Reviewing Paul Bloom on Psychopathology

Comments on the Chapter “Suffering Minds”

I read Paul Bloom’s 2023 book Psych: The Story of the Human Mind a few months ago, and I enjoyed it. It’s an excellent overview of psychology as a scientific discipline for a general audience, and it’s based on a popular course that Bloom taught for many years at Yale (he is the Brooks and Suzanne Ragen Professor Emeritus of psychology and cognitive science at Yale University and Professor of Psychology at the University of Toronto). Fortunately for many of us, he also has a delightful Substack titled “Small Potatoes” (

Paul Bloom

) that I follow. I don’t usually read books about introductions to psychology at this point in my life, but I was curious what Bloom had to say. And I am happy to report that there was much of interest to me and that even practicing psychiatrists and psychologists would find this introduction instructive. People much more distinguished than me have already said some really nice things about the book, so I don’t really need to reinvent the wheel here. I’ll go with a quote from Jennifer Senior, a Pulitzer Prize winner, that aligns with my own impression: “Paul Bloom’s Psych is perhaps the wittiest, most captivating overview of the field of psychology to date. Bloom is edifying without being pedantic, profound without being pretentious (or, let’s face it, exhausting), and authoritative while still maintaining an admirable sense of humility. Plus: his eye for the just-right anecdote or bit of fanciful trivia is impeccable.”

Alright, with that out of the way, let’s get to business. I am going to focus here on just one chapter from Bloom’s book, the chapter about mental disorders (or psychopathology). Nothing that Bloom writes in the chapter is false or inaccurate, but as I was reading it, I couldn’t help but feel that there are things that I would describe and explain differently. I am a practicing psychiatrist with one leg in the philosophy of psychiatry academic community. I have been thinking, discussing, and writing about conceptual issues in psychiatry for years now, and it’s no surprise that I have opinions. So this is an opportunity for me to highlight how I approach such discussions.

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Bloom answers the question, “What do we mean by mental illness?” by using the following question as a starting point:

“What is it about certain patterns of thought and behavior that made psychologists and psychiatrists include them in these big books [DSM and ICD]?” (p 341)

That’s a perfectly legitimate way of beginning the discussion, but it comes with the risk of being distracted by the scientific and institutional peculiarities of the diagnostic manuals. The risk is that we can focus on the manuals and lose sight of psychopathology itself, as if the decision to create big books about mental illness somehow preceded the recognition and treatment of mental illness. Although Bloom doesn’t get derailed in this way, we can see in the text that this question shapes his discussion in subtle ways. Better questions may have been along the lines of: What is it about certain patterns of thought and behavior such that practically every society has some sort of category for them, for behaviors recognized as abnormal, problematic, or mad? What sort of psychological and behavioral problems cause distress, disability, and disruption, and by doing so, come to the attention of the healing professions? Why is the recognition of such problems so variable from time to time and culture to culture?

Psychiatric conditions are identified and treated in the clinic long before they are officially recognized by the diagnostic manuals. For example, “Prolonged Grief Disorder” was added to the DSM and ICD only a few years ago, but clinicians have been talking about and addressing pathological grief in the context of psychotherapy for decades. “What is it about some forms of grief that made psychologists and psychiatrists include them in the DSM/ICD?” perhaps isn’t the most helpful question to ask. One reason to be wary is that those critical of the very existence of psychopathology have relied on precisely this kind of framing for their inquiry. It’s an easy way to reduce psychiatric disorders to “social constructions voted into existence by committees” and to pretend that uncertainties around operationalization mean that the whole project is simply disease mongering. The better question, IMO, would be: What is it about certain forms of grief that people get stuck for years, unable to move on, paralyzed, their social and interpersonal lives in ruins? What is it about certain forms of grief that makes people seek professional help? If we are really interested in suffering minds, we should start with suffering minds. This is not necessarily Bloom’s fault. Bloom is following the convention in psychiatry and psychology education that looks to these “big books” for scientific guidance. I am just pointing out that we don’t have to do it this way, and maybe it’ll be better if we don’t.

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A History of Prolonged Grief Disorder's Inclusion in the DSM — And What Is Missing From It

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Bloom writes:

“There are some successful people, after all, who look like they have a narcissistic personality disorder. Is it reasonable to point to someone who is thriving—maybe doing better in every tangle way than the psychologist or psychiatrist who is evaluating them—and insist that they have a problem and need treatment? Perhaps yes, but then the problem might be more of a moral one, rooted in ideas about what a good life should be and how people should treat others. Should psychiatrists and psychiatrists be in the business of these sorts of judgments?” (p 342)

