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Should Mental Disorders Have Names?

126 points by LinuxBender 8y ago

mhuffman 8y ago
Should anything have a name? It seems that people are just running out of shit to write about at this point. And from Scientific American! I trusted you as a kid!
- nimonian 8y ago
  I not sure if you are just trolling here, but reading the article it seems clear that the author has a point beyond the usual signifier-signified semiotic crisis. The author ends by musing about mental diseases being described by coordinates in several dimensions. Sure, perhaps connected regions of that space can be given their own names, but in general, the author believes that our vocabulary lacks the granularity to identify the fingerprint of individual diseases. I know a lot of hands have already been wrung over the ineffectiveness of natural language in describing the phenomena of the inner world, but in a clinical setting this takes on a new meaning, and the essay is, in my opinion, poignant.
teekert 8y ago
Us humans certainly prefer to put boundaries and names on things. And indeed, it is often unwise i.e. with (one of our) species definitions: A can procreate with B, B can with C but A cannot with C, meaning A==B, B==C but A!=C, a paradox because of our tendencies. Could it be a cultural thing? While I grow older I find it more natural to think of things as continuous or to assign uncertainty to "facts", but perhaps our educational system does not give much attention to this. Perhaps it's too much about facts and names and boundaries. In this articles' case though, of course mental disorders are a continuum but the drugs and methods for treatment we have are not. So perhaps in this case a label is nice. One should always keep the continuous nature in the back of one's mind though.
- darkerside 8y ago
  I agree with much of what you say. I've heard it said that education is a series of increasingly small lies. If you started teaching the whole truth and nothing but, from a young age, the student would fail to grasp the big picture and the broad connections in the way the world works. When you let something go, it drops. Well, unless it's lighter than air. And it doesn't drop, it attracts to the Earth. And actually, it attracts the Earth back to itself. And it doesn't simply "drop", it accelerates. And gravitational forces and air friction determine the acceleration and the jerk. If you don't omit anything, you can't communicate anything. The broader point I'm getting at is, first you need to learn about the artificial distinctions so you can "from" the subject. Then, once you know all the rules by heart, you can feel free to break them.
  - teekert 8y ago
    Nice way of putting it. Yesterday morning my son asked how humans came to be and I ended up stuttering that perhaps at some point some molecule of unspecified complexity gained the ability to replicate at which point it became subject to natural selection based on descent with modification... You get the problem. Better say: It started with simple life and the best ones (sometimes more complex ones) ended up in the next generation. FFWD 3.5 billion years and voila. It's a bit of a lie because "what's life, what's before that, what's best, what's fitness" etc. But it works. I keep having problems with this though, but yeah, what to say to someone without any grasp of cells or DNA or "1 billion years", do even grasp it "correctly"??... Man, speak about rabbit holes. I didn't even start on evolution on the population level.. I see my son loosing interest during my explanation, while I get more and more enthusiastic. It's a hard problem.
- MrQuincle 8y ago
  True, but do definitions not encourage a more thorough analysis? If A is a male, B is a female, C is a male, your operator definition is even troublesome within a species. What kind of mathematical object comes closer to this abstraction of a species? Maybe it's not about names and boundaries, but about getting to understand things for which you need abstractions. I always appreciate when people do not fuss about definitions and easily change them but reason consistently after indicating their interpretation of those concepts.
elmo2you 8y ago
Sure they should, they have a life of their own. Mine are called Alice and Edward... Sorry, we could not resist.
keiferski 8y ago
The danger of naming mental disorders (or any other abstract concept) is when you confuse the map for the territory. The map (the name) should serve as the best possible mental model of the territory (the actual, descriptive physiological condition) - not as the thing-in-itself.
- dragonwriter 8y ago
  The name of a disorder mental or physical is a map or model in the same way that the name of a town or street is. Which is to say, it's not, though it's necessary for identification of a component of a model. “Diabetes mellitus” isn’t any kind of a model. It's a symptom description dressed up in Latin. We've since attached a useful model to it, but the name long predates the model and has little to do with it.
- heisenbit 8y ago
  It is tempting to stare at the map when the territory is obscured by the fog of war. The rigor of the SCID very much hides the fact that several places on the territory have similar features but are miles apart. And then every observer loves certain places and hates working in others. As bad as the state of diagnosis is (some say >50% for certain conditions) there is no way around a diagnosis for treatment as one needs to make decisions and these need to be based in whatever tenuous grasp one has on reality. At this point imho. we can only try to make sure all sources of bias, tendency to defend previous decisions, treatment capacity and financial considerations (diagnosis is key to insurance payments) are as far isolated from decision making as possible. There is lots to be done. SCID is only the symptom.
- Shivetya 8y ago
  I am of the opinion the worst part about naming disorders is the holy hell some groups will have if what they suffer from is described as a mental disorder. Then you will get the other side of the coin where people self diagnose and that sets off a different chain of issues. So it become six of one and a half dozen of another. For the benefit of the medical community yes we should name them or slot them into broad categories. For the public its best to probably just use broad categories
komali2 8y ago
I'm skeptical as hell of the entire field of psychotherapy, psychology, psychiatry, and cog sci. I think we're doing better than before, sure, but it's all such a shit show from my perspective as a participant. Rambles: Back in highschool we had a massively depressed friend. They tried it all with her: cognitive behavioral therapy, drugs (ALL OF THEM), weed, religion. Tough love. Exercise. Diet. Nothing cured her and her depression killed her via suicide. What's the psych tell me after? Sometimes there's nothing we can do? That sucks. Human genome, done. Prevent HIV from killing someone. Can't do shit about depression sometimes. And if you get depression - do you take the ssris? Fuck knows? http://www.healthtalk.org/peoples-experiences/mental-health/experiences-antidepressants/deciding-take-antidepressant http://www.healthtalk.org/peoples-experiences/mental-health/... and the "next page." Sometimes they make you numb to the world or feel like you're being controlled. Sometimes they make you have suicidal thoughts. Sometimes they take a weight off your shoulders. Sometimes they make you feel like you actually have a chance. None of my psychs were able to describe any of this. I had to research it on my own. And Lord forbid you've got multiple. Is it ADHD still? Newest psych has the idea that it's all ADD now - so, my memories of wildcat behavior that I'd be ashamed of in seconds as a kid, what was that? When shit bubbles up out of my mouth without me thinking, is that not the H anymore but just