In my view the set of mechanisms that cause most mental illness are already well-established, but for some reason aren’t commonly all put together or popular. I’m very curious for people’s thoughts, especially on what fraction of mental illness this model describes.
Most cases of mental illness are individually unique complex adaptive system attractor states whose reinforcing elements are something like:
1. Learned (predictive processing) bayesian priors (e.g. a belief like “I am bad” associated with a fear response that drives thought and behavior) that emerged as an adaptive response to a different context than the individual is currently in. The different context is often an emotionally dangerous childhood, which often result in sets of priors that we call things like “attachment disorders.”
2. Attention (predictive processing) and its lack (avoidance). Incoming sensory evidence is typically sufficient to update (called reconsolidation in memory research) priors that are no longer adaptive, but that only works when the strength (how much attention is payed to it) of the sensory evidence is within some range of the strength of the prior. So it fails when there isn’t sufficient attention to the sensory evidence or when the strength of the prior is too high.
3. Priors predicting certain levels of threat and powerlessness activate the set of autonomic nervous system functions called the defense cascade, i.e. sympathetic/parasympathetic hypo- and hyper-activation. This is fight or flight, freeze, arousal, tonic immobility, and collapsed immobility.
4. A bunch of other stuff whose role is harder to understand, like medical history, medication, environment, genes, sleep quality, mental illness symptoms, and a variety of low-level neurobiological dynamics from which priors and attention emerge.
Together, certain sets of priors and avoidance create stable and maladaptive attractor states. The priors involved often erroneously predict threat and powerlessness and therefore activate defense cascade states.
You can permanently destabilize these maladaptive attractor states (and associated defense cascade activation) by updating/reconsolidating the reinforcing priors by activating them and juxtaposing them with strong contradictory evidence that the person may otherwise be avoiding, e.g. the best examples of psychotherapy. This juxtaposition creates prediction error, which updates the priors reinforcing the maladaptive attractor state. Of course this is easier said than done; it’s hard to pay attention to contradictory evidence when you’re in flight or flight or tonic immobility, you feel that feeling emotions is a threat itself, you don't even know what the relevant prior is, etc. I personally think MDMA therapy is particularly helpful here because it seems to facilitate prediction error for most or all maladaptive priors that are activated/triggered during a session and often works during fight or flight or tonic immobility.
Maybe there’s some use in categorizing most mental illness into boxes, but in this model you would still cure it contradictory evidence specific to each case (or possibly through practices that facilitate universally applicable prediction error), so why bother other than for legal reasons.
To be clear, this model doesn’t fully describe disorders involving certain clear biological issues like psychosis (aberrant salience), a swath of neurological disorders, brain damage, etc. This model also doesn't explain anything about how, when, and why a lot of psychiatric drugs work and don't work.
Thank you for this comment! I agree that this is a promising way of thinking about mental heath problems and I find it appealing too, as do a lot of other people who are drawn to complex dynamic systems thinking. I recently posted (book review of Nicole Rust’s Elusive Cures) about how clinical neuroscience is moving in this direction too. However, I would not say that mechanisms understood in this manner are “already well-established.” We have not yet moved beyond theoretical appeal and plausibility and methodological fervor to actual empirical demonstrations of well-defined hypotheses. And there are significant challenges involved in getting to that point.
Thanks for the reply! I wonder if some of our different interpretations of establishment come from perspective. I started out in the psychotherapy prediction error/memory reconsolidation world surrounding "Unlocking the Emotional Brain" by Bruce Ecker. I think people there more readily think that the framing I laid out is more established, or common knowledge, at least the "previously adaptive priors that are no longer adaptive," and "facilitating prediction error/memory reconsolidation is the solution" parts. That group might have less strong views about the parts of the framework involving the defense cascade, attention, and complex system attractor states. As far as I can tell the defense cascade stuff is also somewhat established, but I'm less confident about the specifics of the attractor state dynamics and how attention plays into that.
