Scientific Reality Versus Anti-Psychiatry: Once More Unto the Breach

Why should scientific skeptics care about refuting anti-psychiatry? Compared with other forms of pseudoscience, such as creationism or climate change denialism, anti-psychiatry has received considerably less skeptical attention. Yet anti-psychiatry is a dangerous pseudoscience that causes real harm. Like alternative medicine quacks, anti-psychiatry exploits vulnerable people and by denying the existence of psychiatric conditions or dismissing them as harmless, proponents of anti-psychiatry deny the suffering of human beings.

After debunking the claims made by the anti-psychiatry proponent Tin, this person continued to make a long list of assertions about psychiatry. When your opponent blasts you with multiple, long texts, it is very difficult to ensure that you responded to every single assertion (I am sure I accidentally missed some in this post, and I’m sure I will be hearing about it too). To a certain extent, that is the goal of this kind of shotgun approach (sometimes called the Gish Gallop in honor of the young earth creationist Duane Gish who frequently used this technique): make as many flawed and unsupported assertions as possible in an attempt to overwhelm the opposition. If any claim is forgotten or not decisively refuted due to time or space, declare victory. This is also related to what is known as the asymmetry of pseudoscience: it takes a few seconds to make a pseudoscientific claim, but anywhere from ten minutes to several hours to research and refute one of the claims in detail. In that sense, scientific skepticism is always an uphill battle. However, once the refutation is out there online, anyone who comes across a similar claim can find it with a search engine and review the material in the references. So although I have little hope that the arguments and evidence I present will convince a ingrained anti-psychiatry proponent, it is still worth doing.

The real difference between psychology, psychiatry and neurology

There seems to be a lot of confusion among anti-psychiatry proponents concerning the difference between psychology, psychiatry and neurology. Although overlapping, there are distinct differences between these three disciplines. Psychiatry and neurology, unlike psychology, are medical specialties. That means that neurologists and psychiatrists have a medical degree, whereas psychologists generally do not. Neurology and psychiatry share a considerable overlap, like rheumatology and immunology, and the distinction is mostly artifact of history. Traditional neurological conditions, such as Huntington disease and Alzheimer’s disease and traditional psychiatric conditions, such as schizophrenia or ADHD have neurological underpinnings. Simplified, neurology involves the diagnosis and treatment of conditions affecting all aspects of the nervous system: central, peripheral, somatic and autonomic (including areas they innervate such as muscles) and thus is a bit broader in scope than psychiatry. Modern research on psychiatric conditions are often interdisciplinary, involving neurologists, neuroscientists, cognitive psychologists and psychiatrists.

The mainstream scientific account of psychiatric conditions is that they result from the complex interaction of many different biological, psychological and social factors and that these psychiatric conditions produce behavioral symptoms. This is accepted across neurology, psychiatry and psychology. Tin makes the false assertion that psychiatry thinks that brain dysfunction is caused by the symptoms of psychiatry conditions. As we saw, this is wrong, as there is general agreement that brain dysfunction creates and/or constitutes the symptoms of psychiatric conditions.

ICD-9-CM, not ICD-9, is the standard for assigning codes to diagnoses and procedures in the U. S.

In an effort to maintain a consistent system of codes for various diagnoses and procedures related to the health care system, billing and health insurance, the National Center of Health Statistics (NCHS) have adapted the ICD-9 and made a version called ICD-9-CM, where the CM stands for clinical modification (CDC, 2013a). Although the ICD-9 proper was published in the late 1970s, the ICD-9-CM is updated every year (CDC, 2013b). It is the standard system for assigning codes to diagnoses and procedures in the United States is a diagnostic manual called ICD-9-CM. This, however, does not mean that medical personnel in the United States used ICD-9 instead of ICD-10 for diagnostic purposes. ICD-9-CM also, contrary to Tin, does not include homosexuality as such (). Rather, it only lists an anxiety condition caused by having an orientation contrary to ones desired self-image and the WHO rejects the notion that any particular sexual orientation is a psychiatric condition.

The poverty of anti-psychiatry dualism

Some anti-psychiatry proponents claim that psychiatric conditions do not exist. When strong evidence is presented from heritability studies, genome-wide association studies, studies on psychological and social risk factors, studies on the efficacy of specific psychiatric medications and so on for the existence of a psychiatric condition (e. g. schizophrenia or depression), the anti-psychiatry proponent instantly tries to redefine the psychiatric condition as “that is just a brain disease“. In such a no-true-Scotsman fallacy approach, the anti-psychiatry proponent can keep claiming that psychiatric conditions do not exist.