something else? And why did nobody tell me in 2 decades that a common symptom of ADD is shit memory? I had to find out on Reddit. Is it actually? Who knows! Does Adderall help? Well, I suppose! Hard to say. Technically, I could work without it. I am more productive with. But, also more robotic. And, it's nearly impossible to track the subtle personality changes that come with medicating via Adderall, no matter how hard I journal. Ask the psychs and they shrug and say "keep a journal." Ask what dosage and they say "higher until the side effects are unbearable, then one dosage down," instead of "lower until the medicine is ineffective, then one dose up." And as for those personality changes - perhaps that's a "better" me anyway? It's certainly a smarter one. Don't get me started on what fresh hell you find yourself in if the State discovers someone is suicidal and locks them in a psych ward. Came damn close to ruining my life by performing a full on jail break to get my friend out of that psuedo science nightmare. I welcome all thoughts on my rambles and I apologize if no helpful meaning was able to be extracted, on this subject I can think of no other way to get my thoughts on paper.
- jstarfish 8y ago
darkpuma 8y ago
If you don't have multiple names, you'll have a single name ('insane', or some new euphemism.) People with any sort of disorder would all get lumped together, and human nature being what it is, others would tend to assume the worst of all of them. I find it hard to believe this would be an improvement over the status quo, as imperfect as it may be.
aaron695 8y ago
"Weeks after Mr. Perry’s involvement in my study ended, he and I met to discuss this article. After I explained the topic of this article, he voluntarily gave me written consent to use his name and describe his clinical history." ? OT: It's not seriously his real name? There's no way he could have consented. Nor is there value to him or society in naming him. Is it a metaphor?
padolsey 8y ago
The neurological field has grappled, over the last few decades, with an increasing understanding of the interconnectedness and pliability of the brain and the rest of the body. We've gone from categorical localization of function to neuroplasticity for example, and likewise we've seen how distinct disorders can involve a number of different physiological differences and deficits (comorbidites are rife, e.g. see atopy + neurological sensitivities). The brain is especially complex. Our grappling with the terminology around its disorders is entirely ok IMHO. It's important to not get tied down in dogmatic categorical thinking. It's also important to let people explore different treatment paths, and find what works for them. There is never going to be a canonical "cure" for depression, just as there won't be for IBS.
DoreenMichele 8y ago
The root issue here is finding some path forward for helping people. Psychiatry, psychology etc aren't doing a great job with that. He tries to determine what has happened historically but not why. Why was this guy using drugs starting at age ten? What led up to that? Shouldn't it be classified as a parenting failure, not a "disorder" on his part? What was the history with the father? Perhaps assaulting his father wasn't simply due to insanity. Some parents are really awful to their kids and it's a huge problem for the kid. That doesn't necessarily stop being true just because the kid became a legal adult. Labels determine what mental models we use when trying to intercede in a problem. Different labels get very different reactions and treatment modes. We need to up our game in myriad ways, but labels are a critical tool for this problem space. I hate labels, but they are a useful communication tool.
- blanche_ 8y ago
  This is different situation here. He is not doing therapy nor treatment for this guy just evaluating for the study.
  - DoreenMichele 8y ago
    I realize that. I don't think it's pertinent to my point. It matters very, very much whether we label someone as "a victim of a crime suffering PTSD" or "crazy" by some fancier term for crazy. If the diagnostic tools he is using make no effort to make such distinctions, they won't make that distinction for purposes of clinical treatment either.
  - PavlikPaja 8y ago
    Don't you think it's pretty damning for psychiatry if this guy is the first one who figured out he's actually ill from taking drugs, after decades when he was treated as mentally ill?
- renholder 8y ago
  >Labels determine what mental models we use when trying to intercede in a problem. Different labels get very different reactions and treatment modes. I think he ever-so-briefly touched on a different angle of that problem: "The psychoanalysts don’t like it because it ignores the “unique milieu of individuality.” The more biologically-oriented clinicians don’t like it because it ignores biology. The DSM lacks “validity,” they say. A diagnosis based on a combination of symptoms is, they might argue, like a constellation of stars — sure, you could reliably identify the Big Dipper, but no one would argue that the Big Dipper is a valid interstellar system. It’s just a name." The problem is that the label matches no defined model; which is why I think that everyone dislikes it. >I hate labels, but they are a useful communication tool. Agreed but without the matching underlying models, they're just added toil; especially, if they're only "valid" in niche use-cases (such as clinical settings). For example, we have a general idea of what Schizophrenia is but when it comes to the classification, diagnosis, and/or treatment, that's when we lose context. Schizophrenia isn't - implicitly - the same classification, diagnosis, and treatments across the board for every patient. So, effectively, you're coupling a large group of individuals under a very generic label, which has no effective model applied to it.
mrburton 8y ago
Just imagine a doctor telling you what ICD code you have. There's nothing wrong with classification and labeling things. I think society is getting a little carried away with such topics. Personally, I think it's a phase that collectively we'll pass and reflect on how extreme we took things in order to try and obtain balance. There's a difference in calling someone "crazy" vs saying they have a mental disorder. The meaning of "crazy" has changed over the years due to the abusive context it's been used in more and more. A lot of words got redefined over the years, so this isn't new, but the idea of dropping labels or trying to eliminate well established scientific and testable classifications is new. To future generations, I hope you don't create a culture in which you're continuously stressed out about how others will label you publicly. When I was younger, a kid that was bullied in school could escape it by coming home. These days, you have no escape because of social media. I hope you learn to adjust and navigate these new times. Even older folks struggle with how things are currently.
- hrktb 8y ago
  For me one of the issue of the current names is that their definition change too much depending on the context and the person interpreting them. For instance if you say someone your arm is 'broken', they understand something is deeply damaged (not just fissured). They might not know the specifics on how it broke, where exactly, how you are healing it or how it impacts you, but they know the basic criticality of it. If you say you have "depression", they don't know if you'll take your week off to recover or actually need extensive professional follow up with a long term medication. There is no common sense of how bad it is 'broken'. From there people all have their anecdotes, visions of how they solved "depression" and come with a very personal idea of what your issue is that most of the time will have nothing to do with your actual diagnosed issue. In that sense the word doesn't work that much as a conveyor of information, they'll just know you have "something". I see the reasoning behind getting rid of a word in medical context if it doesn't bring any viable information with it.