I imagine actually verifying these attractor state dynamics might be experimentally difficult! Especially since each case seems at least a bit unique.
Thank you, Awais, for a thorough and thoughtful survey of this fraught topic--one I have been grappling with for four decades! I would like to suggest another way of looking at the concept of "validity" in psychiatry--one that shifts the discussion from etiological considerations to pragmatic, instrumental and ethical issues. I discuss this under the rubric of "instrumental validity" in this article:
"Following the pragmatic tradition of William James and John Dewey, I define “instrumental
validity” as that property of a diagnostic criteria set which bears on how fully it achieves a par-
ticular aim or goal. Now - to hyper-condense along argument - I believe that the fundamental
goal of general medicine and psychiatry is to reduce certain kinds of human suffering and inca-
pacity..."
With respect to general medicine, I think that the issue of "validity" does arise fairly frequently, albeit (usually) without the polemical flourishes that typically accompany discussions in psychiatry. For example, there is intense interest and discussion regarding the validity of the entity commonly called "Long Covid" See:
There are other debates that border on the "validity" question in general medicine and neurology, such as whether Persistent Idiopathic Facial Pain is a valid diagnosis (this was formerly known as "atypical facial pain")
There's a lot to think about in that last sentence.
Perhaps one of the complications faced by any attempt to forge a 'once and for all valid' classification of diagnoses is the severe entanglement between diagnosis and values in the case of psychiatry. (In order to be a 'psychotic delusion' a belief must be 'bizarre', and held 'irrationally'. Etc.) It isn't absent in somatic medicine, but as you say the latter is largely grounded in physiology in a way that psychiatric diagnosis is unlikely ever to be; one might add that human values as they relate to somatic health seem to be somewhat more unified (which is not to say 'totally unified') and more easily identifiable--indeed in many cases they don't even need stating. (Most people would agree, I guess, that broken arms and malfunctioning kidneys are deviations from 'normality' that do present problems of living. There are, of course, areas of greater contention, and it is in these areas where 'diagnosis' is also more contentious.)
It isn't at all clear that this entanglement between the subject-matter of psychiatry and values can be avoided. Or rather, a version of psychiatric diagnosis that sought significant disentanglement from values (perhaps all diagnosis is based on standardized brain scans, or blood samples, or whatever) would probably cease to be at all effective (low utility, in Solomon's sense).
If strong entanglement with values is inevitably part of the diagnostic picture, and if values are (as they seem to be) quite variable across time, space, culture, etc., then at the very least what counts as 'end game' in the case of psychiatry is going to look very different from 'endgame' in the case of somatic medicine.
I appreciated your thoughtful and carefully nuanced comment on "values" as they pertain to "somatic medicine" as distinct from psychiatry. (I will resist the temptation to make the case for why psychiatrists also practice "somatic" medicine--but we assuredly do!).
I find your use of the term "entanglement" interesting, and--if I may pursue a bit of a linguistic turn--I wonder if you might consider alternative terms. For example, what if we were to say that psychiatry is "informed" by values? Or, that psychiatry is deeply integrated with values? Substituting these terms for "entangled" may allow us to pursue this issue in more neutral terms, in as much as "entangled" connotes a kind of twisted state of disorder that, in some sense, hampers action or understanding.
I would argue that, on the contrary, psychiatry's deep involvement with certain humane values is integral to the psychiatrist's medical ethos and--as you imply--to the very effectiveness of our work with patients. And, of course, all of "somatic" medicine--meaning, e.g., internal medicine, neurology, etc.--operates from a set of implicit and explicit values. The former include such fundamental beliefs as, "It is better to take care of one's body than to neglect it," and "It is better to reduce intense pain when possible than to ignore it." Explicit values include the well-known tetrad of beneficence, non-malfeasance; autonomy, and justice, made famous by Childress and Beauchamp. [1]
To be sure, these are not specifically diagnostic values. But here I would suggest that in general medicine, too, there are evaluative terms that guide diagnosis, over and above "objective" criteria, such as a broken arm or malfunctioning kidneys. True, these are not as pronounced or dispositive, outside of psychiatry, but they are nevertheless present in general medicine, particularly when a new or poorly-characterized syndrome is being considered. For example, the evolving definition of the syndrome known as "Long Covid" [2] includes this feature:
"Long Covid can impair affected patients’ ability to work, attend school, and care for themselves and can have a profound emotional and physical effect on patients, families, and caregivers." [3]
Clearly, the notion of "profound emotional and physical" effects entails an evaluative dimension, not fundamentally different than deciding that a belief is "bizarre" or "irrational."
