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How a Scientific Field Can Collapse: The Case of Psychiatry

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Psychology has long struggled to be considered scientific, given the checkered history of its eccentric pioneers, like Freud and Jung. Each of the contradictory theories emerging from psychology has struggled to do better at prediction or explanation than the “folk psychology” ordinary people use to gauge the motivations and behaviors of their fellow human beings. And the recent cases of outright fraud among some of social psychology’s leading lights (examples in the New York Times and Nature) have made the field suspect, some would say a laughingstock as science.
Psychiatry, though, was supposed to be better. Its practitioners had to earn an MD. It had a widely accepted, peer-reviewed guidebook, the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by its professional society, the American Psychiatric Association. With its focus on observable symptoms, presumably rooted in biology, it had all the trappings of science. The things being said about psychiatry now, though, on the eve of publication of its latest upgrade, the DSM-5, are revealing it to be a science in crisis — if it ever was a science at all. As we list the problems, ponder whether many of the same criticisms could be leveled against Darwinism.
DSM-5, coming out on May 22, is the latest edition of the official diagnostic “bible” for psychiatrists that had its genesis in 1952. Writing for Nature, David Dobbs says,

Each such manual, DSM or others, has tried to improve on its predecessor. All have failed, says psychotherapist Gary Greenberg in his entertaining, biting and essential The Book of Woe. But none has failed so spectacularly as the DSM-5. (Emphasis added.)

DSM-5 removes some diagnoses, like Asperger’s syndrome, reclassifies others, and adds a number of new conditions that are, to most of us, just weird: like “Skin Picking Disorder,” “Sluggish Cognitive Tempo,” and “Compulsive Hoarding.” What about the new “Hypersexual Disorder”? Are psychiatrists just giving excuses for irresponsible behavior? Is psychiatry “cutting nature at its joints” or just manufacturing artificial pigeonholes?
Writing for New Scientist, psychiatrist Allen Frances doesn’t believe that one manual should dictate U.S. health research. The new diagnoses and reductions in thresholds for old ones “expand the already stretched boundaries of psychiatry and threaten to turn diagnostic inflation into hyperinflation,” he says. By inflation, he’s speaking of the tendency to overdiagnose, as when too many boys are diagnosed with “Hyperactivity Disorder” and given ritalin to calm down what might in other contexts be considered normal boyish behavior. Worse, the DSM threatens psychiatry’s standing as a science:

In my opinion, the DSM-5 process has been secretive, closed and sloppy — with confidentiality restraints, constantly missed deadlines, botched field testing, the cancellation of an important quality control step, and a rush to publication. A petition for independent scientific review endorsed by 56 mental health organisations was ignored. There is no reason to believe that DSM-5 is safe or scientifically sound.

According to Nick Craddock, professor of psychiatry at Cardiff University, also writing for New Scientist, psychiatry is still waiting for its “Higgs boson moment,” when some prediction-come-true from biological theory will actually confirm its legitimacy. He says, “Not since Freud’s pseudoscientific theories early last century has psychiatry claimed any broad theoretical basis for making sense of our normal and abnormal feelings, thinking and social behaviours — the complexities at the heart of being human.” In other words, psychiatry never made it to scientific status in the first place. Its claims remain “atheoretical,” he believes, even though he is optimistic its day will come.
In another article for New Scientist, “Psychiatry divided as mental health ‘bible’ denounced,” Andy Coghlan and Sara Reardon point out other problems, like internal squabbling:

The world’s biggest mental health research institute is abandoning the new version of psychiatry’s “bible” — the Diagnostic and Statistical Manual of Mental Disorders, questioning its validity and stating that “patients with mental disorders deserve better”. This bombshell comes just weeks before the publication of the fifth revision of the manual, called DSM-5.

Even though the DSM has been “the mainstay of psychiatric research for 60 years,” practitioners are rising up against it:

The DSM has been embroiled in controversy for a number of years. Critics have said that it has outlasted its usefulness, has turned complaints that are not truly illnesses into medical conditions, and has been unduly influenced by pharmaceutical companies looking for new markets for their drugs.

Thomas Insel, director of the National Institute of Mental Health, calls for “diagnoses based on science not symptoms.” Sounds good, but that would require theoretical bases for linking genes and neurons to behavior, a devilishly hard business. Insel believes it will take a decade to achieve the “precision medicine” desired. But what if it never comes? Michael Owen at the University of Cardiff says, “These are incredibly complicated disorders. To understand the neuroscience in sufficient depth and detail to build a diagnosis process will take a long time, but in the meantime, clinicians still have to do their work.” That implies that psychiatrists are treating patients on a non-scientific basis. And now, many are abandoning all they have — their official guidebook. As MD’s they might be qualified to diagnose physiological symptoms that could affect behavior, but on what scientific basis could they diagnose mental disorders any better than a pastor, rabbi or wise older person?
Dobbs’s review in Nature of Gary Greenberg’s new book, The Book of Woe: The DSM and the Unmaking of Psychiatry, is the most devastating critique of psychiatry as a science. Dobbs writes under the headline: “Psychiatry: a very sad story.” He notes that a century ago, psychiatrists considered “masturbatory insanity” and “wedding night psychosis” as mental illnesses. That those categories were dropped and new ones added in the interim suggests psychiatry lacks scientific footing, and instead evolves according to cultural norms. Yet the APA vigorously defends DSM-5, partly because it relies on sales for revenue. Greenberg writes about the sordid history of the DSM:

From the adventure in bookmaking-by-committee that followed, Greenberg builds a splendid and horrifying read. He digs up delicious dirt; extracts from the rivalrous main players a treasure chest of kvetching, backbiting, rebuttal, regret, sibling rivalry, Oedipal undercutting and just plain pithy talk. He relates gruesome sausage-making stories about the APA’s tortured attempts to refashion rusty diagnoses or forge shiny new ones. (The aetiology of that new temper-dysregulation disorder? You’ll throw a fit.)