  - mrburton 8y ago
    I think what you're doing is comparing medical vs layman usage. A doctor will tell his patient they have a "broken arm" due to past experiences in speaking with patients using medical terms. e.g, fracture or distal radius fracture in the case of a broken wrist. When it comes to mental disorders, it can be very difficult to accurately classify the severity. It reminds me of how doctors prescribe blood pressure medication; it's guess work. e.g, They will prescribe what they think will work and have you come back later to see if it's working properly. In my mom's case, the first prescription made things worse. Depression can be rooted in chemical imbalances, diet, sudden loss of a job or family member, etc,. It's not like taking a walk will solve everyone's depression. In most cases, it's much more complex than that. That's why there's psychologist and psychiatrist. In some cases cognitive therapy works, some a good diet + workout routine works, and other cases medication is required. There are different levels of depression and they are properly classified by professionals. The word "depression" is like a doctor telling you that you're arm/wrist is broken. e.g, Bipolar Disorder is a type of depression that's treated with medication. It's a terribly complex thing we're talking about and telling professionals how to define their own vernacular is pretty foolish. It would be like my mom telling me that engineers should drop the phrase "eventually consistent" and just say "consistent". :)
spacesuitman2 8y ago
>It’s 7:30 A.M. on a frosty Wednesday in December. Exited there. Does anyone know of a bot that condenses the article to get to the point? I don't have time for this.
- PavlikPaja 8y ago
  tl;dr: He needs subjects with a particular mental illness, so he needs to recheck the diagnosis. Turns out this person is actually ill from using drugs since he was 10, so he can't use him in his study, and he wonders how meaningful the diagnoses are.
  - spacesuitman2 8y ago
    Thank you very much.
deleted 8y ago
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jgrowl 8y ago
The thing that unsettles me is that the diagnosis is all self reported. If I'm already going in to see a doctor because I think my mind isn't right, how can I trust that I am answering the questions correctly with respect to how they are intending them. You're trusting me to answer your questions when I don't feel confident in my ability to answer them and in a couple of hours you've handed down a diagnosis which basically amounts to 'here take these drugs and we'll see you again in a month' Good luck navigating the side effects as well as the problems you originally came in here with by yourself.
- leemailll 8y ago
  Most of the neurological diseases have no conclusive and unique biomarkers or tests, and symptoms often not unique. There is not much can do to without scales with current knowledge
ToFab123 8y ago
Sure, we can label and categorize human behavior, but first you need to define what is normal.
- dsego 8y ago
  Jordan Peterson, is that you? Pretty sure we can ballpark it. I had a cup of coffee this morning - normal, a woman in the news kept her dead sister in a freezer for almost 20 years - not normal.
  - kkarakk 8y ago
    how about "i had a cup of coffee and felt like the world was ending but i got over it with some anti-depressants"? have i been normalized?
  - pennaMan 8y ago
    >I had a cup of coffee this morning - normal You casually drank a psychoactive drug. Is "normal" just another word for common? If your culture demanded that you keep your dead refrigerated, and everyone around you did exactly that, would that behavior be promoted to normality?
    - dsego 8y ago
      Now you're just playing semantics.
nrev 8y ago
I personally think this is a great sort of walk-through of the pitfalls of the strictly DSM-based approach. I don’t necessarily see it as something that particularly reflects this guy. If he wanted to create a new diagnostic approach to include people who are, in a sense, indistinguishable from the patient population of strictly DSM-V bipolar that would be its own study. In addition to the above, and a host of other matters, this article does demonstrate something about how diagnosis and diagnostic approaches greatly influence how we understand, classify, and teach psychiatry, psychology, medicine, and other clinical fields. Plus, it presents some things about practitioners understanding of patients and clinical priorities in patient visits can be so structured by these approaches, research based on them, even conventional clinical wisdom structured by them, and so on. They cause a ripple effect, and one that influences clinical and academic practice in a sufficiently complex and opaque way. So, even clinical providers, academics who try to radically depart from these approaches are still quite effected by it. That said, the point I really want to reach is that it’s my opinion—and there is a body of academic work within and about many clinical fields on this matter— that the longevity of these diagnostic approaches and their bases, the categorization of disorders, how clinical fields themself are taught, how priorities are set in the clinic is owed and hugely influenced by the necessity (and the hegemony) of US insurance coding, especially as it relates to prescription drugs. I’m not insisting that prescriptions, or necessarily any of this is inherently negative in it’s effects, just that insurance coding as it is, health insurance in the US as it is, has (sometimes quite extreme) far reaching influence over essentially every aspect of clinical practice, research practices. At least that’s my opinion/conclusion/interest in this article.
darkerside 8y ago
The conclusion of the article raises a great question. Wouldn't it be more valuable to diagnose based on quantitative criteria instead of binary answers to extremely complex questions? I'd love to hear an opinion from a SCID practitioner.
- betulaq 8y ago
  Something like the SCID is useful as a structured way of measuring or assessing behavior. A binary output is probably not helpful though. What's interesting is that the people who developed the SCID (and the DSM and its predecessor, the RDC) actually developed a very similar tool in the 60s, but instead of it producing binary diagnoses, it produced scale scores more like test scores. It actually had better statistical properties and provided fairly detailed information. It's always been a mystery why they moved away from that, except that the DSM as a whole moved away from that.
  - darkerside 8y ago
    That's interesting. It reminds of the BMI, a metric intended only for use at the population level. It's been adopted (some would say misappropriated) as a yardstick for individual health, because... reasons?
afpx 8y ago
Why is the author is so troubled? They’re just using an instrument to transform qualitative data into quantitative data. Such methods are used pretty much anywhere there’s subjectivity in observation. To do science, you have to have a standard way of measuring.
- nimonian 8y ago
  Are names quantities?
  - afpx 8y ago
    Yes, categories are as long as they’re well-defined. Measurement instruments get better over time.
Lerc 8y ago
I tell people I have Tourette's. I don't have Tourette's. I'm missing one of the required criteria - must have tics that begin before he or she is 18 years of age. In a medical standpoint that makes it different, but in any practical sense the name conveys all of the information people need, it is perhaps unusual in that it is also a condition that occasionally requires rapid explanation.
- jstarfish 8y ago
  > I'm missing one of the required criteria Are you sure about that? Tics don't always manifest in obvious ways. You may well have had them in a very mild form but never noticed.