This is an odd example to focus on, as if psychiatrists and psychologists go patrolling out in the community, pointing towards unsuspecting people who are living happy, flourishing lives, and telling them that they have a disorder! If someone with a narcissistic personality is thriving in every tangible way, they will not come to clinical attention; they will not show up in the clinic. They would only come to clinical attention if there was some sort of problem. If the person felt depressed, or if they were experiencing repeated interpersonal issues, or perhaps they got into legal trouble and are now being examined by a forensic psychologist, etc. Psychiatrists and psychologists do not try to convince thriving people that they are ill. They may try to do so if a person comes to clinical attention. So, the question is: why would a thriving and successful narcissist show up for psychotherapy? When narcissists do show up for psychotherapy, it is usually because they may be superficially doing well, but the psychological dynamics of narcissism have taken a severe toll on their lives. They have estranged their loved ones. They have alienated their colleagues. They are full of anger. They don’t know how to make sense of the confusing mix of insecurity and self-importance they feel in their hearts. A diagnosis of narcissistic personality disorder, done properly, isn’t about moralism or some devotion to ethical ideas about “the good life.” It is about well-being (i.e., health) and the psychological obstacles that stand in the way.

Another scenario in which someone thriving may be “diagnosed” may happen in the context of epidemiological or research surveys. Let’s say someone is researching the prevalence of “narcissistic personality disorder.” They administer a self-reported psychological measure of narcissism to a thousand people and then decide that people above a certain cut-off have “narcissistic personality disorder.” This is different from pointing at someone and saying they need treatment, but something similar is happening at an abstract level. What is happening here is that it is being assumed that narcissism above a certain threshold would be “clinically significant,” i.e., it would produce the sort of distress and impairment that brings people to clinical attention. Researchers do something similar with measures of depression or anxiety. They may simply assume that depressive or anxiety symptoms above a threshold constitute disordered states. The assumption is not always correct. This is one major reason why epidemiological surveys generally produce inflated estimates of rates of mental illness. They capture the symptoms necessary for disorder attribution but miss the “clinical significance” part. Someone with anxiety symptoms just above the diagnostic threshold may be doing fine in their life; they may have found productive ways to manage those symptoms, and such people wouldn’t come to clinical attention. We can see here that whether someone is high on “narcissism” (or “neuroticism” or whatever psychological trait you want) doesn’t always go hand in hand with whether that psychological state is causing problems in their lives and whether treatment would be indicated. Researchers may assume so to make epidemiological research feasible, but if we want to be true to our current conception of mental disorders or psychopathology, we need the whole package.

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Bloom mentions arguments from critics that mental illness is a myth, that there is no such thing as mental illness, but his treatment of these issues is superficial. He counters these objections by highlighting the suffering, impairment, and disability of psychopathology—which is exactly the right thing to focus on—but it doesn’t address the philosophical problem of “When does suffering/disability become a disorder?” and “Since suffering and disability are context-dependent, how should our notions of psychopathology take context into account?” No Szaszian is convinced by “But look, these people are suffering!” because Szaszians and their contemporary counterparts want more. They want some objective, factual definition of disorder. Szaszians hold on to a fantasy where an objective definition of “disorder” not only exists, but it also successfully covers recognized disorders in general medicine while conveniently excluding mental illnesses as faux-disorders. Szaszians also commit themselves to some version of the idea that medical authority only applies to genuine disorders, and hence medicine has no authority to treat psychological suffering.

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Psychiatry and Medical Authority

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Other critics focus on things like understandability to challenge psychopathology. Bloom discusses Johann Hari’s objections, for example: depression is a reasonable response to life circumstances. If you have full-blown depression but you are grieving, or homeless, or unemployed, or going through a divorce, you are not ill, you are having a normal response to a terrible event. “Normal,” of course, is a fuzzy, ambiguous concept. If someone who lost their job is so depressed that they cannot get out of bed for weeks, it may be “normal” or “understandable” in some sense of the word, but it will be abnormal in many others. Since the concept is ambiguous, consequently, notions of “normality” (or “understandability”) and “psychopathology” are not mutually exclusive. It may be “understandable” for someone to have a nervous breakdown in the middle of a high-stress divorce or for someone to experience paralyzing fear and traumatic flashbacks months after a sexual assault, but these still represent states of disability and impaired well-being, deserving of clinical interventions and accommodations that are likely to help, and therefore they aren’t “normal” in the ordinary clinical sense.