I am not suggesting that psychiatry is "just like" internal medicine or orthopedics. Evaluative terms are certainly more prevalent in psychiatry than in what you are calling "somatic" medicine. But I think the differences can be overstated and often are.
I would welcome your response and I thank you for your earlier comments.
Best regards,
Ron
Ronald W. Pies MD
1. Beauchamp TL, Childress JF. Principles of biomedical ethics. New York (NY): Oxford University Press; 2009. pp. pp.162–4
3. Ely EW, Brown LM, Fineberg HV; National Academies of Sciences, Engineering, and Medicine Committee on Examining the Working Definition for Long Covid. Long Covid Defined. N Engl J Med. 2024 Nov 7;391(18):1746-1753
Thanks for this response and sorry for the delayed reply. Other business is keeping me busy (and this is Awais’ substack so maybe not the place for a super-extended discussion by others), but here is a short(ish) response. (OK, I just reread it and it is not short. Sorry Aftab! If the discussion continues we can take it elsewhere....) I hope to write more about these issues very soon.
On entanglement: I’m coming at this with a 30-year background working in quantum theory, so my use of the term ‘entanglement’ is probably (i.e., almost surely) idiosyncratic. I wasn’t intending it to have negative connotations, but simply to indicate that psychiatric diagnosis and value-judgments are interdependent, and that this interdependence is (probably, in the case of at least many prominent diagnoses) not eliminable. ('Interdependent' doesn't really capture the idea I'm trying to convey, but I'll not work at it further here.)
We agree that the practice of ‘somatic’ medicine involves making many assumptions about values, such as the ones that you mention. (I’m going to set aside, here, the discussion that we might have about the concept of ‘somatic’ medicine and just use the scare-quotes to acknowledge the need for further discussion. I think it’s very complicated and I shouldn’t have implicitly broached the issue in a comment.) I do think (and you seem to agree) that some of the kinds of value that you mention (e.g., regarding the propriety of taking care of one’s body) are more or less separable from diagnosis (but not from treatment).
You suggest that there are other cases – especially on the borders of ‘somatic’ medicine – where diagnosis is ‘interdependent with’ values. That claim seems plausible. It does seem to me, however, that ‘somatic’ medicine holds to an ideal of eliminating these interdependencies; we want, and perhaps even expect, that eventually there will be clear, non-value-laden (as far as possible), diagnostic criteria for Long Covid.
One sometimes finds, of course, of a similar ideal in psychiatry. Whatever one might think of the ideal in the context of ‘somatic’ medicine, I believe that it is both unattainable and ill-advised in the case of psychiatry, and that this difference arises from the subject-matter of psychiatry. Trying to justify that claim would take a lot.
Finally, and too quickly, I do actually think there are important distinctions between your examples of “profound emotional and physical effects” and “bizarre or irrational”. First (but maybe this point is covered by the intention behind your use of ‘fundamentally different’), these judgments sit in very different ‘realms of value’ (the latter being more or less epistemological, the former not). Second, the former are more akin to the common use (in psychiatric diagnosis of depression or schizophrenia or whatever) to the ‘impairment’ requirement often mentioned in DSM. (I feel compelled to remark that for scz the condition is ‘functional impairment’ while for depression it is “significant distress or impairment” – so one isn’t supposed to pay attention to distress in the former case?) Yes, judgment of ‘impairment’ often involves value-judgments. But in both cases we are talking about the *effects* of some purportedly underlying condition (DSM explicitly uses cause/effect talk), whereas judging whether a belief is ‘bizarre’ or ‘irrational’ is not a judgment about the effects of some purported underlying condition, but a judgment about whether the condition is present in the first place.