Causality1 8y ago
"It's seven am on a frosty Wednesday morning" Oh my God, not another one of these articles that starts with a goddamn novel before it gets to the point.
trombonechamp 8y ago
Most researchers agree that mental disorders should not have names, as it is difficult or impossible to draw discrete boundaries in this complex and poorly-understood spectrum of symptoms. However, as a broad generalization, researchers are the only group who feel this way: - Doctors like names because then they can provide a diagnosis and recommend action based on the diagnosis - Patients and their loved ones (often) like names because it is easier to think/say "I have schizophrenia" than it is to describe their factor scores on a myriad of benchmarks - Drug companies like names because they can develop drugs for specific disorders rather than for a combinatorially large number of factors - Regulators like names because they can approve treatments and standards of care for a finite number of situations - Insurance companies like names because it allows them to approve or deny claims in a more straightforward way. While names are often times arbitrary, they make many things more convenient. I am not saying that I personally agree or disagree that there should or should not be names, only that this is a complex issue with many complexities besides the underlying science. Also, I see nobody has mentioned RDoC yet, which is the taxonomy researchers are starting to use to classify mental disorders: https://www.nimh.nih.gov/research-priorities/rdoc/constructs/rdoc-matrix.shtml https://www.nimh.nih.gov/research-priorities/rdoc/constructs...
- deleted 8y ago
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- jmcgough 8y ago
  We used to get drunk and debate the merits of the DSM as undergrads. Most of my friends who went on to get their PhDs still see it as a imperfect but necessary evil. As a researcher, you need a common language to discuss what you're researching. There is value to studying one particular group of symptoms vs another; different ones have different treatment guideless, medications, and potentially common biomarkers. But people don't always fit neatly in these boxes, as the article shows. It's entirely possible someday that we'll move past specific labels, but we don't have viable alternatives to the DSM right now.
- betulaq 8y ago
  I do research on the topic of the article. I actually initially clicked on it because the title seems so uncannily similar in content to an article I wrote that I thought they might mention something about it. They did not but it's still really salient to me. The article is sort of strange in that it brings up these issues and then fails to discuss the huge range of research in this area. The p-factor stuff is sort of hot lately but is just one subtopic in a vast area, somewhat controversial, and more of theoretical interest than clinical utility. Part of the problem is that there are different purposes for classification systems. I think you're right in that categorical diagnoses have all the appeals you mention at least among some subgroups, but those are a little detached from (1) how many clinicians actually think about a lot of problems, and (2) how many researchers think about these things. Putting aside the "syndrome"-favoring clinicians, a lot of clinicians focus more on behavioral patterns, which tend to be very specific, more targetable, and far removed from broad categorical labels. Many researchers are moving away from these categorical labels also, for many reasons, but mostly generally because the patterns you see in behavior don't map onto the categories in the DSM in reality. Think blood pressure or height as analogies for depression or disorganized thinking, rather than Huntington's disease or malaria. RDoC is important to mention but it's ending up to be about as controversial as the DSM for various reasons. First, it suffers from the same "names by committee fiat" as the DSM, which is problematic when you are dealing with something like neurobehavioral pathology, which can be examined at many levels and from many directions, which is fuzzy and complex, and about which we know very little. Second, despite its noble intents, was kind of developed by neuroscientists with little connection to actual clinical human behavior. I don't mean any offense to them, but when you get together a bunch of researchers, a substantial number of whom study rodent neurobiology, you're going to start losing touch with what clinicians are actually wrestling with in clinical settings. Look for psychosis or subdimensions of psychosis, for example, and it's missing from RDoC. I like to think of RDoC as "revenge of the neuroscientists," people who got tired of trying to connect their research to human public health, and decided to just redefine problems so it's closer to their own research. A similar initiative is HiTOP, which is more phenotypically focused, and uses statistical/quantitative models for classification rather than committee decisions (I'm not saying HiTOP is better, it just is a similar but different approach from RDoC). I think the issue is not whether or not mental disorders should have names, it's whether or not there are mental disorders per se, or how to best describe mental-neural-behavioral patterns. You need to be able to quantify to study something scientifically, and quantifying implies labeling; the question is how.
debbiedowner 8y ago
Pretty great article. This characteristic that many patients have multiple disorders is an interesting point. Reminded me of my real world PCA applications which were never satisfying. In such a case you'd take the attributes of answers to questions in a population, and then get principle components (PCs) to these vectors of examples. Who says that each example in a population has to be dominated by 1 principle component? Many people have the view that PCs are just whatever linear combinations of attributes that explain your data, and I've seen many people try to name them in ways that encapsulate the attributes that each PC selects for, but it always seems like an awkward exercise after you get past the first few PCs. And of course, I'm not literally saying this SCID is the attributes to the DSM "PCA," or any other subspace method. I don't work with subspace methods often, so if anyone wants to fill me in on what is done in the medical world (or other high stakes domains) in practice, much appreciated. In cases of segmenting customers and then targeting each one differently, I have found that subspace methods work well for raising typical startup metrics. But the interpretability was not cut and dry in my experience, something that obviously is needed when you work with individuals like Doctors, not populations like many companies. My guess is that the DSM segments patients to different treatments though. If this is the case then it does't really matter what the name of the constellation is as long as after they send the patient there, everything is hunky dory.
jVinc 8y ago
Person comes to conclusion that objective tool doesn't work because it doesn't give him the results he wants. I'm glad he didn't get to just subjectively call people bipolar or not based on what he wants, it would just bias his research and make it all scientifically useless. Whether you like skid or not, at least "According to skid patient is in box X" has a definite meaning, and can be scientifically trusted to mean something. Opposite to that "This one specific doctor based on this one single interaction decided that the person fits in box Y" is just completely useless.
existentialhalt 8y ago
I have been diagnosed with bipolar disorder, schizophrenia, depression, anxiety, and autism. All caused by chronic mercury toxicity. The name of the disorder should be "mercury toxicity" in my case.

