Ronald Pies, MD, and Mark Ruffalo, DPsa, were busy in June. They published two papers in defense of psychiatry: What Is Meant by a Psychiatric Diagnosis? (“Psychiatric diagnoses are not merely descriptive; they reflect genuine illness”); and Psychiatric Diagnosis 2.0: The Myth of the Symptom Checklist (“More on the meaning of psychiatric diagnosis”). Both were published by Psychology Today.
Here’s their opening to the first paper:
“It has become fashionable for some in the social sciences to assert that psychiatric diagnoses represent ‘constructs’ and not genuine disorders or diseases. During a recent Twitter exchange, one of us (Mark Ruffalo) was pointed to an article published here on Psychology Today in 2019 by the psychoanalytic psychologist Jonathan Shedler, Ph.D., titled, ‘A Psychiatric Diagnosis Is Not a Disease.'”
Note the word “fashionable”, as if those of us on this side of the issue dispute the validity of psychiatric diagnoses on the grounds of fashions or whims.
“We wish here to counter the claims made in the Shedler piece, particularly as they pertain to the meaning and implication of a psychiatric diagnosis. One of us (Ronald Pies), a psychiatrist, has spent a large part of his career thinking and writing about the philosophical foundations of psychiatry; and the other (Mark Ruffalo), a psychoanalytic psychotherapist, has developed a keen interest in discussions surrounding the meaning of psychiatric diagnosis.”
Most of the content of the two papers is simply a regurgitation of previous contentions of Dr. Pies, to which I have responded on several occasions. These I will address in a fairly cursory manner. But our dynamic defenders of the psychiatric corpus have also collated a few new points of contention to which I will devote more space.
Drs. Pies’ and Ruffalo’s initial tactic is to reduce Dr. Shedler’s position to four “claims.” The four claims are:
That “Medical diagnoses describe underlying biological causes—and psychiatric diagnoses do not.”
That “Psychiatric disorders and medical disorders are categorically different (i.e., are not ‘equivalent’).”
That “Psychiatric diagnoses provide nothing more than a label or a description of the person’s problems.”
That “Psychiatric disorders and their diagnostic criteria cannot be considered the ’cause’ of the patient’s problems.”
CRITIQUE OF DRS. PIES’ AND DR. RUFFALO’S ARTICLES
Here are some quotes from the Pies-Ruffalo articles, interspersed with my observations and critiques.
“A careful reading of history teaches us that there is no ‘essential’ definition of disease universally accepted by physicians (or by philosophers of science); however, historically, the concept of ‘disease’ has always been more intimately tied to the degree of suffering and incapacity experienced by the individual person than to demonstrable biological dysfunction (see Pies, 1979, 2019). While abnormal biological or laboratory findings can sometimes aid in the diagnosis of a disease—e.g., as confirmatory tests—they are neither necessary nor sufficient for an entity to be considered a disease, nor for the diagnosis of disease.”
“A careful reading of history…”
Note the blatant arrogance and condescension in the implication that Drs. Pies and Ruffalo are the “careful” readers of history, and that, presumably, those of us in the anti-psychiatry movement are simply being careless and slapdash in this regard.
“…there is no ‘essential’ definition of disease universally accepted by physicians (or by philosophers of science);”
Actually, there is an essential definition of disease. It’s to be found in dictionaries. It may not be universally accepted by physicians or by philosophers, but where is the justification for such a sweeping requirement?
I myself keep three reputable dictionaries on my desk. Here’s what they each say under the entry disease:
Merriam-Webster’s Collegiate Dictionary, Eleventh Edition, 2009:
“a condition of the living animal or plant body or of one of its parts that impairs normal functioning and is typically manifested by distinguishing signs and symptoms; sickness; malady.”
Random House Webster’s College Dictionary, 1992:
“a disordered or abnormal condition of an organ or other part of an organism resulting from the effect of genetic or developmental errors, infection, nutritional deficiency, toxicity, or unfavorable environmental factors; illness; sickness.”
Webster’s New World Dictionary of American English, Third College Edition, 1988
“a particular destructive process in an organ or organism, with a specific cause and characteristic symptoms; specif., an illness; ailment”
Each of these dictionaries also gives analogical or extended uses of the word, e.g. any harmful condition, as of society (Random House). But the essential definition in each case is as presented above.
