HIV/AIDS. What I said was that “Since the second blog post tells me he accepts the consensus position that HIV causes AIDS, I will pick an example from this area.” When I used the phrase “consensus position” I am making the descriptive statement, that “HIV causes AIDS” is generally accepted by the scientific community (much like the existence of biological factors influencing the development of mental conditions). I did not imply that S. P. accepts that HIV causes AIDS because it is a consensus position. I am just referring to the current consensus position as “HIV causes AIDS”.
Biological markers, again
S. P. makes a subtle shift when it comes to the existence of biomarkers. In a previous entry, he quoted the American Psychiatric Association out of context saying that “brain science has not advanced to the point where scientists or clinicians can point to readily discernible pathologic lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder or mental disorders as a group”. I explained that this is because the mental conditions are heterogeneous (just like many other diseases) and that they are strongly multifactorial, so we should not except the existence of a particular biomarker that can be found in all cancer patients and cannot be found in individuals without the mental condition. This is true for other conditions as well, such as type-I diabetes. The genetic risk factors for type-I diabetes are different in different subgroups with the disease and people with certain genetic risk factors that lack other risk factors may never develop the disease. Does this mean there is no genetic influence for type-I diabetes? Of course not.
Remember, the entire quote from the American Psychiatric Association was:
Research has shown that serious neurobiological disorders such as schizophrenia reveal reproducible abnormalities of brain structure (such as ventricular enlargement) and function. Compelling evidence exists that disorders including schizophrenia, bipolar disorder, and autism to name a few have a strong genetic component. Still, brain science has not advanced to the point where scientists or clinicians can point to readily discernible pathologic lesions or genetic abnormalities that in and of themselves serve as reliable or predictive biomarkers of a given mental disorder or mental disorders as a group. Ultimately, no gross anatomical lesion such as a tumor may ever be found; rather, mental disorders will likely be proven to represent disorders of intercellular communication; or of disrupted neural circuitry. Research already has elucidated some of the mechanisms of action of medications that are effective for depression, schizophrenia, anxiety, attention deficit, and cognitive disorders such as Alzheimer’s disease. These medications clearly exert influence on specific neurotransmitters, naturally occurring brain chemicals that effect, or regulate, communication between neurons in regions of the brain that control mood, complex reasoning, anxiety, and cognition. In 1970, The Nobel Prize was awarded to Julius Axelrod, Ph.D., of the National Institute of Mental Health, for his discovery of how anti-depressant medications regulate the availability of neurotransmitters such as norepinephrine in the synapses, or gaps, between nerve cells.
Now, S. P. has shifted towards denying the existence of biological influences on mental conditions completely, just because none of the risk factors are unique to the conditions. So not only is the quote out of context, but S. P. has shifted the usage of the term biomarkers to support his anti-psychiatry position. In other words, S. P. confuses the existence of a unique and reliable biomarker for a given condition with the existence of a biological basis for the same condition. There is no contradiction in saying that there is nothing that categorically and uniquely distinguish people with ADHD from all other people without it, but that there are biological influences for the origin of ADHD. S. P. is ignoring the multifactorial origin of mental conditions.
Cancer, psychological questionnaires and migraine
I pointed out that there is no unique biomarker on cancer cells that uniquely distinguish them from healthy cells. Guess what S. P. does then? He points out that there are imaging techniques that can be used. This is true, but the same can be done for e.g. ADHD and schizophrenia. S. P. cannot escape it.
S. P. then makes the straw man assertion that I think psychological questionnaires are as reliable as diagnostic tests for HIV. Psychological questionnaires have been demonstrated to have a high reliability, but of course tests like PCR are more reliable. But that is not the issue. The issue is that there are reliable tests for many mental conditions.
S. P. rejects my migraine analogy by saying that there is physical pain associated with migraines. But there are physical symptoms associated with a depressive episode or an anxiety attack as well. So what is the qualitative difference? If you accept the existence migraines, you must accept the existence of anxiety disorders and many other mental conditions with physical symptoms.
SSRIs and suicidality
I linked to a study showing that SSRIs do not increase suicides in the reference section. I can even link to a review in the Lancet (Hall, 2006), showing that treatment with SSRIs actually reduce suicide risk and the supposed increase in suicidality early in treatment is due to not controlling for base line level of suicidal thoughts.
SSRIs are more effective than placebo and the studies S. P. references demonstrates it!