The main problem with this dishonest re-definition tactic (besides the fact that it is clearly a logical fallacy) is that it assumes substance dualism: the notion that the brain and the mind are somehow separate, distinct entities. Modern brain sciences, on the other hand, have concluded that the mind is what the brain does. Thus, the gambit of re-defining psychiatric conditions as “just a brain disease” falls apart.

Abusing dated references and the refinement of psychiatric diagnosis

In the previous post, I exposed how Tin misrepresented the scientific literature on the efficacy of antidepressants. He did not discuss two recent meta-analyses that showed that antidepressants had a clinically meaningful effect above placebo. Instead, he cited five papers he thought supported his position. In reality, they did not support anti-psychiatry, actively contradicted his position or was irrelevant to the research question. Tin did not bother to address my detailed criticisms on this issue. This behavior is a typical debating tactic used by proponents of pseudoscience: just cite a bunch of papers without discussing them in detail to give the appearance of a thin veneer of scientific credibility and hope no one bothers to actually read those papers.

Instead, Tin continues to cite papers that Tin believes support anti-psychiatry. In reality, those papers are 20-30 years old and involve finding previously unidentified non-psychiatric conditions in a small population of psychiatric inpatients as a way to test a (at the time new kind) of psychiatric physical examination. Tin tries to spin this as if meant that these non-psychiatric conditions gave rise to the psychiatric symptoms and were subsequently misdiagnosed. In reality, non-psychiatric conditions frequently found in a psychiatric physical examination involve things like high blood pressure, anemia, respiratory disease and diabetes. Hardly conditions that closely mimics known psychiatric conditions. A large proportion of these secondary physical examinations (~80%) agreed with the initial psychiatric diagnosis (Summers, Munoz, Read and Marsh, 1981)

With respect to the scientific literature, proponents of anti-psychiatry (and proponents of pseudoscience in general) find themselves in a troublesome lose-lose situation: either they take the time to read and understand the papers they want to cite (in which case they cannot cite them as support without being intentionally intellectually dishonest) or they cite the papers without reading or understanding them (in which case they risk considerable embarrassment once a scientific skeptic expose their false characterization of published research).

A psychiatric condition is not another term for demonic possession, thyroid problems or malnutrition

Tin tries to dismiss, minimize and deny the existence of psychiatric conditions by claiming that they are just thyroid issues, sexually transmitted infections or malnutrition. He even goes as far as to claim that the psychiatric condition label is indistinguishable from calling them possessed by demons. Tin fails to realize that conditions such as neurosyphilis and thyroid issues produce specific psychiatric and cognitive symptoms and can be diagnosed with a blood tests. If a person comes in with psychiatric and cognitive symptoms typical for neurosyphilis and the tests for neurosyphilis comes back positive, then it is unlikely that the doctors would confuse this with, say, clinical depression.

Intelligent design creationists are not my “blogger friends”

Tin repeats the claim that my “blogger friends” are critical of psychiatry. I refuted this in a previous post by noting that (1) a debate about details is not the same as a complete rejection of the entire research field and (2) the fact that other people are selective in their commitment to rational arguments and scientific evidence is not an argument for why I should abandon these tools. Tin does not address my argument whatsoever, but instead links to what he thinks are one of my “blogger friends”.

Guess what Tin links to? The an anti-psychiatry post on the intelligent design creationist website “Evolution News and Views”! The irony is hard to contain: intelligent design creationists reject central aspects of evolutionary biology, molecular biology and paleontology and these are as far from my “blogger friends” as you can get.

Psychotherapy has comparable levels of suicidality as antidepressants, but neither is a direct effect of treatment

Both antidepressants and drug-free psychotherapy treatment appear to increases suicidality during the first few weeks of treatment (but not after) compared with placebo (Bridge et. al. 2005). Two explanations have been proposed: (1) it is partly an artifact because in-take interviews tend to underestimate the baseline level of suicidality compared with self-reports and (2) treatment tend to increase motivation faster than it decreases other depressive symptoms, such as suicidality (thus in the initial weeks, the person undergoing the treatment has more motivation to put his or her ideas into action). Proponents of anti-psychiatry falsely claim that antidepressants increase suicidality during the entire course of the treatment. In reality, emergent suicidality is comparable in drug-free psychotherapy trials, only occurs during the first few weeks and can be explained as partly an artifact, partly a result of the increased motivations of individuals undergoing treatment. The FDA requires black box warnings on antidepressants only as a precaution and antidepressant treatment tend to decrease overall suicides (Cuffe, 2007).