126 points by LinuxBender 8y ago

Should anything have a name? It seems that people are just running out of shit to write about at this point. And from Scientific American! I trusted you as a kid!

nimonian 8y ago
I not sure if you are just trolling here, but reading the article it seems clear that the author has a point beyond the usual signifier-signified semiotic crisis. The author ends by musing about mental diseases being described by coordinates in several dimensions. Sure, perhaps connected regions of that space can be given their own names, but in general, the author believes that our vocabulary lacks the granularity to identify the fingerprint of individual diseases. I know a lot of hands have already been wrung over the ineffectiveness of natural language in describing the phenomena of the inner world, but in a clinical setting this takes on a new meaning, and the essay is, in my opinion, poignant.

teekert 8y ago

Us humans certainly prefer to put boundaries and names on things. And indeed, it is often unwise i.e. with (one of our) species definitions: A can procreate with B, B can with C but A cannot with C, meaning A==B, B==C but A!=C, a paradox because of our tendencies. Could it be a cultural thing? While I grow older I find it more natural to think of things as continuous or to assign uncertainty to "facts", but perhaps our educational system does not give much attention to this. Perhaps it's too much about facts and names and boundaries. In this articles' case though, of course mental disorders are a continuum but the drugs and methods for treatment we have are not. So perhaps in this case a label is nice. One should always keep the continuous nature in the back of one's mind though.

darkerside 8y ago
I agree with much of what you say. I've heard it said that education is a series of increasingly small lies. If you started teaching the whole truth and nothing but, from a young age, the student would fail to grasp the big picture and the broad connections in the way the world works. When you let something go, it drops. Well, unless it's lighter than air. And it doesn't drop, it attracts to the Earth. And actually, it attracts the Earth back to itself. And it doesn't simply "drop", it accelerates. And gravitational forces and air friction determine the acceleration and the jerk. If you don't omit anything, you can't communicate anything. The broader point I'm getting at is, first you need to learn about the artificial distinctions so you can "from" the subject. Then, once you know all the rules by heart, you can feel free to break them.
- teekert 8y ago
  Nice way of putting it. Yesterday morning my son asked how humans came to be and I ended up stuttering that perhaps at some point some molecule of unspecified complexity gained the ability to replicate at which point it became subject to natural selection based on descent with modification... You get the problem. Better say: It started with simple life and the best ones (sometimes more complex ones) ended up in the next generation. FFWD 3.5 billion years and voila. It's a bit of a lie because "what's life, what's before that, what's best, what's fitness" etc. But it works. I keep having problems with this though, but yeah, what to say to someone without any grasp of cells or DNA or "1 billion years", do even grasp it "correctly"??... Man, speak about rabbit holes. I didn't even start on evolution on the population level.. I see my son loosing interest during my explanation, while I get more and more enthusiastic. It's a hard problem.
MrQuincle 8y ago
True, but do definitions not encourage a more thorough analysis? If A is a male, B is a female, C is a male, your operator definition is even troublesome within a species. What kind of mathematical object comes closer to this abstraction of a species? Maybe it's not about names and boundaries, but about getting to understand things for which you need abstractions. I always appreciate when people do not fuss about definitions and easily change them but reason consistently after indicating their interpretation of those concepts.

elmo2you 8y ago

Sure they should, they have a life of their own. Mine are called Alice and Edward... Sorry, we could not resist.

keiferski 8y ago

The danger of naming mental disorders (or any other abstract concept) is when you confuse the map for the territory. The map (the name) should serve as the best possible mental model of the territory (the actual, descriptive physiological condition) - not as the thing-in-itself.

dragonwriter 8y ago
The name of a disorder mental or physical is a map or model in the same way that the name of a town or street is. Which is to say, it's not, though it's necessary for identification of a component of a model. “Diabetes mellitus” isn’t any kind of a model. It's a symptom description dressed up in Latin. We've since attached a useful model to it, but the name long predates the model and has little to do with it.
heisenbit 8y ago
It is tempting to stare at the map when the territory is obscured by the fog of war. The rigor of the SCID very much hides the fact that several places on the territory have similar features but are miles apart. And then every observer loves certain places and hates working in others. As bad as the state of diagnosis is (some say >50% for certain conditions) there is no way around a diagnosis for treatment as one needs to make decisions and these need to be based in whatever tenuous grasp one has on reality. At this point imho. we can only try to make sure all sources of bias, tendency to defend previous decisions, treatment capacity and financial considerations (diagnosis is key to insurance payments) are as far isolated from decision making as possible. There is lots to be done. SCID is only the symptom.
Shivetya 8y ago
I am of the opinion the worst part about naming disorders is the holy hell some groups will have if what they suffer from is described as a mental disorder. Then you will get the other side of the coin where people self diagnose and that sets off a different chain of issues. So it become six of one and a half dozen of another. For the benefit of the medical community yes we should name them or slot them into broad categories. For the public its best to probably just use broad categories

