Imagine that Scientific American published a blog post promoting the idea that we should abandon a disease-centered perspective on autoimmunity because the simplified notion of “immunological imbalance” surely cannot explain all aspects of autoimmune conditions. Imagine that it argued that heart diseases are not really diseases since cognitive and lifestyle interventions can sometimes decrease symptoms of many heart-related conditions and because social factors like poverty and childhood experience also influence heart disease risk. Imagine that the post claimed that biological explanations of autoimmunity implies a deterministic worldview that stigmatizes patients with autoimmune conditions and that biological factors should therefore not be emphasized in the understanding of these conditions.
Most rational and scientifically-minded people would rightly dismiss such “arguments” as unscientific nonsense that was clearly based on several, profound misunderstanding of the results of basic medical research. A lot of them would also seriously consider unsubscribing from Scientific American content because of the massive credibility loss. Yet when it comes to psychiatry and psychiatric conditions, these ignorant claims are often prominently featured online by popular science magazines without any critical consideration.
Recently, Scientific American Mind published an anti-psychiatry piece written by clinical psychologist Peter Kinderman on their guest blog and it regurgitates a large number of commonly used anti-psychiatry tropes. It misrepresents mainstream psychiatric explanations of psychiatric conditions as “chemical imbalance”, when it is really about a complex interaction between many different biological, psychological and social factors. It dismisses biological explanations of hallucinations and delusions by pointing out that social factors also play a role, when both are clearly important. It misunderstands the nature of biological heritability by conflating it with immutable, when genes are risk factors, not absolute determinants. It erects a false dichotomy between medication and psychotherapy and claim that since psychotherapy can often be effective, biological explanations and medical treatments should be deemphasized. In reality, the best available treatment for a wide range of psychiatric conditions seems to be a combination of medication and psychotherapy.
Scientific American tries to avoid responsibility by posting a disclaimer (not once, but twice) that the “views expressed are those of the author and are not necessarily those of Scientific American”, but the fact remains that Scientific American has an intellectual and moral responsibility not to promote flawed and pseudoscientific content. This incident shows that they failed that responsibility, and in doing so, join the ranks of bad science journalism that increasingly plague popular science spaces on the Internet.
The “chemical imbalance” straw man
Psychiatric conditions influenced by a complex interaction of biological, psychological and social factors. A common anti-psychiatry trope is to misrepresent the mainstream view described above as merely being about “chemical imbalances”. Although neurotransmitter systems does play a role in the etiology of psychiatric conditions, it is vital to emphasize the role of interacting biological, psychological and social factors. Even a cursory look in a modern introductory textbook in psychology for factors influencing e. g. depressions makes this obvious (Passer et. al, 2009, p. 24):
Biological factors: genetic predisposition, chemical factors in the brain affected by antidepressants, perhaps an exaggerated form of adaptive withdrawal shaped by evolution etc.
Psychological factors: negative thought patterns/distortions, pessimistic personality style, susceptibility to loss and rejection, perhaps linked to early life experiences etc.
Environmental factors: previous life experiences of loss and rejection, current decrease in pleasurable experiences, increased life stress, loss of social support, cultural factors etc.
Thus, when Kinderman claims that modern psychiatry is committed almost exclusively to explanations based on “chemical imbalances”, he is attacking a straw man.
He repeats this assertion throughout his post by erecting a false dichotomy between biological and social factors. In his view, evidence of social factors being important in the etiology of psychiatric conditions is evidence against biological factors being important:
Many people continue to assume that serious problems such as hallucinations and delusional beliefs are quintessentially biological in origin, but we now have considerable evidence that traumatic childhood experiences (poverty, abuse, etc.) are associated with later psychotic experiences.
His prime example is suicide, which seems to be affected by the recent economic recession. However, the evidence that social factors are important is not argument against biological factors. Perhaps the best example is the condition called phenylketonuria (PKU). Individuals with PKU has a mutation in a liver enzyme that severely diminishes the ability of the person to break down the amino acid phenylalanine. Instead, it is converted to another substance that accumulates and causes long-term harm. The fact that a diet high in phenylalanine has a strong influence on the condition does not mean that the underlying mutation is less relevant. Both biological and environmental factors are important in their own right.
Astonishingly, he even claims that mainstream psychiatry thinks that psychiatric conditions are “random” (!):
It’s all too easy to assume that mental health problems — especially the more severe ones that attract diagnoses like bipolar disorder or schizophrenia — must be mystery biological illnesses, random and essentially unconnected to a person’s life.