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Bloom is absolutely spot-on in countering the argument that mental disorders aren’t disorders if they have a primarily “environmental” etiology:

“Also, even if this weren’t true—even if mental illness was solely a product of the immediate environment—it wouldn’t be a knockdown critique of the medical approach. Environmental causes don’t mean environmental treatments. An analogy with cancer might be helpful here. There are carcinogens in the world, and this is well worth knowing and acting on. It doesn’t follow that the only way to treat cancer is to change the world, and it doesn’t follow that cancer isn’t a disease. One can make precisely the same argument for disorders such as depression.” (p 346)

I don’t have many issues with Bloom’s discussion of particular conditions such as schizophrenia, depression, and anxiety disorders. It’s fairly standard textbook stuff, with the added bonus that Bloom is mindful of mistaken popular narratives and makes sure to highlight them. The following passage is a good example of how Bloom captures the complexity of issues and conveys the unknown with admirable brevity:

“And the evidence that serotonin is implicated in both the cause of depression and its treatment is surprisingly weak, as one commentator said: “To put it bluntly, there is no decisive evidence that low mood is caused by low serotonin levels.”[33] The drugs often work, but we don’t know why they work. A quite different theory is that depression is related to a more general lack of plasticity in the brain, where one loses the capacity to make appropriate restructuring in response to the environment—though there is hardly a consensus here.[34] At a more cognitive level, depression is associated with (though perhaps not caused by—the usual problems with cause and effect apply) certain patterns of thought. These include a tendency to ruminate on one’s problems.[35]” (pp. 352-353)

And then we have gems such as: “Put this way, depression doesn’t make you stupid; you’re as clever as you’ve always been, but your intelligence is turned against you.” (p 353) Love it. 10/10

Something prominently missing from the discussion are the shortcomings of DSM/ICD in facilitating a scientific understanding of the underlying mechanisms of psychopathology and how frameworks such as RDoC and HiTOP have emerged to address that challenge. It would’ve been really useful to have some discussion of that.

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Are Critiques of DSM/ICD as Devastating for Psychiatric Diagnosis as Some Critics Seem to Think?

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I also greatly admire Bloom for writing this:

“I cannot stress this enough—if you are in distress, seek treatment. It works. But, and I can’t stress this enough either, the treatment of mental illness is at a primitive stage.” (p. 361)

We absolutely need this kind of honesty. As I said in my conversation with Nicole Rust: “I once heard Kendler say in a lecture, “Psychopathology is an immature, faddish science” and I loved it so much that I try to say it every time I give a public-facing talk because I think we owe the public this sort of clear acknowledgment.”

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Bloom ends with a discussion of the dimensionality of psychopathology.

“To be diagnosed with a mood disorder or an anxiety disorder means that you have too much of a certain sort of sadness or anxiety, and this involves all sorts of judgment calls… therapists might disagree on how much low mood, how much diminished interest in pleasure, and so on, counts as clinically significant. And some of the criteria are themselves partially arbitrary.” (p. 364)

“The question “What is the prevalence of psychopathy in the general adult population?” might not be a scientifically meaningful one; it’s a lot like the question “What proportion of the population is really tall?” It all depends on what you mean by “really tall.” None of this is an argument against categorization. We put people into discrete categories for all sorts of reasons… (p. 365)

That’s true, but we have ways of making continua scientifically meaningful. “Really tall” isn’t quite scientifically meaningful, but “dwarfism” and “gigantism” are recognized medical conditions, and official estimates of their prevalence are just one Google search away. Similarly, blood pressure and weight are continuous, but we can scientifically study “hypertension” and “obesity” without tripping over ourselves.

Bloom concludes:

“When thinking about disorders like depression, anxiety, addiction, autism spectrum disorder, and schizophrenia, we can no longer simply view them as problems to be solved. Rather, they are the names we give to certain extremes of human variation. What counts as extreme enough to warrant treatment isn’t just a psychological question. It is a moral and political one.” (p. 366)

I agree with that, but to say that it is a moral and political issue gives a somewhat misleading impression. It is a moral issue in the general sense that treating states of suffering and studying them scientifically is a moral imperative. It is political in the sense that deciding what conditions to cover for healthcare and investing in public health and medical treatment are political matters. And this applies to medicine generally. What dimensionality highlights isn’t that the matter is moral or political, but rather that pragmatic clinical and scientific considerations determine our thresholds rather than natural discontinuities. “When is low mood a clinical problem?” isn’t primarily a moral or political question. It’s a question of what thresholds offer us the most useful guidance with regards to identification and treatment, and what thresholds allow us to meaningfully ask scientific questions about etiology and mechanisms in a diverse range of contexts. (DSM gives the misleading impression that there is one optimal threshold, but in all likelihood, different thresholds are optimal for different purposes.) What makes psychopathology more moral and political than general medical conditions isn’t dimensionality per se. It’s the tension between changing the individual vs. changing society to relieve distress or disability, and it’s the potential source of error around, “Are we calling this condition abnormal because we are socially prejudiced and have reified social oppression into individual disadvantage?” Medicine isn’t exempt from these considerations, but they are of particular relevance to the science and treatment of psychopathology.

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The Social Construction of “Disease”

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In a future post, I will comment on Bloom’s chapter on Freud and psychoanalysis.

See also:

• Mental disorder and social deviance

• Conceptual and historical evolution of psychiatric nosology