We make choices based on our understanding of concepts. My Concepts posts deal with abstract and complex concepts and with the axioms, tenets, paradigms, principles and values enmeshed with, derived from and inherent to them.
For a few seconds I contemplated an alternative title, viz. Psychiatry is a pseudoscience, but I realised that this would be throwing out the baby with the bathwater. There’s some pretty good stuff in journals like MP, and I’ve met a few compassionate humans who practice this profession.
But to get this show on the road, let me start with an analogy.
Astronomy and astrology were once a single discipline, but eventually they split, based on scientific observations and people’s reaction to the facts. Today they still discuss some of the same phenomena, and the names of certain heavenly (?) bodies and constellations remain the same across these disciplines. But astronomy is now a modern science, whereas modern astrology is merely an evolved version of an ancient belief system about the significance of what we observe in the sky.
The evolution of psychiatry did not follow a similar path. Psychiatry may have split with religion, but modern psychiatry (and its slightly less conceited sister, psychology) drag along a lot of old beliefs, unproven hypotheses, and cultural values packed into labeled baggage. Psychiatry dresses up in a suit, collects this baggage from the airport terminal, and attends medical conferences along with Endocrinology, Haematology and other legit branches of medicine, as though it’s one of them.
In its current form, it’s actually not, though.
Central to the practice of psychiatry are diagnostic classification systems such as the DSM. And here’s the crunch:
The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity.Thomas Insel, Former Director: National Institute of Mental Health (US)
Thank you, thank you, thank you for sharing this, Prof. Laura Dilley. It’s 2019 and now that I at last have this precious declaration from Someone Who Should Know. I feel less gaslighted now.
What that quote says, essentially, is that the classification system used by modern psychiatry is rubbish. (And if you care to share my indulgence in sarcasm as a refined art, I recommend this scathing essay in which the DSM-5 is reviewed as a dystopian novel. Until I encountered Dr. Insel’s writing, this had been the closest thing I had to comfort in this matter.)
The problem with this taxonomic disaster is that the manner in which any mental/behavioural/psychiatric phenomenon is classified and defined determines how the people who receive a diagnostic label will be viewed and treated (I talk about it in this video) — and right now that’s really, really messy. See, the head is attached to the rest of the body, and what happens below the chin — in the thyroid and adrenal glands, for example, and the intestines — affect what happens in the brain. But how often do psychiatrists run tests to see what’s happening in your intestines? You can easily get a diagnosis from a psychiatrist without any tests to establish what’s happening inside; and then you get pills, which don’t necessarily address the actual problem! In this respect, mainstream psychiatry is super-unscientific, and taxonomies like the DSM help to keep it that way.
So, if the DSM and its ilk are rubbish, what should we be using instead?
Well, basically, according to Dr. Bruce Cuthbert (see video below), we should rip out all the pages, keep the covers, plonk a new version number on the thing, and fill it with scientific stuff… which unfortunately hasn’t been sufficiently scienced yet for us to actually do that, but we really should do it once it’s kinda, er, ready.
Which means we need to do the development work to make it ready.
And that’s what Dr. Cuthbert and his colleagues are doing.
I’m OK with that. As long as we recognise that what we’re working with while we wait for something better is in fact rubbish, we can approach insanity and its other atypical friends with greater sanity.
So, that brings me to my definition of autism. People often ask me what autism is, and I say this:
Autism is an umbrella term for a specific cluster of neurodevelopmental endophenotypes — or, more accurately, a cluster of clusters. As such, it sometimes makes sense to speak of autisms, the plural, rather than just autism.
“What characterises this cluster of clusters?” you may ask. The truth is, I don’t really know, and that’s not because I am not a scientist or because I lack experiential or observational knowledge. I can list traits that frequently occur among many of the clusters — systems thinking, impairments in purposeful motor systems, and sensory anomalies — and I can even name some genetic and epigenetic tidbits; but I don’t think I am ready to define autism until we have a better classification system for autisms, the plural. What the basis for this classification system should be, I cannot say either. There are people who talk about channelautisms like they talk about channelepsies, but that’s just one branch or basket.
What I can tell you is that what the DSM says autism is, is rubbish.