I’m only gesturing, here! I do need to think more carefully about this distinction, and I thank you for pressing me to do so. If I make any headway, I’ll probably write about it soon(ish).
Many thanks for your cordial and considered response. Coming, as you do, from the Land of Schrödinger's Cat, I now understand why you used the term, “entanglement”, without pejorative intent. Speaking of entanglement, I think we both realize that these issues (values, validity, “somatic” medicine, etc.) comprise something of a conceptual hairball, and are ill-suited to resolution in the confined space of online comments. Furthermore, I fear we would be straining Awais’s renowned online hospitality by too much back-and-forth. Perhaps there will be a more suitable venue for further elaboration of these complex issues. (Feel free to write me at piesr@upstate.edu).
For now, suffice it to say that we are in broad agreement as regards your point that, “…psychiatric diagnosis and value-judgments are interdependent, and that this interdependence is (probably, in the case of at least many prominent diagnoses) not eliminable.” Many scholars (Kendler, Sadler, Fulford et al) address these issues in the excellent Oxford Textbook of Philosophy and Psychiatry (edited by Fulford, Thornton and Graham). The general consensus is that psychiatry operates from a “facts + values” paradigm.
Where I differ from many critics of psychiatry (I do not include you in this group) is in claiming that diagnosis and value-judgments are interdependent in all of general medicine, though less obviously than in psychiatry; and that this relationship, too, is not eliminable—even as general medicine strives to eliminate subjective judgment in diagnosis. I regard the latter as related to, but distinct from, the elimination of values. (We could, of course, engage in a long scholastic debate over the terms, “subjective” and “objective”!). [1]
The core of my thesis is summarized in one paragraph from the Oxford Textbook (chap. 20, p. 565), with which I’ll close my comments--and you are more than welcome to the last word:
“Our conclusion…will be that the traditional medical model, and the claim to value-free diagnosis on which it rests, is unsupportable; and that, to the contrary, diagnosis, although properly grounded on facts, is also, and essentially, grounded on values. This conclusion…although currently of practical importance mainly for psychiatry, will become, under the pressure of twenty-first century medical-scientific advances, increasingly important in bodily medicine as well.”
One approach might to think of DSM (and ICD) as a kind of atlas of psychiatry, allowing conceptual structure, but not necessarily believing in the concrete reality of a condition. We can point to a country on a map, and we can have a good idea of the political boundaries; but the map is not the territory. But atlases are useful, perhaps indispensable
What do you think of other medical conditions that don't based on subjective symptoms and don't really have biological anchors. Migraines, IBS, CFS, chronic pain etc. the dispute of Thier validity I never see come into question
There are definitely disputes around etiology or causes of such conditions but rare to see them framed as being about their “validity,” which again suggests something peculiar is happening in psychiatric debates. Some of it is a bias against mental illness but it also speaks to the complexity and ambiguity of mental health problems in terms of their conceptualization (illnesses, life problems, personality problems, spiritual problems, etc) as well as their relationship to biology.
In my view the set of mechanisms that cause most mental illness are already well-established, but for some reason aren’t commonly all put together or popular. I’m very curious for people’s thoughts, especially on what fraction of mental illness this model describes.
Most cases of mental illness are individually unique complex adaptive system attractor states whose reinforcing elements are something like:
1. Learned (predictive processing) bayesian priors (e.g. a belief like “I am bad” associated with a fear response that drives thought and behavior) that emerged as an adaptive response to a different context than the individual is currently in. The different context is often an emotionally dangerous childhood, which often result in sets of priors that we call things like “attachment disorders.”