I found this to be endlessly entertaining. S. P. thinks that SSRIs are no more effective than placebo, and links two studies that he thinks demonstrates this. However, the results of both studies contradict his claim! The golden rule in discussion scientific studies is to actually read the study. This rookie mistake shows that S. P. is probably not being completely honest when he says that he has a high level scientific degree. Let’s take them chronologically, starting with Turner.
Turner et. al. (2008) looked at studies on SSRIs submitted to the FDA and found that, like all other medications, studies that show a larger effect are more likely to be published. Taking this into account, he calculates an overall effect size for both published and unpublished studies and concludes that:
For each of the 12 drugs, the effect size derived from the journal articles exceeded the effect size derived from the FDA reviews (sign test, P<0.001) (Figure 3B). The magnitude of the increases in effect size between the FDA reviews and the published reports ranged from 11 to 69%, with a median increase of 32%. A 32% increase was also observed in the weighted mean effect size for all drugs combined, from 0.31 (95% CI, 0.27 to 0.35) to 0.41 (95% CI, 0.36 to 0.45).
In other words, the effect size of published and unpublished studies was 0.31 compared to placebo. This lies between a small effect and a moderate effect. So SSRIs are more effective than placebo. S. P. quotes the article out of context, emphasizing the publication bias, but ignoring the fact that even when the bias is taken into account, all the SSRI drugs tested were still superior to placebo.
What about the Kirsch et. al. (2008) study? This one actually concludes that SSRIs are no more effective than placebo, but the results do not support this conclusion. The results show that SSRIs have an effect size of 0.32 (looking at both published and unpublished studies):
Represented as the standardized mean difference, d, mean change for drug groups was 1.24 and that for placebo 0.92, both of extremely large magnitude according to conventional standards. Thus, the difference between improvement in the drug groups and improvement in the placebo groups was 0.32, which falls below the 0.50 standardized mean difference criterion that NICE suggested.
In fact, Kirsch studied pretty much the same data as Turner et. al. So how could they reach the opposite conclusion? It is because Kirsch used an arbitrary standard for clinical significance that is no longer being used by National Institute for Clinical Excellence (NICE). As we see, the effect size from Kirsch is even bigger than that from Turner. Even psychotherapy has an effect size of 0.22, so if you reject antidepressants, you have to reject psychotherapy as well. A bold move for any proponents of anti-psychiatry to make, save perhaps the lunatic fringe.
So when we look at the actual data for effect size of antidepressants such as SSRIs, controlled for publication bias, it is around 0.3 compared with placebo. This shows that SSRIs have a practically significant better effect than placebo.
There is really nothing else of substance in the rebuttal S. P. posted so I think I will stop here for now, but i suspect the rock will roll down soon enough again.
References and further reading
Hall, W. D. (2006). How have the SSRI antidepressants affected suicide risk? The Lancet, 367(9527), 1959-1962.
Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, et al. (2008). Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration. PLoS Med 5(2): e45.
Turner, E. H., Matthews, A. M., Linardatos, E., Tell, R. A., & Rosenthal, R. (2008). Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy. New England Journal of Medicine, 358(3), 252-260.
S. P. has now made a second reply to me, where S. P. keeps calling me mentally retarded (ironic as S. P. denies the usefulness of psychiatric disorders), does not understand the difference between reliable and reproducible data on biological causes of mental conditions and unique biomarkers and S. P. did not even address my detailed analysis of Kirsch and Turner.
I argue that DSM-IV has a high degree of reliability, and S. P. counters with saying that the DSM-V (which is not even going to be released for another year at least) does not have as high. This is of course an irrelevant argument since DSM-V is still a work in progress and is undergoing changes and improvements as time goes by in response to criticisms such as the one that S. P. mentioned.
In the end of S. P.’s latest blog post, S. P. claims that I treat opponents like enemies when I said that Tom Insel was not only wrong, but pathetically so (in response to his claim that he expects there to be vaccines against mental conditions). This is a comment on the argument, not Tom Insel as a person. A key distinction that S. P., as we have seen, does not fully grasp.
Finally, S. P. has chosen not to provide any more details about the severity of S. P.’s own condition or the legal regulation of involuntary psychiatric care in the unnamed European country S. P. was committed. This means that there is really nothing left to discuss. It is like talking to a wall. I shall not waste more of my time on S. P. For now. Although, as always, I am probably going to get sucked into the vortex of anti-psychiatry sooner or later again.