This shows that Kinderman is almost completely disconnected from modern psychiatry. Psychiatric conditions, like many other conditions, are often influenced by biological factors. However, no serious researcher or clinician is claiming that these conditions are unrelated to the psychology of the individual or social factors and certainly not that they are random. That absurdity of that claim is on par with the equally flawed creationist claim that evolution is random.
Difficulty distinguishing between different conditions reflects underlying biology
It is sometimes difficult to distinguish between psychiatric conditions that are very similar. This is due to many factors. Psychiatrists, like all medical doctors, are humans and not supercomputer. Another factor that is very important to keep in mind is comorbidity: individuals with e. g. depression are also likely to have anxiety and vice-versa. Thus, many individuals do not have “pure” conditions, but rather complex, overlapping diagnoses which makes exact differential diagnosis challenging. Also, one tantalizing possibility is that many different psychiatric conditions share an underlying genetic architecture by sharing genetic risk factors and are thus not as distinct as traditional non-genetic research envisioned. Ironically, Kinderman references one such paper, Cross-Disorder Group of the Psychiatric Genomics Consortium (2013), in a different section of his diatribe, clearly without recognizing its practical significance.
Inter-rater agreement still going strong
A psychiatric diagnosis is reliable if different mental health professionals often agree on whether or not specific patients have it. Reliability is often operationalized as inter-rater agreement measured by Cohen’s kappa (κ). A value of 1 indicates perfect agreement, whereas a value of 0 indicate only chance agreement.
Kinderman complains that the reliability of psychiatric diagnoses have been declining over time. However, if we look at the paper concerning initial field trials that he references we see that the kappa values are pretty high for a large number of DSM diagnosis (Freedman, 2012) as 14 out of 20 had good or very good agreement. It is also worth remembering that many of these conditions are very similar or overlapping, so some degree of disagreement is expected. Cohen’s kappa also depends on the population prevalence of the condition and the breadth of the diagnostic category being examined. To be sure, it is always good to improve reliability of psychiatric diagnoses, but we should not sacrifice realistic classification schemes just to blindly optimize a single parameter.
“Missing heritability” is a general issue with genome-wide association studies
The issue of “missing heritability” is a current unsolved problem in genetics (Manolio et al., 2007; Eichler et al., 2010). It is based on the observation that the heritability of identified genetic risk factors estimates can only account for a fraction of observed heritability estimates from classic twin and adoption studies. This means that it is difficult to identity the precise nature of genetic risk factors behind medical conditions. Several proposed solutions are currently being discussed, such as genetic interactions, copy number variants and that the precise identity of genetic risk factors differs between populations.
Kinderman ignores all of this and says that it counts as a scientific reason to be “skeptical” about mainstream psychiatry. However, that argument can be made against any condition that is influenced by more than one genes. Would Kinderman ever claim that heart disease, autoimmunity (or even mundane phenotypes such as tallness) did not have important biological causes simply because of the issue of missing heritability? Hardly.
Thomas Insel supports a stronger biological perspective, not anti-psychiatry
Kinderman then goes on to deploy another classic anti-psychiatry trope based on misrepresenting a statement made by Thomas Insel (the director on National Institutes of Mental Health) a while back. Right now, the DSM is atheoretical, which means that it does not include information about the causes of the condition in question. Insel wants to include biological data, such as information on genetic risk factors and brain scan imagery, into the diagnostic procedure. So while anti-psychiatry proponents abuse Insel in an effort to undermine mainstream psychiatry and diagnostic manuals, Insel wants to make psychiatry more biological, not less. This anti-psychiatry trope is discussed in additional details in this article.
The explanatory scope of neurotransmitter alterations
Kinderman attacks neurotransmitter-based explanations:
Some neuroscientists have asserted that all emotional distress can ultimately be explained in terms of the functioning of our neural synapses and their neurotransmitter signalers. But this logic applies to all human behavior and every human emotion and it doesn’t differentiate between distress — explained as a product of chemical “imbalances” — and “normal” emotions
Let us compare with immunology and see how the claim reads:
Some immunologists have asserted that all immunological dysfunction can ultimately be explained in terms of the functioning of our immune system and their chemical signalers. But this logic applies to all immune system reactions and it doesn’t differentiate between immunological dysfunction — explained as a product of immunological “imbalances” — and “normal” immune system function.
When put in this way, we can easily see the absurdity of his claim. What is being offered as a contributing factor is not brain function generally, but specific alterations in neurotransmitter systems. Similarly, it is not immune system functioning generally that causes autoimmune diseases, but particular alternations in immunological reactions.