2. Attention (predictive processing) and its lack (avoidance). Incoming sensory evidence is typically sufficient to update (called reconsolidation in memory research) priors that are no longer adaptive, but that only works when the strength (how much attention is payed to it) of the sensory evidence is within some range of the strength of the prior. So it fails when there isn’t sufficient attention to the sensory evidence or when the strength of the prior is too high.
3. Priors predicting certain levels of threat and powerlessness activate the set of autonomic nervous system functions called the defense cascade, i.e. sympathetic/parasympathetic hypo- and hyper-activation. This is fight or flight, freeze, arousal, tonic immobility, and collapsed immobility.
4. A bunch of other stuff whose role is harder to understand, like medical history, medication, environment, genes, sleep quality, mental illness symptoms, and a variety of low-level neurobiological dynamics from which priors and attention emerge.
Together, certain sets of priors and avoidance create stable and maladaptive attractor states. The priors involved often erroneously predict threat and powerlessness and therefore activate defense cascade states.
You can permanently destabilize these maladaptive attractor states (and associated defense cascade activation) by updating/reconsolidating the reinforcing priors by activating them and juxtaposing them with strong contradictory evidence that the person may otherwise be avoiding, e.g. the best examples of psychotherapy. This juxtaposition creates prediction error, which updates the priors reinforcing the maladaptive attractor state. Of course this is easier said than done; it’s hard to pay attention to contradictory evidence when you’re in flight or flight or tonic immobility, you feel that feeling emotions is a threat itself, you don't even know what the relevant prior is, etc. I personally think MDMA therapy is particularly helpful here because it seems to facilitate prediction error for most or all maladaptive priors that are activated/triggered during a session and often works during fight or flight or tonic immobility.
Maybe there’s some use in categorizing most mental illness into boxes, but in this model you would still cure it contradictory evidence specific to each case (or possibly through practices that facilitate universally applicable prediction error), so why bother other than for legal reasons.
To be clear, this model doesn’t fully describe disorders involving certain clear biological issues like psychosis (aberrant salience), a swath of neurological disorders, brain damage, etc. This model also doesn't explain anything about how, when, and why a lot of psychiatric drugs work and don't work.
I flesh this out in much more, fully-cited, detail in Chapter 2 of https://www.researchgate.net/publication/394097304_Open_MDMA_An_Evidence-Based_Mixed-Methods_Review_Theoretical_Framework_and_Manual_for_MDMA_Therapy.
Thank you for this comment! I agree that this is a promising way of thinking about mental heath problems and I find it appealing too, as do a lot of other people who are drawn to complex dynamic systems thinking. I recently posted (book review of Nicole Rust’s Elusive Cures) about how clinical neuroscience is moving in this direction too. However, I would not say that mechanisms understood in this manner are “already well-established.” We have not yet moved beyond theoretical appeal and plausibility and methodological fervor to actual empirical demonstrations of well-defined hypotheses. And there are significant challenges involved in getting to that point.
Thanks for the reply! I wonder if some of our different interpretations of establishment come from perspective. I started out in the psychotherapy prediction error/memory reconsolidation world surrounding "Unlocking the Emotional Brain" by Bruce Ecker. I think people there more readily think that the framing I laid out is more established, or common knowledge, at least the "previously adaptive priors that are no longer adaptive," and "facilitating prediction error/memory reconsolidation is the solution" parts. That group might have less strong views about the parts of the framework involving the defense cascade, attention, and complex system attractor states. As far as I can tell the defense cascade stuff is also somewhat established, but I'm less confident about the specifics of the attractor state dynamics and how attention plays into that.
I imagine actually verifying these attractor state dynamics might be experimentally difficult! Especially since each case seems at least a bit unique.