Hehe. Don’t lose heart, but also be cognizant and allow yourself to take a mental break from the eternal task at hand. It is easy to become discouraged and/or burn out from arguing against stubborn delusions. I’ve found, personally, that it’s important for my mental health to be able to let go of a particular argument and even to let it drop completely if I no longer feel the will to push the rock uphill. During that break, my mental energy naturally replenishes, and I return another day. Perhaps to the same argument, perhaps to a completely different one. No one has unlimited persistence and energy. Nor unlimited time on this Earth. I must pick and choose the arguments worth spending my time on, and which are not worth it.
One thing that helps keep things in perspective and to continually renew my mental resources is the knowledge that the single person I’m arguing with is not the only member of the audience. There are potentially hundreds or thousands of people who might eventually read this and find your efforts of great value. I admire your persistence and thoroughness, so I’m not trying to discourage you from pursuing it. But I do want to warn you of potential burn-out. I have found over the years, having burnt out on several occasions, that my own mental health is precious and a limited resource, and not something to be squandered. I’m much more relaxed and gentle on myself these days.
Thanks for the tips and encouragements!
First off, I think it is important to point out that you simply cannot subsume all criticisms of psychiatry under the rubric, ‘anti-psychiatry’. The naysayers on this subject are not part of one homogenous group with a single manifesto.
The term often functions rhetorically to discredit all criticisms as indicative of an intolerant mindset. Maybe Karlsson isn’t one of these people, but there is a tendency to indulge in this kind of name-calling amongst those who are defensive of this sacred cow, so I thought I’d point that out.
He asks how severe the condition of S.P. is. One thing we can be sure of is that there was no independent verification of the diagnosis, such as empricial proof of structural or functional lesion. When the people are medicalized from below (that is, engage in consensual relations), I have no problem with this; when people are medicalized from above (that is, when the role is imposed on them), I have every problem. Some of us aren’t that naive as to accept the ipse dixits of psychiatrists as if they were proof of a real problem, nor that psychologically naive as to believe that their powers of observation are infallible, nor that they are these Ubermenschen, educated at the University of Mount Olympus, sufficiently enlightened to go around engineering the behaviour of the Untermenschen according to their infallible doctrines. Such people who put that kind of faith in psychiatric diagnoses are delusional, but don’t worry, in our age it is not about whether or not you are delusional that qualifies you for psychiatric diagnosis, but the manner in which you are delusional and whether or not that delusion is an extraordinarily popular one or one that offends dominant society.
For the sake of argument, let’s say the guy does have a real debilitating illness or disorder or disease (the words are used interchangeably by many psychiatrists and proponents of biopsychiatry). A person with an empirically validated disease, can reject treatment that could save their lives, yet whether an individual is deserving of freedom and the right to self-ownership is left to the discretion of some shrink. Severity of condition is not used as a criterion for determining whether a cancer patient should be able to decide or whether the state should act in loco parentis vis a vis the patient. It logically issues from all this that involuntary commitment of the denominated ‘mentally ill’ person is a grossly discriminatory sanction, and shows just how deeply perverted the law has been by psychiatric prejudice. The Bill of Rights is for all people, not just the people sanctified by psychiatric ideology as ‘mentally healthy’. Maybe I should say Karlsson and others of a similar ideological bent are anti-bill of rights and anti-equality before the law?
He says that imaging techniques can be used for patients who supposedly have ADHD or schizophrenia (I am not denying the percept, but I do deny the psychiatric perception of the percept). Yet this hasn’t trickled down into the diagnostic process for some reason. The reason is that imaging studies have been inconclusive, so there’s no real point incorporating them into the diagnostic procedure. I know a lot of people diagnosed ‘schizophrenic’ (I am one) , none of them have ever had, say, an MRI scan. I wonder why?
He quotes the APA as saying that venticular enlargement has been observed in some patients. In every computerized tomographic and magnetic resonance imaging scan which has been done with the denominated ‘schizophrenic’ patient and ‘normal controls’, it has been found that the large majority of schizophrenic patients had normal sized ventricles. This attests to the simple fact that when viewing data, psychiatrists see what they want to see. Believing is seeing it would seem. In fact, studies have shown that ventricular enlargement is relatively common amongst people who are not diagnosed as ‘schizophrenic’, especially left-handed people. Yet psychiatry collectively rarely acknowledges its blunders or corrects its prevarications, so the most destitute of shame among them irresponsibly go on lying, communally reinforcing their BS rather than having the decency to own up.
