Should Mental Disorders Have Names?

The article is sort of strange in that it brings up these issues and then fails to discuss the huge range of research in this area. The p-factor stuff is sort of hot lately but is just one subtopic in a vast area, somewhat controversial, and more of theoretical interest than clinical utility.

Part of the problem is that there are different purposes for classification systems. I think you're right in that categorical diagnoses have all the appeals you mention at least among some subgroups, but those are a little detached from (1) how many clinicians actually think about a lot of problems, and (2) how many researchers think about these things. Putting aside the "syndrome"-favoring clinicians, a lot of clinicians focus more on behavioral patterns, which tend to be very specific, more targetable, and far removed from broad categorical labels. Many researchers are moving away from these categorical labels also, for many reasons, but mostly generally because the patterns you see in behavior don't map onto the categories in the DSM in reality. Think blood pressure or height as analogies for depression or disorganized thinking, rather than Huntington's disease or malaria.

RDoC is important to mention but it's ending up to be about as controversial as the DSM for various reasons. First, it suffers from the same "names by committee fiat" as the DSM, which is problematic when you are dealing with something like neurobehavioral pathology, which can be examined at many levels and from many directions, which is fuzzy and complex, and about which we know very little. Second, despite its noble intents, was kind of developed by neuroscientists with little connection to actual clinical human behavior. I don't mean any offense to them, but when you get together a bunch of researchers, a substantial number of whom study rodent neurobiology, you're going to start losing touch with what clinicians are actually wrestling with in clinical settings. Look for psychosis or subdimensions of psychosis, for example, and it's missing from RDoC. I like to think of RDoC as "revenge of the neuroscientists," people who got tired of trying to connect their research to human public health, and decided to just redefine problems so it's closer to their own research. A similar initiative is HiTOP, which is more phenotypically focused, and uses statistical/quantitative models for classification rather than committee decisions (I'm not saying HiTOP is better, it just is a similar but different approach from RDoC).

I think the issue is not whether or not mental disorders should have names, it's whether or not there are mental disorders per se, or how to best describe mental-neural-behavioral patterns. You need to be able to quantify to study something scientifically, and quantifying implies labeling; the question is how.

By that logic, we shouldn't name species either.

Which then mysteriously only seem to work on a small fraction of people diagnosed with that disorder, no?

A substantial portion of the things we refer to as "mental illness" are the after-effects of trauma. When you break your leg and you can't walk for 6 months afterwards, people don't say you have a "leg illness". It's not some unspecified thing which caused your leg to stop performing like most people's legs. It's a fracture. If set properly and given time to heal, it will resume normal functioning. If it's never set, or if it gets reinjured, it may lead to a permanent disability.

Minds can be broken as well. Any one who has ever experienced an abusive relationship knows this. Survivors of child abuse know this. A "mental fracture" isn't primarily physical, like a fracture of the leg, but it has a similar effect in terms of impairing the organ to perform its role correctly.

But mental injuries can be "set" and healed, just like physical ones. Perhaps not 100%, perhaps there will always be scar tissue or some version of impaired mobility where the injury occurred. But injuries heal with time, given proper care.

I am aware that this concept is fairly at odds with the western conception of mental health with its myriad disorders, all of which are unexplained and presumably lifelong diseases. I attribute this entire weird world of DSM pseudoscience with its gargantuan and ever-growing list of labels to the massive social pressure against dealing with the actual problem of trauma and abuse.

Correctly diagnosing someone with a "mental injury resulting from trauma/abuse" would lead to some extremely difficult conversations, which most people (even the ones experiencing the abuse) would prefer not to have.

I do wonder if we're absolutely fucking up the minds of a generation of people by giving more and more people the made up labels. They come hand in hand with stigma and insecurity. We've been loosening diagnostic criteria continually on the dubious grounds that we "better understand" mental illness in the past. When it gets down to brass tacks we just decided as society labelling more people as "different" and treating them differently was for the best. Beyond the concern I have for individuals more and more people are qualifying for disability assistance every year and its unsustainable financially.

I do wish we had a model of mental health that was more focused on addressing more granular individual strengths/weaknesses and one less prone to just saying a broad swathe of people who are nothing alike are part of the same "spectrum".

I think he ever-so-briefly touched on a different angle of that problem: "The psychoanalysts don’t like it because it ignores the “unique milieu of individuality.” The more biologically-oriented clinicians don’t like it because it ignores biology. The DSM lacks “validity,” they say. A diagnosis based on a combination of symptoms is, they might argue, like a constellation of stars — sure, you could reliably identify the Big Dipper, but no one would argue that the Big Dipper is a valid interstellar system. It’s just a name."

The problem is that the label matches no defined model; which is why I think that everyone dislikes it.

>I hate labels, but they are a useful communication tool.

Agreed but without the matching underlying models, they're just added toil; especially, if they're only "valid" in niche use-cases (such as clinical settings).

