The Evolution of Psychiatry
worksinprogress.co
worksinprogress.co
If Waterhouse's position is correct, then trying to find a single evolutionary explanation for numerous diverse brain conditions (that people have lumped together under a single label) is probably not a very useful approach.
[1] https://books.google.com/books?id=IaFY8r0rpn8C&printsec=fron...
[2] https://link.springer.com/article/10.1007/s40489-016-0085-x
The desire to categorize and use reductive reasoning is powerful and seductive, but not always effective until you really understand the system. With human biology and brain we're a long way from that.
Does she propose a better classification system, something like what she'd replace it with in the next DSM if it were up to her? Because if we don't yet know how to split current ASD diagnoses into more specific classifications, isn't it better to have this rough grouping than to say "this person has an unknown disorder"?
Her book is largely focused on research, it has little to say about clinical practice. The paper she coauthored which I cited does argue, yes, that the current DSM diagnosis should be retained in clinical practice for the time being, even while they think it should be largely abandoned in research. However, I think their justifications for its continued clinical use are somewhat undermined by their arguments against its research use. That paper says "The ASD diagnosis remains necessary in the clinic to assign a child to early behavioral intervention and to explain a child’s condition". The paper argues that ASD lacks biological validity and construct validity – how can something which lacks validity actually explain anything? A diagnosis lacking validity must in itself be causally inert; and if the diagnosis is reduced to a symptom set as Waterhouse's book argues, then using it to explain symptoms becomes circular ("the symptoms are explained by the symptoms").
> Does she propose a better classification system, something like what she'd replace it with in the next DSM if it were up to her?
Her book proposes the definition of two phenotypes (not disorders) on p. 434-435. The first is "Neurodevelopmental Social Impairment Only Phenotype", which is basically equivalent to DSM-5 ASD criterion A (social impairment present from childhood), but with an exclusion for atypical sensory behaviours, atypical motor behaviours, rigidity in behaviours or interests, atypical language development (functional language impairment), ADHD symptoms, intellectual disability, developmental delay, or seizures. This phenotype is broadly similar to DSM-5 social (pragmatic) communication disorder (SCD), except it makes no claim to be a disorder, only a phenotype (symptom set), and also that it has broader exclusions – DSM-5 SCD doesn't exclude ADHD symptoms or seizures, for example, her first phenotype does. Her second phenotype is "Neurodevelopmental Social Impairment Multi-symptom Phenotype" which requires neurodevelopment social impairment combined with one or more of the exclusions from her first phenotype.
As well as criticising the DSM-5 for proposing a disorder as opposed to a mere symptom set / phenotype, she also criticises its two-domain model, which requires both social communication symptoms and RRBI/sensory symptoms for a diagnosis. She instead proposes a model with one core domain (social communication) and a set of optional domains, none of which are required, and of which RRBI symptoms and sensory symptoms are just two additional symptom domains out of several. She justifies this on the grounds of clinical experience that social communication impairment can occur without RRBIs or sensory issues – this clinical experience is reflected in the DSM-5 diagnosis of SCD.
The relationship between SCD and ASD is arguably one of the most poorly thought out aspects of the DSM-5, and in practice many people who strictly speaking should get an SCD diagnosis get given an ASD diagnosis instead, despite not actually fully meeting the ASD criteria – many clinicians are very hesitant to use the SCD diagnosis even when the letter of the DSM-5 would indicate it, due to SCD's lack of public awareness and unclear eligibility for funding. SCD itself is a strange lacuna in Waterhouse's book – despite SCD's obvious relevance to her argument, she hardly ever mentions it by name.
From TFA:
"Investigating the most severely disabled autistic individuals you almost always discover damaging genetic mutations or early life trauma, such as foetal alcohol syndrome. These are clear cases of biological dysfunction. On the other hand, the less severely disabled individuals (who would once have been called Asperger’s or “high-functioning”) show none of those biological signs of dysfunction, instead showing evidence we expect from functional adaptations: the associated genes are common and complex, brain differences are subtle, the characteristics appear early in life when they are guaranteed to affect reproduction, and the prevalence is high enough that at least one person per Dunbar-sized hunter-gatherer social group of one hundred and fifty would show the same traits – in which case, every one of our ancestors would have known an autistic person. These biological signs are those we expect to see from adaptations, not dysfunction. The question we are led to ask is what autism’s function could have been."