komali2 8y ago

I'm skeptical as hell of the entire field of psychotherapy, psychology, psychiatry, and cog sci. I think we're doing better than before, sure, but it's all such a shit show from my perspective as a participant. Rambles: Back in highschool we had a massively depressed friend. They tried it all with her: cognitive behavioral therapy, drugs (ALL OF THEM), weed, religion. Tough love. Exercise. Diet. Nothing cured her and her depression killed her via suicide. What's the psych tell me after? Sometimes there's nothing we can do? That sucks. Human genome, done. Prevent HIV from killing someone. Can't do shit about depression sometimes. And if you get depression - do you take the ssris? Fuck knows? http://www.healthtalk.org/peoples-experiences/mental-health/experiences-antidepressants/deciding-take-antidepressant http://www.healthtalk.org/peoples-experiences/mental-health/... and the "next page." Sometimes they make you numb to the world or feel like you're being controlled. Sometimes they make you have suicidal thoughts. Sometimes they take a weight off your shoulders. Sometimes they make you feel like you actually have a chance. None of my psychs were able to describe any of this. I had to research it on my own. And Lord forbid you've got multiple. Is it ADHD still? Newest psych has the idea that it's all ADD now - so, my memories of wildcat behavior that I'd be ashamed of in seconds as a kid, what was that? When shit bubbles up out of my mouth without me thinking, is that not the H anymore but just something else? And why did nobody tell me in 2 decades that a common symptom of ADD is shit memory? I had to find out on Reddit. Is it actually? Who knows! Does Adderall help? Well, I suppose! Hard to say. Technically, I could work without it. I am more productive with. But, also more robotic. And, it's nearly impossible to track the subtle personality changes that come with medicating via Adderall, no matter how hard I journal. Ask the psychs and they shrug and say "keep a journal." Ask what dosage and they say "higher until the side effects are unbearable, then one dosage down," instead of "lower until the medicine is ineffective, then one dose up." And as for those personality changes - perhaps that's a "better" me anyway? It's certainly a smarter one. Don't get me started on what fresh hell you find yourself in if the State discovers someone is suicidal and locks them in a psych ward. Came damn close to ruining my life by performing a full on jail break to get my friend out of that psuedo science nightmare. I welcome all thoughts on my rambles and I apologize if no helpful meaning was able to be extracted, on this subject I can think of no other way to get my thoughts on paper.

jstarfish 8y ago

darkpuma 8y ago

If you don't have multiple names, you'll have a single name ('insane', or some new euphemism.) People with any sort of disorder would all get lumped together, and human nature being what it is, others would tend to assume the worst of all of them. I find it hard to believe this would be an improvement over the status quo, as imperfect as it may be.

aaron695 8y ago

"Weeks after Mr. Perry’s involvement in my study ended, he and I met to discuss this article. After I explained the topic of this article, he voluntarily gave me written consent to use his name and describe his clinical history." ? OT: It's not seriously his real name? There's no way he could have consented. Nor is there value to him or society in naming him. Is it a metaphor?

padolsey 8y ago

The neurological field has grappled, over the last few decades, with an increasing understanding of the interconnectedness and pliability of the brain and the rest of the body. We've gone from categorical localization of function to neuroplasticity for example, and likewise we've seen how distinct disorders can involve a number of different physiological differences and deficits (comorbidites are rife, e.g. see atopy + neurological sensitivities). The brain is especially complex. Our grappling with the terminology around its disorders is entirely ok IMHO. It's important to not get tied down in dogmatic categorical thinking. It's also important to let people explore different treatment paths, and find what works for them. There is never going to be a canonical "cure" for depression, just as there won't be for IBS.

DoreenMichele 8y ago

The root issue here is finding some path forward for helping people. Psychiatry, psychology etc aren't doing a great job with that. He tries to determine what has happened historically but not why. Why was this guy using drugs starting at age ten? What led up to that? Shouldn't it be classified as a parenting failure, not a "disorder" on his part? What was the history with the father? Perhaps assaulting his father wasn't simply due to insanity. Some parents are really awful to their kids and it's a huge problem for the kid. That doesn't necessarily stop being true just because the kid became a legal adult. Labels determine what mental models we use when trying to intercede in a problem. Different labels get very different reactions and treatment modes. We need to up our game in myriad ways, but labels are a critical tool for this problem space. I hate labels, but they are a useful communication tool.

blanche_ 8y ago
This is different situation here. He is not doing therapy nor treatment for this guy just evaluating for the study.
- DoreenMichele 8y ago
  I realize that. I don't think it's pertinent to my point. It matters very, very much whether we label someone as "a victim of a crime suffering PTSD" or "crazy" by some fancier term for crazy. If the diagnostic tools he is using make no effort to make such distinctions, they won't make that distinction for purposes of clinical treatment either.
- PavlikPaja 8y ago
  Don't you think it's pretty damning for psychiatry if this guy is the first one who figured out he's actually ill from taking drugs, after decades when he was treated as mentally ill?
renholder 8y ago
>Labels determine what mental models we use when trying to intercede in a problem. Different labels get very different reactions and treatment modes. I think he ever-so-briefly touched on a different angle of that problem: "The psychoanalysts don’t like it because it ignores the “unique milieu of individuality.” The more biologically-oriented clinicians don’t like it because it ignores biology. The DSM lacks “validity,” they say. A diagnosis based on a combination of symptoms is, they might argue, like a constellation of stars — sure, you could reliably identify the Big Dipper, but no one would argue that the Big Dipper is a valid interstellar system. It’s just a name." The problem is that the label matches no defined model; which is why I think that everyone dislikes it. >I hate labels, but they are a useful communication tool. Agreed but without the matching underlying models, they're just added toil; especially, if they're only "valid" in niche use-cases (such as clinical settings). For example, we have a general idea of what Schizophrenia is but when it comes to the classification, diagnosis, and/or treatment, that's when we lose context. Schizophrenia isn't - implicitly - the same classification, diagnosis, and treatments across the board for every patient. So, effectively, you're coupling a large group of individuals under a very generic label, which has no effective model applied to it.

mrburton 8y ago

Just imagine a doctor telling you what ICD code you have. There's nothing wrong with classification and labeling things. I think society is getting a little carried away with such topics. Personally, I think it's a phase that collectively we'll pass and reflect on how extreme we took things in order to try and obtain balance. There's a difference in calling someone "crazy" vs saying they have a mental disorder. The meaning of "crazy" has changed over the years due to the abusive context it's been used in more and more. A lot of words got redefined over the years, so this isn't new, but the idea of dropping labels or trying to eliminate well established scientific and testable classifications is new. To future generations, I hope you don't create a culture in which you're continuously stressed out about how others will label you publicly. When I was younger, a kid that was bullied in school could escape it by coming home. These days, you have no escape because of social media. I hope you learn to adjust and navigate these new times. Even older folks struggle with how things are currently.