Thank you, Awais, for a thorough and thoughtful survey of this fraught topic--one I have been grappling with for four decades! I would like to suggest another way of looking at the concept of "validity" in psychiatry--one that shifts the discussion from etiological considerations to pragmatic, instrumental and ethical issues. I discuss this under the rubric of "instrumental validity" in this article:
https://scispace.com/pdf/toward-a-concept-of-instrumental-validity-implications-for-4j3yc4xt2d.pdf
The core of my thesis is as follows:
"Following the pragmatic tradition of William James and John Dewey, I define “instrumental
validity” as that property of a diagnostic criteria set which bears on how fully it achieves a par-
ticular aim or goal. Now - to hyper-condense along argument - I believe that the fundamental
goal of general medicine and psychiatry is to reduce certain kinds of human suffering and inca-
pacity..."
With respect to general medicine, I think that the issue of "validity" does arise fairly frequently, albeit (usually) without the polemical flourishes that typically accompany discussions in psychiatry. For example, there is intense interest and discussion regarding the validity of the entity commonly called "Long Covid" See:
https://www.psychiatrictimes.com/view/what-long-covid-can-teach-psychiatry-and-its-critics
There are other debates that border on the "validity" question in general medicine and neurology, such as whether Persistent Idiopathic Facial Pain is a valid diagnosis (this was formerly known as "atypical facial pain")
Best regards,
Ron
Ronald W. Pies MD
There's a lot to think about in that last sentence.
Perhaps one of the complications faced by any attempt to forge a 'once and for all valid' classification of diagnoses is the severe entanglement between diagnosis and values in the case of psychiatry. (In order to be a 'psychotic delusion' a belief must be 'bizarre', and held 'irrationally'. Etc.) It isn't absent in somatic medicine, but as you say the latter is largely grounded in physiology in a way that psychiatric diagnosis is unlikely ever to be; one might add that human values as they relate to somatic health seem to be somewhat more unified (which is not to say 'totally unified') and more easily identifiable--indeed in many cases they don't even need stating. (Most people would agree, I guess, that broken arms and malfunctioning kidneys are deviations from 'normality' that do present problems of living. There are, of course, areas of greater contention, and it is in these areas where 'diagnosis' is also more contentious.)
It isn't at all clear that this entanglement between the subject-matter of psychiatry and values can be avoided. Or rather, a version of psychiatric diagnosis that sought significant disentanglement from values (perhaps all diagnosis is based on standardized brain scans, or blood samples, or whatever) would probably cease to be at all effective (low utility, in Solomon's sense).
If strong entanglement with values is inevitably part of the diagnostic picture, and if values are (as they seem to be) quite variable across time, space, culture, etc., then at the very least what counts as 'end game' in the case of psychiatry is going to look very different from 'endgame' in the case of somatic medicine.
Hi, Prof. Dickson,
I appreciated your thoughtful and carefully nuanced comment on "values" as they pertain to "somatic medicine" as distinct from psychiatry. (I will resist the temptation to make the case for why psychiatrists also practice "somatic" medicine--but we assuredly do!).
I find your use of the term "entanglement" interesting, and--if I may pursue a bit of a linguistic turn--I wonder if you might consider alternative terms. For example, what if we were to say that psychiatry is "informed" by values? Or, that psychiatry is deeply integrated with values? Substituting these terms for "entangled" may allow us to pursue this issue in more neutral terms, in as much as "entangled" connotes a kind of twisted state of disorder that, in some sense, hampers action or understanding.
I would argue that, on the contrary, psychiatry's deep involvement with certain humane values is integral to the psychiatrist's medical ethos and--as you imply--to the very effectiveness of our work with patients. And, of course, all of "somatic" medicine--meaning, e.g., internal medicine, neurology, etc.--operates from a set of implicit and explicit values. The former include such fundamental beliefs as, "It is better to take care of one's body than to neglect it," and "It is better to reduce intense pain when possible than to ignore it." Explicit values include the well-known tetrad of beneficence, non-malfeasance; autonomy, and justice, made famous by Childress and Beauchamp. [1]
To be sure, these are not specifically diagnostic values. But here I would suggest that in general medicine, too, there are evaluative terms that guide diagnosis, over and above "objective" criteria, such as a broken arm or malfunctioning kidneys. True, these are not as pronounced or dispositive, outside of psychiatry, but they are nevertheless present in general medicine, particularly when a new or poorly-characterized syndrome is being considered. For example, the evolving definition of the syndrome known as "Long Covid" [2] includes this feature:
"Long Covid can impair affected patients’ ability to work, attend school, and care for themselves and can have a profound emotional and physical effect on patients, families, and caregivers." [3]
Clearly, the notion of "profound emotional and physical" effects entails an evaluative dimension, not fundamentally different than deciding that a belief is "bizarre" or "irrational."