I think this is a dangerous misunderstanding of the reason for the grouping of autism-spectrum disorders under a common umbrella. The danger lies in the (all-too-common) tendency of people to think that the rejection of autism's categories means "autism doesn't exist" or something similar. The purpose of such categories is not to help understand the causes, but to help cement the reality that autism is a group of very serious disorders with similar traits.
As an analogy, many cancers that are grouped under a single name -- such as breast cancer -- are actually caused by very different genetic alterations. To use these differences as a justification to reject the concept of breast cancer would be ludicrous.
Serious question, do you actually have any evidence for that postulation?
Even with the analogy you have listed doesn't show evidence that people would consider non-existence or reject care from individuals suffering what we today characterize as autism.
Who are you accusing of a "dangerous misunderstanding" here – her, or me? If you haven't read her work, I don't know how you can fairly accuse her of misunderstanding anything; likewise, I think having read at least some of her work is a prerequisite to be able to fairly accuse me of having misunderstood her
If your accusation is that she doesn't understand "the reason for the grouping" may I point out that she played a central role in the drafting of the PDDs section in the DSM-III-R [1]. As a former member of the DSM working group on autism, Waterhouse has a very good knowledge of the reasons and history behind the development of the "ASD" diagnostic label. Waterhouse may or may not be right, but her argument cannot be dismissed anywhere near as easily as you seem to think it can.
I wasn't accusing anyone specifically, merely commenting on the idea you shared. However, since you asked, I would say that the misunderstanding is on both your parts -- yours, for interpreting her arguments to mean "ASD doesn't exist" (as far as I can tell, she makes no such claim); and hers, for arguing that the formal definitions and categorizations of ASD need to be biologically valid (which they can't be, as we don't understand enough about the biology for that to be possible).
It's common for many fields of research to start with "stamp-collecting", where people just identify and group diseases and conditions and birds based on shared characteristics; and later, as the field becomes more mature, to develop more meaningful categories. I think this same concept applies to ASD.
To quote page 431 of her book Rethinking Autism (my emphasis):
> Taken together, these three claims and associated lines of evidence argue against the existence of autism as a single disorder, spectrum, or set of autism subgroups. If autism symptoms are not one disorder, and are not many disorders, what are they? The most parsimonious and least speculative view is that autism symptoms must be symptoms.
Her book is quite explicit in its claim that autism spectrum disorder does not exist. Her conclusion (p. 433) is given under the heading "AUTISM SYMPTOMS WITHOUT A DISORDER". The whole point of her book is to argue that the disorder "Autism Spectrum Disorder" does not exist, but the symptoms do. You might say she rejects the "Spectrum" and the "Disorder" in "ASD", but keeps the "Autism" as a reference to a set of symptoms – however, her "autism" is narrower than the DSM-5's "autism", since it only includes social impairment, and considers repetitive behaviours/restricted interests and sensory issues, to be distinct symptom sets coequal with attention-deficit/hyperactive-impulsive symptoms, intellectual disability, functional language impairment, seizures, see p.434-435
To quote the blurb on the back cover "Rethinking Autism... draws the potentially shocking conclusion that 'Autism' does not exist as a single disorder. The conglomeration of symptoms exists, but like fever, those symptoms aren't a disease in themselves..." (But, the book actually goes further than the blurb says it does, because it not only rejects the idea that autism exists as a single disorder, it also rejects the idea that autism exists as multiple disorders or a spectrum of disorders, as my quote above demonstrates.)