For example, we have a general idea of what Schizophrenia is but when it comes to the classification, diagnosis, and/or treatment, that's when we lose context. Schizophrenia isn't - implicitly - the same classification, diagnosis, and treatments across the board for every patient. So, effectively, you're coupling a large group of individuals under a very generic label, which has no effective model applied to it.

However, there are stigmas attached to certain diagnoses and not their differentials so some people prefer less negative labels.

In my experience with world class psychiatrists your views are a little outdated, generally the more academic practitioners are much more like Dr Barron.

The biggest advance in the history of psychotherapy was to stop asking why and start asking what and how.

The psychoanalysts broadly believed that mental disorders could be treated by revealing and resolving unconscious conflicts and forgotten childhood memories. That's a very slow process, and eventually randomised controlled trials would demonstrate that it wasn't particularly effective.

Rational emotive and cognitive behavioural therapists essentially argued I don't care why you're nuts, I just want to teach you how to be less nuts. If you have habitually fearful or negative thoughts, you can learn to disregard those thoughts as unhelpful and consciously replace them with more useful thoughts. Knowing who to blame for your cognitive bugs doesn't really help you fix them. Aaron T. Beck had the good sense to subject his psychotherapeutic approach to randomised controlled trials, demonstrating that a relatively short course of cognitive behavioural therapy was at least as effective as several years of psychoanalysis.

Psychiatry, clinical psychology and psychotherapy undoubtedly has a lot of shortcomings and there are a lot of patients we don't yet know how to treat effectively. A far bigger problem however is lack of access - the vast majority of people who could benefit from psychiatric medicine simply don't get treated. In the developed world, it's usually fairly easy to get prescribed medication, but there are often long waits or financial barriers to access psychotherapy. In the developing world, most people can't even access SSRIs despite the cost being around $1 a month. Stigma and a lack of awareness are still a substantial barrier to accessing care.

We need better treatments, but the priority right now must be simply to get more people to try the treatments we do have. Trying a treatment with a 40% success rate is obviously better than doing nothing, but nothing is still the default and it's causing immense amounts of needless suffering.

I'm not sure that's a fair criticism. They're certainly not doing a perfect job but the number of people who have a higher quality of life than a century ago is a real success.

There are people who are living fulfilling lives who would have been housed in mental institutions or who would have long since killed themselves, given the state of mental health care 50 or 60 years ago.

"So you say your father broke your arm.... This isn't a bone fracture! It's bad parenting, now go home, no medical attention for you".

You are looking to see if some mental/physiological process is in disorder, so it's not about whether you caused it or your father caused it. The question to ask is does the patient fit in box X, because we have scientific studies saying that a large number of patients in box X when given treatment Y move to box Z, which is classified as being better than X.

For instance if you say someone your arm is 'broken', they understand something is deeply damaged (not just fissured). They might not know the specifics on how it broke, where exactly, how you are healing it or how it impacts you, but they know the basic criticality of it.

If you say you have "depression", they don't know if you'll take your week off to recover or actually need extensive professional follow up with a long term medication. There is no common sense of how bad it is 'broken'.

From there people all have their anecdotes, visions of how they solved "depression" and come with a very personal idea of what your issue is that most of the time will have nothing to do with your actual diagnosed issue.

In that sense the word doesn't work that much as a conveyor of information, they'll just know you have "something". I see the reasoning behind getting rid of a word in medical context if it doesn't bring any viable information with it.

“Diabetes mellitus” isn’t any kind of a model. It's a symptom description dressed up in Latin. We've since attached a useful model to it, but the name long predates the model and has little to do with it.

As bad as the state of diagnosis is (some say >50% for certain conditions) there is no way around a diagnosis for treatment as one needs to make decisions and these need to be based in whatever tenuous grasp one has on reality. At this point imho. we can only try to make sure all sources of bias, tendency to defend previous decisions, treatment capacity and financial considerations (diagnosis is key to insurance payments) are as far isolated from decision making as possible. There is lots to be done. SCID is only the symptom.

So it become six of one and a half dozen of another. For the benefit of the medical community yes we should name them or slot them into broad categories. For the public its best to probably just use broad categories

Are you sure about that? Tics don't always manifest in obvious ways. You may well have had them in a very mild form but never noticed.

If A is a male, B is a female, C is a male, your operator definition is even troublesome within a species.

What kind of mathematical object comes closer to this abstraction of a species? Maybe it's not about names and boundaries, but about getting to understand things for which you need abstractions.

I always appreciate when people do not fuss about definitions and easily change them but reason consistently after indicating their interpretation of those concepts.

Maybe a better analogy would be to the informally defined neighbourhoods which exist in many cities. Everyone knows there's a Little Italy and a China Town, and could point out the main street of each. But whether or not an apartment three blocks away is or isn't in that neighbourhood gets pretty fuzzy, and depends a lot on what the realtor thinks you are looking for.