The “evil corporation” distraction

Another kind of anti-psychiatry attack against modern medical science is that pharmaceutical companies sometimes behave grossly unethical and break laws regarding marketing. However, the issue of corporate ethics and regulation is a separate issue. Compare with the GM issue: the fact that GM corporations sometimes behave unethically and break the law is a problem with the regulation of corporations, not an issue with the safety and efficacy of GM crops. Similarly, the issue of pharmaceutical companies sometimes performing illegal and unethical actions is a problem concerning the regulations of corporations, not an issue related to the safety and efficacy of psychiatric medications.

The under-diagnosis of psychiatric conditions is evidence that psychiatry needs more attention

Tin notes that a large proportion of individuals with a diagnosable psychiatric condition are not diagnosed and treated. This is because a lot of factors. First, the general population does not have sufficient knowledge of psychiatry, the symptoms of psychiatric conditions or that there is help to get. Second, there have been a lot of financial cuts made to programs and hospital departments related to mental health issues. Third, there is also a lot of stigma against individuals with psychiatric conditions, partly fueled by anti-psychiatry fearmongering but also general ignorance (e. g. false and dangerous new age beliefs that you can “snap out” of it if you just think positively). In other words, the issue of under-diagnosis does not support anti-psychiatry beliefs.

It is also both curious and directly contradictory that proponents of anti-psychiatry appeal to the existence of under-diagnosis and alleged over-diagnosis in an effort to undermine psychiatry. They cannot have their cake and it eat as well.

Electro-convulsive therapy (ECT) is effective and does not cause lasting brain damage

ECT is a last-resort treatment given to patients with severe, resistant-treatment depression. It has been shown to be effective and it does not produce any lasting brain damage (Abrams, 2000; Devanand et al. 1994, Fink, 2000). The individual undergoing ECT is given general anesthesia and a muscle relaxant. The death rate for ECT is 2-10 per 100k people (10 times lower than the risk of childbirth), comparable to the risk of death from the general anesthesia alone. Some side-effects of ECT includes headaches, muscles aches, nausea, loss of memory of the events just before the treatment. For some, this memory loss can remain for up to 6 months. The vast majority of individuals undergoing ECT would want to do it again if their depression recurred (98%) and view it positively (91%). Most patients undergoing the treatment consider it less scary than going to the dentist (Lilienfeld, Lynn, Ruscio and Beyerstein, 2010).

Single pulse Transcranial magnetic stimulation (TSM) does not induce seizures

Transcranial magnetic stimulation is a method to activate neurons in a specific area of the brain. If they are involved in a certain ongoing cognitive function (reading, doing a puzzle, counting etc.), then that is disrupted for a few hundreds of a seconds. The effects are completely reversible and causes no lasting harm. The major drawback is that each pulse is very loud (~100 dB), so participants have to use headphones. TSM allows researchers to study reaction time tasks in an unprecedented way. Before TSM, researchers were restricted to study individuals with already existing brain lesions or causing brain lesions in animals. Now, researchers can use a safe and effective method that does not require giving experimental brain lesions to animals or restrictions to individuals who already have brain lesions. Single-pulse TSM is generally considered to be safe, but TSM using repetitive pulses has a small risk of causing a seizure in susceptible individuals. Because of this, researchers exclude individuals with a history of epilepsy, pacemakers and other medical devices. They also established stringent guidelines, such as the maximum pulse intensity and the maximum number of pulses to use (Ward, 2012).

Involuntary psychiatric hospitalization is a last resort and heavily regulated

Hospitalization for a severe psychiatric condition does not need to be involuntary. If it in voluntary, it is tightly regulated. This section will look closer at involuntary psychiatric care in Sweden and the United States.

In Sweden, a person can only be subjected to involuntary psychiatric care if three key criteria are all fulfilled: the person has a severe psychiatric condition, the person refuses voluntary treatment or lacks the ability to make informed decisions and the person cannot be taken care of in any other way than 24/7 psychiatric care. It starts with a general practitioner that writes a certificate of care where he or she has to justify all of these requirements. A specialist medical doctor has to critically examine this certificate of care within the first 24 hours after the involuntary commitment. If requires, the time period can be extended to four weeks at most and if the medical doctors want to increase the time further they need to demonstrate this in a special court proceeding where the patient has the right to legal assistant. As any legal case, this can be appealed all the way up to the Supreme Administrative Court of Sweden (the equivalent of the Supreme Court, but for trying the actions of government instead of a criminal). Voluntary psychiatric care can only be converted to involuntary psychiatric by the chief senior doctor and only if a second doctor writes the certificate of care and the decision is tried in court the next day (Allgulander, 2008, pp. 67-74).