> and hers, for arguing that the formal definitions and categorizations of ASD need to be biologically valid
Biologically valid categories would be a lot more useful than biologically invalid categories, and one of her major points is that the research community's fixation on the later is getting in the way of actually discovering the former ([1], [2]). She argues that, in place of the current widespread practice of doing research with ASD-defined samples (a confirmed ASD diagnosis as a study inclusion criteria), samples should be based on all individuals showing neurodevelopmental symptoms (mixing together ASD, ADHD, epilepsy, intellectual disability, etc, into a single sample) and then trying to study the variation in the sample in order to derive biologically valid categories to replace the existing biologically invalid ones such as ASD. [3] is an example of a study along the lines of what she recommends (indeed, they've obviously read [1] since they reference it)
[1] https://link.springer.com/article/10.1007/s40489-016-0085-x
[1] https://slatestarcodex.com/2015/04/30/prescriptions-paradoxe...
Eventually "agreed to disagree" (I hate this expression), I moved on from that place where I was stagnating in pain, and found a sensible knowledgeable psychiatrist who happens to be much older, and we made the switch.
It's hard to understate how much of a change that was in my life. I try not to be bitter about any fresh new psychiatry grad on the block, but I really hope they get their shit together as a collective and observe what their own patients (and their older peers) seem to know better than them.
No matter how much tyramine I ingest (which is supposed to be a no-no on MAOI/RIMA) the worst side effects I suffer can't even get anywhere near what the SSRI would TYPICALLY do to me.
On Trintellix: morning headaches, being unable to have any caffeine, becoming lactose intolerant, frequent cramps and diarrhea. Depression very very mildly alleviated. Transition period when stopping the meds: 2 weeks. Cost of monthly refill: $110 CAD.
On Manerix: some cramps if I ingest gigantic amounts of tyramine (I'm french, I'm talking cured meats+cheese plates and red wine bottles in the same meal). Could be back to coffee and milk with no headaches nor cramps within a couple weeks. Depression mostly alleviated. Transition period when stopping the meds: 2-4 days. Cost of monthly refill: $30 CAD.
Oh and the kicker? Manerix is actually one of the few antidepressants that actually has a chance to "increase libido" as a side effect!
I'm glad someone wrote a good article on what I've been hoping to articulate in different places over time, thanks for the share.
It's generally understood that medication should be used as a backup after CBT or other forms of therapy and if you do need medication, it should be concurrent with that therapy. Psychiatric pharmacology is more complex and opaque than others, but there is progress being made on that front as well.
The more apparent progression being made is in understanding the neural mechanisms for these disorders and thus, determining alternative methods of treatment as a result, such as transcranial magnetic stimulation targeting individualized neural correlates (e.g. stimulating areas near the surface of the brain that have functional connectivity with deeper parts of the brain to activate/inhibit areas like DLPFC) and discovering relationships between certain mechanisms and certain disorders to investigate other pharmacological avenues (e.g. ketamine loses antidepressant effects when opioid receptors are blocked with naltrexone).
Another issue is that this progress in research takes awhile before you see results in practice and much longer for it to disseminate through the whole psychiatric community.
You say that, but from my experience medication is the first line treatment. Often there isn't even any other type of treatment that comes with it. You just try a whole bunch of different ones and hope for the best.
>The more apparent progression being made is in understanding the neural mechanisms for these disorders and thus, determining alternative methods of treatment as a result, such as transcranial magnetic stimulation targeting individualized neural correlates
Considering what happened the last time psychiatrists fiddled with people's brains I find it fascinating that anyone is willing to try this. Lobotomies were done for years by actual physicians, yet it was pretty much the worst possible horror show imaginable. Did they get it right this time?
I think the greatest problem with it is its adjacency to psychology and patient care. It removes some of the rigor from the treatment that the patient gets, because most of the time the patient is not interacting with doctors or even nurses. It'll be social workers of some form that may or may not have some training in trying to help people with mental health issues.
I should have expanded on that particular point. It's widely understood in the research side that medicine should be a back up, but the practicing side of psychiatry is often completely detached from the current research, so it takes far too long for the body of knowledge to propagate into the practicing side. The impact of research on application is a far cry from where it should.
> Considering what happened the last time psychiatrists fiddled with people's brains I find it fascinating that anyone is willing to try this. Lobotomies were done for years by actual physicians, yet it was pretty much the worst possible horror show imaginable. Did they get it right this time?