Medication and psychotherapy together is usually the best treatment
Kinderman deploys yet another classic anti-psychiatry talking-point: the dismissal of medical treatment by pointing out that psychotherapy is also beneficial. However, he fails to mention that the best available treatment is usually a combination of medication and psychotherapy (e. g. DeRubeis et al., 2008). Thus, the efficacy of psychotherapy is not an argument against medication. Rather, it is an argument for combination therapy.
Heritable does not mean immutable
Kinderman thinks that biological aspects of psychiatry contributes substantially to mental illness stigma:
Unfortunately, the emphasis on biological explanations for mental health problems may not help matters because it presents problems as a fundamental, heritable and immutable part of the individual.
This is only because people lack a basic understanding of how genetics work. If a phenotypic feature is heritable, it means that variation in that trait can be accounted for by variations in genotype. Thus, the existence of genetic risk factors does not imply genetic determinism because other factors, both protective factors and risk factors, are important. Taking the example of PKU discussed earlier, eliminating phenylalanine from the diet greatly protects the individual from the detrimental effects of the condition. Having a mutated liver enzyme of this kind does not mean that PKU symptoms are “immutable”.
It is therefore unreasonable to say that a perspective does not reduce stigma if the problem really is that the general public does not understand that perspective.
Book advertisement, mental illness denial, anti-medication
So what is Kinderman’s end game? As it turns out, it is to promote his new book on psychiatry. So what are the main ideas of his new book?
– That mental health “services should be based on the premise that the origins of distress are largely social”. This means, despite his own lip-service, that we should replace the mainstream account of psychiatric conditions as being caused by a complex interaction between biological, psychological and social factors with a strong emphasis on social factors in isolation. This would directly harm the scientific understanding of the causes of psychiatric conditions, and indirectly harm patients since treatments would be based on a strongly incomplete understanding of the conditions in question.
– That psychiatric diagnoses are false, irrelevant and harmful since they “lack reliability, validity and utility”. This is despite the fact that one of his references shows that most psychiatric diagnoses have a good to very good reliability.
– That we should “sharply reduce our reliance on medication”, that we “should not look to medication to ‘cure’ or even ‘manage’ non-existent underlying ‘illnesses'” and that a “disease model is inappropriate”, thus making it anti-medication to the core and even going so far as denying the very existence of psychiatric illnesses.
If there was any doubt that Kinderman’s post was deeply anti-psychiatry, his last passage completely annihilated it.
There is also a link in Kinderman’s byline to an online course he manages on “exploring our understanding of mental health and well-being”. While the course is “free”, learners need to pay him to obtain a “statement of participation”. In other words, it is not a free course if you want it to mean anything official. According to a Guardian article on the topic, a statement of participation costs 24 GBP (about 40 USD), and if you want to take an exam, you need to fork up 120 GBP (about 190 USD).
The intellectual responsibility of Scientific American
Why did Scientific American post an article promoting anti-medication and the absurd notion that psychiatric conditions do not exist? The reasons are unclear at the moment, but it is clear that they failed in their intellectual responsibility by publishing pseudoscientific nonsense. Their attempt at distancing themselves from the content with multiple disclaimers also indicates that they are acutely aware about the problems in that post, or about the problem with their set-up generally. Defenders might say that this was not the fault of Scientific American, but rather the individual editor(s) of Scientific American Mind that allowed this to be posted on a blog. However, Scientific American and its subsidiaries have an intellectual and moral responsibility for content on their websites, regardless of it being in an article or blog format.
References and further reading
Cross-Disorder Group of the Psychiatric Genomics Consortium. (2013). Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis. The Lancet 381(9875): 1371-1379.
DeRubeis, R. J., et al. (2008). Cognitive therapy versus medication for depression: treatment outcomes and neural mechanisms. Nat Rev Neurosci 9(10): 788-796.
Eichler, E. E., et al. (2010). Missing heritability and strategies for finding the underlying causes of complex disease. Nat Rev Genet 11(6): 446-450.
Freedman, R., et al. (2013). The Initial Field Trials of DSM-5: New Blooms and Old Thorns. American Journal of Psychiatry 170(1): 1-5.
Manolio, T. A., et al. (2009). Finding the missing heritability of complex diseases. Nature 461(7265): 747-753.
Passer, M., Smith, R., Holt, N., Bremner, A., Sutherland, E., & Vliek, M. (2009). Psychology: The Science of Mind and Behavior. New York: McGraw-Hill Education.