I am not suggesting that psychiatry is "just like" internal medicine or orthopedics. Evaluative terms are certainly more prevalent in psychiatry than in what you are calling "somatic" medicine. But I think the differences can be overstated and often are.
I would welcome your response and I thank you for your earlier comments.
Best regards,
Ron
Ronald W. Pies MD
1. Beauchamp TL, Childress JF. Principles of biomedical ethics. New York (NY): Oxford University Press; 2009. pp. pp.162–4
2. https://www.psychiatrictimes.com/view/what-long-covid-can-teach-psychiatry-and-its-critics
3. Ely EW, Brown LM, Fineberg HV; National Academies of Sciences, Engineering, and Medicine Committee on Examining the Working Definition for Long Covid. Long Covid Defined. N Engl J Med. 2024 Nov 7;391(18):1746-1753
Ron,
Thanks for this response and sorry for the delayed reply. Other business is keeping me busy (and this is Awais’ substack so maybe not the place for a super-extended discussion by others), but here is a short(ish) response. (OK, I just reread it and it is not short. Sorry Aftab! If the discussion continues we can take it elsewhere....) I hope to write more about these issues very soon.
On entanglement: I’m coming at this with a 30-year background working in quantum theory, so my use of the term ‘entanglement’ is probably (i.e., almost surely) idiosyncratic. I wasn’t intending it to have negative connotations, but simply to indicate that psychiatric diagnosis and value-judgments are interdependent, and that this interdependence is (probably, in the case of at least many prominent diagnoses) not eliminable. ('Interdependent' doesn't really capture the idea I'm trying to convey, but I'll not work at it further here.)
We agree that the practice of ‘somatic’ medicine involves making many assumptions about values, such as the ones that you mention. (I’m going to set aside, here, the discussion that we might have about the concept of ‘somatic’ medicine and just use the scare-quotes to acknowledge the need for further discussion. I think it’s very complicated and I shouldn’t have implicitly broached the issue in a comment.) I do think (and you seem to agree) that some of the kinds of value that you mention (e.g., regarding the propriety of taking care of one’s body) are more or less separable from diagnosis (but not from treatment).
You suggest that there are other cases – especially on the borders of ‘somatic’ medicine – where diagnosis is ‘interdependent with’ values. That claim seems plausible. It does seem to me, however, that ‘somatic’ medicine holds to an ideal of eliminating these interdependencies; we want, and perhaps even expect, that eventually there will be clear, non-value-laden (as far as possible), diagnostic criteria for Long Covid.
One sometimes finds, of course, of a similar ideal in psychiatry. Whatever one might think of the ideal in the context of ‘somatic’ medicine, I believe that it is both unattainable and ill-advised in the case of psychiatry, and that this difference arises from the subject-matter of psychiatry. Trying to justify that claim would take a lot.