Creationism is not a homogeneous group, yet we can use the label creationism without any particular problem. That is because it uses a very general definition. The same is true of anti-psychiatry. We can define the movement broadly as people who think that mental illness do not exist or that diagnostic criteria are vague and arbitrary as well as believe the medication are ineffective and do more harm than good. Actual scientific criticisms of psychiatry is discussed all the time and psychiatry has improved from it. This, however, is a far cry from anti-psychiatry.
As far as I can tell, I have written over a dozen tightly argued articles and posts about the claims made by anti-psychiatry. I use the term anti-psychiatry as a general label for those individuals promoting these typical arguments.
The science and arguments discredits anti-psychiatry. Calling a spade a spade is not an “intolerant mindset” and your assertions ironically amount to using rhetorical tools to discredit opponents (“they are intolerant!”).
As been pointed out above, there were and are legitimate criticisms of anti-psychiatry and the field is, like all other sciences, continually improving. Therefore, it does not qualify as a “sacred cow”. This is yet another common denialist tactic: claiming that some part of mainstream science is really a religious belief.
Yes, behavioral symptoms serve as the independent verification of the diagnosis. There is no blood test for migraine. Does that mean that migraines have no independent verification and does not exist? Of course not.
Forced medication is rare compared with consensual medication and it is tightly regulated. Are you also against “forced medication” when you are giving adrenaline to someone who has a cardiac arrest?
Psychiatric diagnosis is based on behavioral symptoms, not on the assertion of psychiatrists. No one beliefs that psychiatrists are infallible. That is the reason supervision exists. That is the reason why independent review exists. That is the reason why there are checks and balances, just like in any other field of medicine.
As a side note, Nietzsche never used the term “übermenschen”. The term used as “übermensch”, which signified a person who had come to understand the vacuous intellectual nature of theistic morality. Instead of resorting to nihilism, Nietzsche posited that the übermensch would derive values from love to this world and other individuals. The Nazis hijacked and distorted Nietzsche and “übermenschen” became synonymous with the flawed notion of a master race.
Also, the entire argument you put forward is really just reductio ad Hitlerum. According to the social context of the famous Godwin’s law, a person guilty of inappropriate Nazi analogies forfeits the argument.
There is no need to put any faith into psychiatric diagnoses as they are evidenced-based, and becoming even more evidence-based over time. Most people with e. g. depression are never discovered, so your subtle appeal to the argument from over-diagnosis has failed.
First of all, you can reject treatment if your condition is not deemed serious, like you can in all other areas of medicine.
The problem with this argument is that an informed consent or rejection presupposes capacity to make informed decisions. This is not always the case for those suffering from severe forms of mental conditions. It is not even the case for individuals with other medical conditions that makes them unable to make informed decisions.
A doctor finds a person choking and performs a tracheotomy after all other methods are exhausted. Is the doctor guilty of assault? Probably not, as we understand that a reasonable person would consent to such a procedure. We also understand that such a situation would constitute an emergency; it is not like the doctor can locate power of attorney and ask if he is allowed to perform the tracheotomy. A similar argument can be made with involuntary psychiatric care. It does not happen arbitrarily, but with people with severe conditions that often is a treat to their life. Decisions about involuntary psychiatric care is reviewed and critically examined by other doctors and medical personnel. You can even take it to court. So you are wrong in claiming that it is just up to the discretion of some shrink.
The legislation is different in the U. S. than Sweden, but we can probably safely conclude that involuntary psychiatric care does not violate the bill of rights or equality before the law.
Probably because the behavioral criteria are sufficient. Many mental conditions are heterogeneous and more research is needed to tease of various subtypes.
This is not true. A systematic review of over 40 imaging studies carried out by Lawrie and Abukmeil showed that there is a marked increased in lateral ventricles (~40%).
It is interesting to many anti-psychiatry proponents claim that psychiatry almost never self-corrects, and at the same time point to changes in diagnostic criteria, that homosexuality is no longer considered a mental illness etc. Logical consistency is not their strongest field.
Your sentiment is better fitting of anti-psychiatry proponents. They have been using the same flawed arguments since Thomas Szasz with very little difference.