The safety of TMS has been studied for a few decades now and its safety (and efficacy) is also being further understood with scanning someone with fMRI while simultaneously stimulating with TMS, which is pretty difficult since you're blasting a magnetic pulse at the same time that you're imaging using magnetism.
As with most medical interventions, there is a risk. More specifically, there are two primary risks: triggering a seizure from an epileptic patient by using too high of a pulse near the motor cortex or exacerbating a patient's current hypomanic/manic symptoms. It's much less invasive and much safer than things like ECT and DBS. Once again, this is a last resort and used for people things like treatment-resistant depression or PTSD. It's used after trying multiple medications, not because it's riskier, but rather because its effects tend to be acute in lasting anywhere from a few months to a few days after a session.
> I think the greatest problem with it is its adjacency to psychology and patient care. It removes some of the rigor from the treatment that the patient gets, because most of the time the patient is not interacting with doctors or even nurses. It'll be social workers of some form that may or may not have some training in trying to help people with mental health issues.
I agree that this where a lot of work needs to be done. In my opinion and in terms of widespread issues like depression and anxiety, psychiatric treatment should sought or referred after clinical psychologists have exhausted most or all of their options and should be taking on the brunt of those problems, not social workers and counselors. Too much rides on the latter's shoulders due to the barriers a lot of people face getting access to effective mental health professionals like clinical psychologists and psychiatrists. It doesn't help that a lot of general physicians will try to play the role of psychiatrist as well.
The problem is that when I was a teenager I could walk into any psychiatrists office and leave with whatever drug I had decided I wanted to get high off for that weekend. I memorized a list of symptoms, said I had them to a GP, got a referral to a specialist and repeated them there again. If I started on Monday I could get a prescription by Thursday. Having talked to "problem" kids of friends it that's still the case today.
I never took the field seriously, and until I became an adult didn't realize anyone else did either. I just thought of them as legal drug dealers with good quality product, but not as fun as the unregulated product you could get on the street.
Imagine my surprise when I found out people actually took prescriptions for decades at a time, something that is as horrifying to me as drinking yourself to sleep every night because someone told you to.
The field of mental health is definitely in a sorry state today, at least in the US. A lot of progress is being made in terms of research and knowledge, but it's not as impactful on the practicing community as it should be.
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I think you might just be blaming other people for your unethical behaviour as a teenager.
https://slatestarcodex.com/2018/10/24/nominating-oneself-for...
If there no way to detect false positives then everyone is a false positive.
That does not logically follow.
Proof by contradiction:
I have invented a dumb test for COVID-19: I look at a linkedin profile of someone, then I lick a block of salt. If my tongue tastes salty, then I conclude they have COVID-19. Trivially, my test has no way to check for false positives. So, if ran this test on someone, your statement implies that they would be a false positive and therefore they would definitely be free of COVID-19.
Unless you think my salty tongue has magical COVID-curing powers, then even a broken clock is still right twice a day.
But to answer your question, yes, it would be statistically prudent to assume that everyone who passed your test is free of covid because the proportion of the general population who have it is less than 1% currently and your test produces a 100% positive rate.
This is a specific case of https://en.wikipedia.org/wiki/Prosecutor%27s_fallacy
I would rather live in a world where people with real psychological problems can get help and you can get high than the reverse.
Psychiatry has a rolling history where everything that was done 30 years ago is so barbarous that the treatments are criminalize, and it has been that way for a century. At what point are we going to realize that there is no baby in the bathwater?
. That was a small trial and another trial showed opposite results such as this one
https://pubmed.ncbi.nlm.nih.gov/30624551/
More details here
https://www.tandfonline.com/doi/full/10.1080/17460441.2020.1...
I believe more research is required for r-ketamine (arketamine) I wonder if it has effects on the opiod system also
They also thought that the mtor pathway was necessary but trials with human subjects and rapamycin showed that it potentiated the AD effects in humans . Which is sad to hear because it was the basis to the creation of NV-5138 that's heading towards phase 2 soon . It could very well work because the mtor pathway Is complicit In mood disorders .