PIES-RUFFALO: SUFFERING AND INCAPACITY ARE THE CRITICAL HALLMARKS OF DISEASE
“however, historically, the concept of ‘disease’ has always been more intimately tied to the degree of suffering and incapacity experienced by the individual person than to demonstrable biological dysfunction…”
Actually, for most of its history, the practice of medicine has been founded on error, superstition, and quackery. Physicians had little or no knowledge concerning the essential nature or causes of the various diseases. Bigotry and guesswork prevailed, and useless or even harmful “treatments” were used extensively. The fact that some physicians stressed the notions of suffering and incapacity is neither surprising nor helpful. These, after all, are very noteworthy and obvious properties of many diseases. The fact that historically there was relatively little emphasis on “demonstrable biological dysfunction” is also unsurprising and unhelpful because until about the mid-1800s, little was known about human biology, normal or abnormal. It wasn’t until the second half of the 1800s that John Snow, Louis Pasteur, and Robert Koch confirmed the existence of germs and developed the germ theory of disease, (here) and it wasn’t until the 1860s that most biologists accepted the basic tenets of the cell theory!
To hold up earlier periods of pre-scientific quackery as the preferential source of our present-day definitions is pure, undiluted nonsense. It’s akin to citing unsplittability as the defining feature of an atom, on the basis that this was the accepted historical view prior to the first lab-controlled fission by Cockroft and Walton in Cambridge in 1932.
. . . . . . . . . . . . . . . .
“And history is replete with examples of disease states whose pathophysiological mechanisms were unknown for decades after the disease had first been described clinically. Parkinson’s disease is perhaps the best-known example.
On Dr. Shedler’s view, no physician in 1817—not even James Parkinson!—could have told a patient with “the shaking palsy” that he or she had bona fide disease—because, for Shedler, the sine qua non of a bona fide disease diagnosis requires a known etiology—or at least, the diagnosis must “point to” etiology, whatever that means. The illogical consequence of this view is that no patient with what we now recognize as Parkinson’s disease could have had actual disease until the etiology or pathophysiology was identified, in the 1960s.”
In the early days of scientific medicine, progress was by fits and starts. Great discoveries were made, but several issues remained poorly understood or not understood at all. The etiology of Parkinson’s disease was not understood. But—and this is the critical point—it was reasonable to believe that there was an underlying pathology, and that the “shaking palsy” was a genuine disease or illness. This, I believe, is what Dr. Shedler meant by the assertion that medical diagnoses “point to etiology—underlying biological causes.”
Apparently the learned doctors have failed to grasp this, so I’ll try a simple analogical explanation. Suppose I am riding a bicycle and I hear a loud grinding noise coming from the rear hub. Without even examining the hub, I surmise, probably correctly, that something has gone amiss in the hub and repairs are called for.
Similar considerations apply to Dr. Parkinson’s position in 1817, when he wrote his “Essay on the Shaking Palsy.” He described six cases of this condition and identified six characteristics: the tremor itself, abnormal posture, abnormal gait, paralysis, diminished muscular strength, and a deteriorating course. Any one of these problems would suggest a disease (in the dictionary-endorsed biological pathology sense of the term). The identification of six characteristics leaves little doubt. After all, there are no other plausible explanatory candidates.
In sharp contrast, most of the criteria items by which psychiatrists define their ever-growing list of mental “illnesses” are explainable in non-pathological terms. Depression in the face of overwhelming adversity does not point to a biological etiology; rather, it is an adaptive mechanism encouraging us to make appropriate changes in our lives and circumstances. Similarly, anxiety concerning the current world-wide pandemic does not point to a biological etiology, but is also adaptive, and encourages us to take such precautions as we can.
But the very learned doctors remain intractable. They list five illnesses for which “the exact cause is either unknown or poorly understood”:
“Even today, many diseases—readily identified as such—have no known underlying biological cause. Alzheimer’s disease, migraine disorders, Kawasaki’s disease, fibromyalgia, and amyotrophic lateral sclerosis (Lou Gehrig’s disease) are but a few examples of conditions for which the exact cause is either unknown or poorly understood.”
And they conclude:
“Thus, the claim that medical diagnoses essentially or necessarily ‘point to’ etiologies is false.”
The essential issue here is that Drs. Pies and Ruffalo are confusing the disease (i.e. the actual biological pathology) with the degree of human knowledge concerning the disease (which could vary from very little to a great deal). Are the
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