Finally, and too quickly, I do actually think there are important distinctions between your examples of “profound emotional and physical effects” and “bizarre or irrational”. First (but maybe this point is covered by the intention behind your use of ‘fundamentally different’), these judgments sit in very different ‘realms of value’ (the latter being more or less epistemological, the former not). Second, the former are more akin to the common use (in psychiatric diagnosis of depression or schizophrenia or whatever) to the ‘impairment’ requirement often mentioned in DSM. (I feel compelled to remark that for scz the condition is ‘functional impairment’ while for depression it is “significant distress or impairment” – so one isn’t supposed to pay attention to distress in the former case?) Yes, judgment of ‘impairment’ often involves value-judgments. But in both cases we are talking about the *effects* of some purportedly underlying condition (DSM explicitly uses cause/effect talk), whereas judging whether a belief is ‘bizarre’ or ‘irrational’ is not a judgment about the effects of some purported underlying condition, but a judgment about whether the condition is present in the first place.
I’m only gesturing, here! I do need to think more carefully about this distinction, and I thank you for pressing me to do so. If I make any headway, I’ll probably write about it soon(ish).
Dear Michael,
Many thanks for your cordial and considered response. Coming, as you do, from the Land of Schrödinger's Cat, I now understand why you used the term, “entanglement”, without pejorative intent. Speaking of entanglement, I think we both realize that these issues (values, validity, “somatic” medicine, etc.) comprise something of a conceptual hairball, and are ill-suited to resolution in the confined space of online comments. Furthermore, I fear we would be straining Awais’s renowned online hospitality by too much back-and-forth. Perhaps there will be a more suitable venue for further elaboration of these complex issues. (Feel free to write me at piesr@upstate.edu).
For now, suffice it to say that we are in broad agreement as regards your point that, “…psychiatric diagnosis and value-judgments are interdependent, and that this interdependence is (probably, in the case of at least many prominent diagnoses) not eliminable.” Many scholars (Kendler, Sadler, Fulford et al) address these issues in the excellent Oxford Textbook of Philosophy and Psychiatry (edited by Fulford, Thornton and Graham). The general consensus is that psychiatry operates from a “facts + values” paradigm.
Where I differ from many critics of psychiatry (I do not include you in this group) is in claiming that diagnosis and value-judgments are interdependent in all of general medicine, though less obviously than in psychiatry; and that this relationship, too, is not eliminable—even as general medicine strives to eliminate subjective judgment in diagnosis. I regard the latter as related to, but distinct from, the elimination of values. (We could, of course, engage in a long scholastic debate over the terms, “subjective” and “objective”!). [1]
The core of my thesis is summarized in one paragraph from the Oxford Textbook (chap. 20, p. 565), with which I’ll close my comments--and you are more than welcome to the last word:
“Our conclusion…will be that the traditional medical model, and the claim to value-free diagnosis on which it rests, is unsupportable; and that, to the contrary, diagnosis, although properly grounded on facts, is also, and essentially, grounded on values. This conclusion…although currently of practical importance mainly for psychiatry, will become, under the pressure of twenty-first century medical-scientific advances, increasingly important in bodily medicine as well.”
Best regards,
Ron
P.S. Three quarks for Muster Mark!
1. https://www.psychiatrictimes.com/view/four-dogmas-of-antipsychiatry
One approach might to think of DSM (and ICD) as a kind of atlas of psychiatry, allowing conceptual structure, but not necessarily believing in the concrete reality of a condition. We can point to a country on a map, and we can have a good idea of the political boundaries; but the map is not the territory. But atlases are useful, perhaps indispensable
What do you think of other medical conditions that don't based on subjective symptoms and don't really have biological anchors. Migraines, IBS, CFS, chronic pain etc. the dispute of Thier validity I never see come into question
There are definitely disputes around etiology or causes of such conditions but rare to see them framed as being about their “validity,” which again suggests something peculiar is happening in psychiatric debates. Some of it is a bias against mental illness but it also speaks to the complexity and ambiguity of mental health problems in terms of their conceptualization (illnesses, life problems, personality problems, spiritual problems, etc) as well as their relationship to biology.
IDK if this is specifically about validity, but Van den Bergh wrote an influential paper interpreting these symptoms through the predictive processing framework: https://orbilu.uni.lu/bitstream/10993/30368/1/Van_den_Bergh_et_al_Symptom_Perception_NBBR_2017.pdf