Also advances towards TMS is very interesting check out stanford's SAINT TMS trial
Currently what I'm interested in is vistagen's pipeline of drugs . It works unlike any thing else and also the various FAAH inhibitors
The history of legal psychoactive medications is littered with dubious and ethically questionable choices. Here's some 1950s era psychiatric medication advertisements targeted at doctors:
>Simone doesn't want to cook breakfast for her husband, a lobotomy and Thorazine fixed her right up.
>Little Timmy doesn't want to do homework for his parents, Adderall and gender reassignment fixed her right up.
There is more diversity to people and their thoughts than your simple philosophy suggests; people may suffer from mental illnesses for no apparent reason, like how people may suffer from poor health in the same environment as a healthy person. And with antidepressants on a person with a condition stemming from a poor lifestyle, the effects can be what makes the difference that helps them transition to a more sustainable lifestyle.
Ignorant, grandiose claims like these really don't help people suffering from mental illnesses.
The author also makes a grave but subtle misstep when he says “the eye evolved to see” - the eye most decidedly DID NOT evolve to see. The eye evolved and does see but importantly evolution has no intent, it has no goal and it has no purpose. I might sound pedantic but there is an important distinction between “the eye sees” and “the eye was meant to see”.
For example, mood disorder may mean you get yelled at and insulted or put down a lot, unpredictably and for no own fault. It may be result of sickness, but verbal abuse consequence is same.
I'm not sure if there exists a such crisp boundary. Lifetime prevalence of mental illness in the US is about 50%. In any given year 25% of the adult US population will have a mental illness. [1]
> That's probably why cancer research gets a multiple in funding of what research into mental disorders gets.
Cancers amounts for 15% of disability claims while mental illness does 10%, that might be one driving factor. (Not saying it is justified). The other one is, unlike cancer, most mental illnesses are explained with a bio-psycho-social model, which is incredibly hard to design comprehensive interventions for, or to get enduring results with one-shot interventions.
We know quite a good deal about how adverse childhood experiences, economic hardships, familial structures etc affect mental health. The problem is there is only so much space for intervention there that doesn't hinge on societal restructuring. Which is why the agency we exercise in response is limited to pharmacotherapy and talk therapy, at least those insurance would pay for.
[1] https://psychcentral.com/blog/cdc-statistics-mental-illness-...
We have a huge number of theories and arguments that all sound reasonable but are contradictory and fail horribly when applied to everybody with the same disfunction label.
We are not without success examples but I don't know if overall we are at net possitive.
What I dislike mostly about the situation is pacients and families rarely being made aware of the gamble that is treatment. If the situation is bad enough you have basically nothing to lose, so sure, try anything at your disposal. But medicating young boys for being unruly for example...
The trouble with evolutionary explanations of human psychology is that they are "just so stories". Actual tests of these hypotheses are extremely difficult. Sometimes you can get somewhere with experiments on other mammals, but for the most part its high piles of speculation. The little story about the possibly autistic reindeer herdsman is a case in point. Nice anecdote, but the plural of anecdote is not evidence.
Then you mix in speculation about primitive tribes with considerations of supernormal stimulii and possible actual disease or genetic damage, and you wind up with exactly the same morass that the article complains about in current psychiatry.
And even when you have a tested theory it provides very little guidance about how to help afflicted individuals live in modern society.
Or simply when one's mind is not a threat to others. Perhaps those who see abnormality as a threat are themselves disordered?
I frequent a website where most people are seeking to end their life from an assortment of mental illnesses. Majority of them have tried multiple psychiatrists as well as therapists and with little to no success in curing their suffering. I find it egregious that people may think psychiatrists actually seek the benefit of the patient's wishes because I know personally the request for MAiD falls on deaf ears. Instead these patients continue to experience involuntary treatment if they live in less civil countries or advised to try different medication.
I've known someone labeled schizophrenic where it costed their insurance well over 60k and in less than a year from involuntary hospitalization while being drugged & observed. I know other psychological illnesses like Gender Dysphoria where a person went through the wrong puberty never get that funded for their quality of life to improve (fixing voice & appearance). Anyway I think the whole field is very questionable if psychiatrists have a sincere interest in the person their treating that's basically their customer that keeps coming back.