The broader point I'm getting at is, first you need to learn about the artificial distinctions so you can "from" the subject. Then, once you know all the rules by heart, you can feel free to break them.

Yay! You've overcome splitting! Now if the profession could achieve what they want from patients...

"I need help. My life is falling apart. I'm struggling with work and school. I might have a learning disability."

"You sound depressed. Here's a prescription for some obscure variant of an SSRI not covered by your insurance."

"These meds you put me on make me feel sick."

"Let's increase your dose."

"I want to hurt other people. I want to die."

"It takes 4-6 weeks for it to take full effect."

"This just isn't working."

"Let's add another variable to the equation. Here's a second prescription. Take both and see what happens."

The experiment must continue. It always ends the same way.

I know psychiatry helps some people (especially where sedatives are involved), but for the rest of us who slip through the cracks it's just the new Nazi science.

The main takeaway from the Human Genome Project was that we understand less about DNA now than we thought we did in 1999.

I'd argue that chemistry really began with Lavoisier in the late 1700s. Physics? Late 1600s with Galileo and Newton. What about psychiatry? I'd argue that it really got going in the latter half of the 20th century. Freud and lobotomies? They were the equivalent of alchemy. Other fields have been around in a recognizably modern fashion for hundreds of years. The same cannot be said of psychiatry and psychology.

And that's not surprising. The brain and mind are incredibly difficult to study directly. Until the advent of EEC, fMRI, and other modern tools, the only real way to do it was by studying behavior. Similarly, the brain is very complex. We didn't have, what could be considered, a modern picture of the atom until the early 1900s and that was after several major discoveries spread over a few decades. It's not surprising that we're still struggling with the brain.

>Back in highschool we had a massively depressed friend. They tried it all with her: cognitive behavioral therapy, drugs (ALL OF THEM), weed, religion. Tough love. Exercise. Diet. Nothing cured her and her depression killed her via suicide. What's the psych tell me after? Sometimes there's nothing we can do? That sucks. Human genome, done. Prevent HIV from killing someone. Can't do shit about depression sometimes.

That's still the case for a lot of things. You have ALS? On average, you'll be dead in two to four years. 90% of people die within 10 years. Treatment is mainly supportive. Likewise, it's the 1800s and you contract a bacterial disease? Can't do anything about that, antibiotics won't be invented for decades. Drain the pus and hope that you survive.

On ADHD, it turns out that Concerta and Adderall are indistinguishable to me. I take a low dosage and the side effects are basically non-existent and it also gets rid of my anxiety and depression. But it also happens that exercise reduces the intensity of all my symptoms. I only found this out when I stopped going to the gym for two weeks and noticed that my medication doesn't seem to be as effective.

It's quite possible that, if I hadn't been in the habit of exercising regularly, I would've required a higher dosage that would give me severe side effects. It's also possible that I would be fine. How is my psychiatrist supposed to know that? Maybe exercise doesn't work for some people, maybe diet is critical, maybe it's getting enough sunlight. The entire web of interactions is extremely complex and we don't currently have the ability to examine it at a fine level.

Speaking of complex interactions, ADHD is predominantly genetic and there are a number of genes that can contribute to it. For example, a variant of the gene that codes the protein Latrophilin 3 is estimated to be responsible for roughly 10% of ADHD cases. People with this variant are also very responsive to stimulant medication. Given the way that I respond to medication, it wouldn't be surprising if that's responsible for my ADHD.

But other people might have multiple gene variants, each contributing to a portion of the severity of their ADHD. Adequately treating them might require a very specific combination of drugs. The current process is trial and error, but it's possible that you'll never hit that magic combination. Likewise, maybe there is no magic combination in existing drugs or maybe the ideal dose is 6mg, but it only comes in 5mg and 10mg doses.

The medication situation is getting better. There are services that will run a genetic analysis to determine which medications might be most effective. But it's still in its infancy and that's only a portion of the picture.

The brain is complex and our current tools for examining and treating it are still blunt. Don't get me wrong, there are definitely systemic issues in those fields that need to be corrected. But a lot of criticisms seem to boil down to the equivalent of "It's 1819, why haven't chemists invented acrylic to replace the glass in my glasses?"

What's interesting is that the people who developed the SCID (and the DSM and its predecessor, the RDC) actually developed a very similar tool in the 60s, but instead of it producing binary diagnoses, it produced scale scores more like test scores. It actually had better statistical properties and provided fairly detailed information. It's always been a mystery why they moved away from that, except that the DSM as a whole moved away from that.

The author ends by musing about mental diseases being described by coordinates in several dimensions. Sure, perhaps connected regions of that space can be given their own names, but in general, the author believes that our vocabulary lacks the granularity to identify the fingerprint of individual diseases.

I know a lot of hands have already been wrung over the ineffectiveness of natural language in describing the phenomena of the inner world, but in a clinical setting this takes on a new meaning, and the essay is, in my opinion, poignant.