hrktb 8y ago
For me one of the issue of the current names is that their definition change too much depending on the context and the person interpreting them. For instance if you say someone your arm is 'broken', they understand something is deeply damaged (not just fissured). They might not know the specifics on how it broke, where exactly, how you are healing it or how it impacts you, but they know the basic criticality of it. If you say you have "depression", they don't know if you'll take your week off to recover or actually need extensive professional follow up with a long term medication. There is no common sense of how bad it is 'broken'. From there people all have their anecdotes, visions of how they solved "depression" and come with a very personal idea of what your issue is that most of the time will have nothing to do with your actual diagnosed issue. In that sense the word doesn't work that much as a conveyor of information, they'll just know you have "something". I see the reasoning behind getting rid of a word in medical context if it doesn't bring any viable information with it.
- mrburton 8y ago
  I think what you're doing is comparing medical vs layman usage. A doctor will tell his patient they have a "broken arm" due to past experiences in speaking with patients using medical terms. e.g, fracture or distal radius fracture in the case of a broken wrist. When it comes to mental disorders, it can be very difficult to accurately classify the severity. It reminds me of how doctors prescribe blood pressure medication; it's guess work. e.g, They will prescribe what they think will work and have you come back later to see if it's working properly. In my mom's case, the first prescription made things worse. Depression can be rooted in chemical imbalances, diet, sudden loss of a job or family member, etc,. It's not like taking a walk will solve everyone's depression. In most cases, it's much more complex than that. That's why there's psychologist and psychiatrist. In some cases cognitive therapy works, some a good diet + workout routine works, and other cases medication is required. There are different levels of depression and they are properly classified by professionals. The word "depression" is like a doctor telling you that you're arm/wrist is broken. e.g, Bipolar Disorder is a type of depression that's treated with medication. It's a terribly complex thing we're talking about and telling professionals how to define their own vernacular is pretty foolish. It would be like my mom telling me that engineers should drop the phrase "eventually consistent" and just say "consistent". :)

spacesuitman2 8y ago

>It’s 7:30 A.M. on a frosty Wednesday in December. Exited there. Does anyone know of a bot that condenses the article to get to the point? I don't have time for this.

PavlikPaja 8y ago
tl;dr: He needs subjects with a particular mental illness, so he needs to recheck the diagnosis. Turns out this person is actually ill from using drugs since he was 10, so he can't use him in his study, and he wonders how meaningful the diagnoses are.
- spacesuitman2 8y ago
  Thank you very much.

deleted 8y ago

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jgrowl 8y ago

The thing that unsettles me is that the diagnosis is all self reported. If I'm already going in to see a doctor because I think my mind isn't right, how can I trust that I am answering the questions correctly with respect to how they are intending them. You're trusting me to answer your questions when I don't feel confident in my ability to answer them and in a couple of hours you've handed down a diagnosis which basically amounts to 'here take these drugs and we'll see you again in a month' Good luck navigating the side effects as well as the problems you originally came in here with by yourself.

leemailll 8y ago
Most of the neurological diseases have no conclusive and unique biomarkers or tests, and symptoms often not unique. There is not much can do to without scales with current knowledge

ToFab123 8y ago

Sure, we can label and categorize human behavior, but first you need to define what is normal.

dsego 8y ago
Jordan Peterson, is that you? Pretty sure we can ballpark it. I had a cup of coffee this morning - normal, a woman in the news kept her dead sister in a freezer for almost 20 years - not normal.
- kkarakk 8y ago
  how about "i had a cup of coffee and felt like the world was ending but i got over it with some anti-depressants"? have i been normalized?
- pennaMan 8y ago
  >I had a cup of coffee this morning - normal You casually drank a psychoactive drug. Is "normal" just another word for common? If your culture demanded that you keep your dead refrigerated, and everyone around you did exactly that, would that behavior be promoted to normality?
  - dsego 8y ago
    Now you're just playing semantics.

nrev 8y ago

I personally think this is a great sort of walk-through of the pitfalls of the strictly DSM-based approach. I don’t necessarily see it as something that particularly reflects this guy. If he wanted to create a new diagnostic approach to include people who are, in a sense, indistinguishable from the patient population of strictly DSM-V bipolar that would be its own study. In addition to the above, and a host of other matters, this article does demonstrate something about how diagnosis and diagnostic approaches greatly influence how we understand, classify, and teach psychiatry, psychology, medicine, and other clinical fields. Plus, it presents some things about practitioners understanding of patients and clinical priorities in patient visits can be so structured by these approaches, research based on them, even conventional clinical wisdom structured by them, and so on. They cause a ripple effect, and one that influences clinical and academic practice in a sufficiently complex and opaque way. So, even clinical providers, academics who try to radically depart from these approaches are still quite effected by it. That said, the point I really want to reach is that it’s my opinion—and there is a body of academic work within and about many clinical fields on this matter— that the longevity of these diagnostic approaches and their bases, the categorization of disorders, how clinical fields themself are taught, how priorities are set in the clinic is owed and hugely influenced by the necessity (and the hegemony) of US insurance coding, especially as it relates to prescription drugs. I’m not insisting that prescriptions, or necessarily any of this is inherently negative in it’s effects, just that insurance coding as it is, health insurance in the US as it is, has (sometimes quite extreme) far reaching influence over essentially every aspect of clinical practice, research practices. At least that’s my opinion/conclusion/interest in this article.

darkerside 8y ago

The conclusion of the article raises a great question. Wouldn't it be more valuable to diagnose based on quantitative criteria instead of binary answers to extremely complex questions? I'd love to hear an opinion from a SCID practitioner.