Greenberg is not just an outsider. He participated in a clinical trial. “The process proved so convoluted that he wanted to apologize to one patient for the ‘inadequacy, the pointlessness, the sheer idiocy of the exercise,'” Dobbs writes.
Psychiatrists are fallible members of the human race they’re trying to diagnose. On Live Science, Tanya Lewis uncovered the “cutthroat side of science” — how not a few scientists lie, cheat and steal to gain recognition. “In light of all these problems, science loses some of its luster,” she said, excusing it because “scientists are humans, too.”
In his book, Greenberg alleges that many psychiatric diagnoses are “constructs of convenience rather than descriptions of biological ailments.” It only pretends to accomplish anything: the DSM “dresses up symptoms as diseases that are not real and then claims to have named and described the true varieties of our suffering.” The APA has been more concerned about consistency and consensus than about truth.

A slippery deal, but essential. For by formalizing this scheme, psychiatry can claim medical legitimacy and accompanying insurance coverage and pay rates so that it can help people. Unfortunately, writes Greenberg, this scheme has led everyone, psychiatrists included, to talk about and treat DSM‘s conceptual constructs as if they are biological illnesses — a habit that has bred troubles ranging from overconfidence to incestuous liaisons with Big Pharma.

All this talk of “scheming” sounds political, not scientific. Indeed, Dobbs points out that some practitioners feel it’s time to start over. Yet here is a major field of “science” with important consequences for human beings. Some patients, trusting their psychiatrist, come to think they are “wired differently” and have a medical excuse for their behavior. Maybe psychiatry should just recognize variations in normal human behavior rather than categorize people as having biological dysfunctions. Who decided that a person grieving for more than two weeks over the loss of a loved one should be diagnosed with clinical depression?
Dobbs ends with an indictment of psychiatry as a (so far) failed science:

For more than 100 years, psychiatry has been getting by on pseudo-scientific explanations and confident nods while it waited for the day, always just around the corner, in which it could be a strictly biological undertaking. Part of the DSM-5‘s long delay occurred because, a decade ago, APA leaders actually thought that advances in neuroscience would allow them write a brain-based DSM. Yet, as former APA front liner Michael First, a psychiatrist at Columbia University in New York, confirms on Greenberg’s last page, the discipline remains in its infancy.
Greenberg shows us vividly that psychiatry’s biggest problem may be a stubborn reluctance to admit its immaturity. And we all know how things go when you won’t admit your problems.

These stinging criticisms of psychiatry as a pseudoscience can be summarized as follows:

  1. Long history of failure.
  2. No theoretical basis grounded in biological reality.
  3. Reliance on a book.
  4. Conflicts of interest.
  5. Lack of quality control.
  6. Ignoring critics.
  7. Focus on symptoms instead of causes.
  8. Category errors: confusing arbitrary classification with reality.
  9. Attempting to pigeonhole complex entities into simple categories.
  10. Concern for consistency and consensus over empiricism.
  11. Tortured attempts to fashion theories.
  12. Formalizing schemes to gain legitimacy.
  13. Promissory notes to do better in the future.
  14. Hopes that other sciences will legitimize it.

Evolutionists would probably argue against our using #2, 4, and 5 as criticisms of neo-Darwinism, and would quibble about 3, 8, 11 and perhaps others. But Darwin skeptics could charge, and have charged, evolutionists with all these flaws. Let’s briefly see if psychiatry’s failures also apply to Darwinists:

  1. Failure to explain the Cambrian Explosion since Darwin.
  2. Extrapolating natural selection far beyond the evidence.
  3. Continuing to exalt Darwin and his Origin.
  4. Scheming to keep criticisms of Darwin out of journals and classrooms.
  5. Flimsy assertions that “it evolved,” with little rigor.
  6. Refusing to hear or publish scientific critiques of Darwinism.
  7. Use of homology as evidence and explanation for adaptation.
  8. Inventing terms like “kin selection” and “evo-devo.”
  9. Attributing the whole biosphere to undirected causes.
  10. Claiming the consensus accepts evolution in every meaning of the word.
  11. Applying natural selection recklessly to everything, even the universe.
  12. Scheming to prevent intelligent design from gaining a hearing.
  13. Always saying “more research is needed.”
  14. Misappropriating genetics, computer science, and development to support it.

To the extent that these kinds of criticisms should debunk psychiatry as a science, they should also debunk Darwinism as science. Science is a noble word. Its standards should be high. Often, however, the word is applied too broadly; it stands for too little because it stands for too much. Having a degree in science, belonging to a scientific society, or getting one’s ideas published in a journal are no guarantee you are “getting the world right” when it comes to describing entities as complex as human behavior or the biosphere.
If psychiatry doesn’t survive its current crisis, it will demonstrate that an entrenched, respected field can collapse, even after over a century of trying to act like a science. We shouldn’t think that Darwinism is impregnable. Many of the same criticisms apply. Darwinism’s collapse will occur when insiders are no longer afraid to level the same long-standing criticisms that outsiders have lodged for decades. Keeping those critiques alive is key. A true science endures criticism. A pseudoscience ignores it or tries to squelch it. Darwinists should invite scrutiny, for as Darwin himself said, “A fair result can only be obtained by fully stating and balancing the facts and arguments on both sides of each question.”
Image: Freud’s couch, roberthuffstutter/Flickr.

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