In the United States, the precise regulations varies by state. In North Carolina, for instance, a written statement has to be deposited with the Clerk of Superior Court or Magistrate of District Court. The person is then examined by a medical professional and if this expert concludes that the person has a psychiatric condition and pose a danger to him- or herself or others, this individual will be sent to a hospital. At the hospital, a second such examination will be done by a medical doctor employed there and if that doctor concurs, then involuntary admission occurs. After taken into custody, a court procedure must take place before 10 days has passed and the judge decides how many days involuntary psychiatric care will be in effect before another court proceeding is held (NC Department of Health and Human Services, 2013).

Published data on psychiatry have been replicated and translated into clinical practice

Since the advent of science-based psychiatry, there have been many revolutionary improvements in the detection, diagnosis and treatment of psychiatric conditions. Two key examples are the development of first generation antipsychotics was a major contributor to the deinstituionalization of psychiatric hospitals starting in the 1960s and the development of cognitive behavioral therapy turned out to be a substantial improvement in the efficacy of psychotherapy for a wide range of psychiatric conditions, such as clinical depression and anxiety. Tin ignores all of this and incorrectly state that no research finding has been replicated or translated into clinical practice. In reality, most of the improvements in psychiatry seen during the past 50 years is because of advances in psychiatric research.

Anti-psychiatry contributes to stigma related to psychiatric conditions

By denying, dismissing or minimizing the existence of psychiatric conditions, proponents of anti-psychiatry contributes to the stigma related to psychiatric conditions. By spreading dangerous myths about psychiatric medications, proponents of anti-psychiatry contributes to the stigma related to psychiatric conditions. By demonizing psychiatrists, proponents of anti-psychiatry contributes to the stigma related to psychiatric conditions. By rejecting an entire medical field and research discipline without being intimately familiar with the actual scientific facts, proponents of anti-psychiatry contributes to the stigma related to psychiatric conditions.

Conclusion

Tin continues to make a number of errors such as confusing the difference between scientific areas (such as psychology, psychiatry and neurology) and fails to understand the difference between ICD-9, ICD-9-CM and ICD-10. A number of anti-psychiatry tropes are deployed and deflated such as the anti-psychiatry dualism of “that’s just a brain disease”, the suicidality gambit and the evil corporation distraction. Predictably, Tin refuses to engage any of the arguments against the papers he attempts to cite in favor of his position and spends most of the time on spreading fearmongering about psychiatric treatments such as antidepressants, ECT and involuntary psychiatric care.

References

Abrams, Richard. (2000). … and there’s no proof of lasting brain damage. Nature, 403(6772), 826-826.

Allgulander, Christer. (2008). Introduktion till klinisk psykiatri (2nd edition). Studentlitteratur: Lund.

Bridge, J. A., Barbe, R.P., Birmaher, B., Kolko, D. J. Brent, D.A. (2005). Emergent Suicidality in a Clinical Psychotherapy Trial for Adolescent Depression. Am J Psychiatry 162(11). 2173-2175.

CDC. (2013a). International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Accessed: 2013-11-16.

CDC. (2013b). ICD-9-CM Addenda, Conversion Table, and Guidelines. Accessed: 2013-11-16.

Cuffe, Steven P. (2007). Suicide and SSRI Medications in Children and Adolescents: An Update. DevelopMentor. Accessed: 2012-04-18.

Devanand D.P., Dwork A.J., Hutchinson E.R., Bolwig T.G., Sackeim H.A. (1994). Does ECT alter brain structure? Am J Psychiatry. 151(7):957-70.

Fink, Max. (2000). ECT has proved effective in treating depression… . Nature, 403(6772), 826-826.

Lilienfeld, Scott O., Lynn, Steven Jay, Ruscio, John, & Beyerstein, Barry L. (2011). 50 Great Myths of Popular Psychology: Shattering Widespread Misconceptions about Human Behavior. West Sussex: Wiley-Blackwell.

NC Department of Health and Human Services. (2013). Voluntary and Involuntary Commitment. Accessed: 2013-11-16.

Summers WK, Munoz RA, Read MR, Marsh GM. (1981). The psychiatric physical examination – Part II: findings in 75 unselected psychiatric patients. J Clin Psychiatry. 42(3):99-102.

Ward, Jamie. (2012). The Student’s Guide to Social Neuroscience. Hove and New York: Psychology Press.