betulaq 8y ago
Something like the SCID is useful as a structured way of measuring or assessing behavior. A binary output is probably not helpful though. What's interesting is that the people who developed the SCID (and the DSM and its predecessor, the RDC) actually developed a very similar tool in the 60s, but instead of it producing binary diagnoses, it produced scale scores more like test scores. It actually had better statistical properties and provided fairly detailed information. It's always been a mystery why they moved away from that, except that the DSM as a whole moved away from that.
- darkerside 8y ago
  That's interesting. It reminds of the BMI, a metric intended only for use at the population level. It's been adopted (some would say misappropriated) as a yardstick for individual health, because... reasons?

afpx 8y ago

Why is the author is so troubled? They’re just using an instrument to transform qualitative data into quantitative data. Such methods are used pretty much anywhere there’s subjectivity in observation. To do science, you have to have a standard way of measuring.

nimonian 8y ago
Are names quantities?
- afpx 8y ago
  Yes, categories are as long as they’re well-defined. Measurement instruments get better over time.

Lerc 8y ago

I tell people I have Tourette's. I don't have Tourette's. I'm missing one of the required criteria - must have tics that begin before he or she is 18 years of age. In a medical standpoint that makes it different, but in any practical sense the name conveys all of the information people need, it is perhaps unusual in that it is also a condition that occasionally requires rapid explanation.

jstarfish 8y ago
> I'm missing one of the required criteria Are you sure about that? Tics don't always manifest in obvious ways. You may well have had them in a very mild form but never noticed.

Causality1 8y ago

"It's seven am on a frosty Wednesday morning" Oh my God, not another one of these articles that starts with a goddamn novel before it gets to the point.

trombonechamp 8y ago

Most researchers agree that mental disorders should not have names, as it is difficult or impossible to draw discrete boundaries in this complex and poorly-understood spectrum of symptoms. However, as a broad generalization, researchers are the only group who feel this way: - Doctors like names because then they can provide a diagnosis and recommend action based on the diagnosis - Patients and their loved ones (often) like names because it is easier to think/say "I have schizophrenia" than it is to describe their factor scores on a myriad of benchmarks - Drug companies like names because they can develop drugs for specific disorders rather than for a combinatorially large number of factors - Regulators like names because they can approve treatments and standards of care for a finite number of situations - Insurance companies like names because it allows them to approve or deny claims in a more straightforward way. While names are often times arbitrary, they make many things more convenient. I am not saying that I personally agree or disagree that there should or should not be names, only that this is a complex issue with many complexities besides the underlying science. Also, I see nobody has mentioned RDoC yet, which is the taxonomy researchers are starting to use to classify mental disorders: https://www.nimh.nih.gov/research-priorities/rdoc/constructs/rdoc-matrix.shtml https://www.nimh.nih.gov/research-priorities/rdoc/constructs...

deleted 8y ago
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jmcgough 8y ago
We used to get drunk and debate the merits of the DSM as undergrads. Most of my friends who went on to get their PhDs still see it as a imperfect but necessary evil. As a researcher, you need a common language to discuss what you're researching. There is value to studying one particular group of symptoms vs another; different ones have different treatment guideless, medications, and potentially common biomarkers. But people don't always fit neatly in these boxes, as the article shows. It's entirely possible someday that we'll move past specific labels, but we don't have viable alternatives to the DSM right now.
betulaq 8y ago
I do research on the topic of the article. I actually initially clicked on it because the title seems so uncannily similar in content to an article I wrote that I thought they might mention something about it. They did not but it's still really salient to me. The article is sort of strange in that it brings up these issues and then fails to discuss the huge range of research in this area. The p-factor stuff is sort of hot lately but is just one subtopic in a vast area, somewhat controversial, and more of theoretical interest than clinical utility. Part of the problem is that there are different purposes for classification systems. I think you're right in that categorical diagnoses have all the appeals you mention at least among some subgroups, but those are a little detached from (1) how many clinicians actually think about a lot of problems, and (2) how many researchers think about these things. Putting aside the "syndrome"-favoring clinicians, a lot of clinicians focus more on behavioral patterns, which tend to be very specific, more targetable, and far removed from broad categorical labels. Many researchers are moving away from these categorical labels also, for many reasons, but mostly generally because the patterns you see in behavior don't map onto the categories in the DSM in reality. Think blood pressure or height as analogies for depression or disorganized thinking, rather than Huntington's disease or malaria. RDoC is important to mention but it's ending up to be about as controversial as the DSM for various reasons. First, it suffers from the same "names by committee fiat" as the DSM, which is problematic when you are dealing with something like neurobehavioral pathology, which can be examined at many levels and from many directions, which is fuzzy and complex, and about which we know very little. Second, despite its noble intents, was kind of developed by neuroscientists with little connection to actual clinical human behavior. I don't mean any offense to them, but when you get together a bunch of researchers, a substantial number of whom study rodent neurobiology, you're going to start losing touch with what clinicians are actually wrestling with in clinical settings. Look for psychosis or subdimensions of psychosis, for example, and it's missing from RDoC. I like to think of RDoC as "revenge of the neuroscientists," people who got tired of trying to connect their research to human public health, and decided to just redefine problems so it's closer to their own research. A similar initiative is HiTOP, which is more phenotypically focused, and uses statistical/quantitative models for classification rather than committee decisions (I'm not saying HiTOP is better, it just is a similar but different approach from RDoC). I think the issue is not whether or not mental disorders should have names, it's whether or not there are mental disorders per se, or how to best describe mental-neural-behavioral patterns. You need to be able to quantify to study something scientifically, and quantifying implies labeling; the question is how.

debbiedowner 8y ago

Pretty great article. This characteristic that many patients have multiple disorders is an interesting point. Reminded me of my real world PCA applications which were never satisfying. In such a case you'd take the attributes of answers to questions in a population, and then get principle components (PCs) to these vectors of examples. Who says that each example in a population has to be dominated by 1 principle component? Many people have the view that PCs are just whatever linear combinations of attributes that explain your data, and I've seen many people try to name them in ways that encapsulate the attributes that each PC selects for, but it always seems like an awkward exercise after you get past the first few PCs. And of course, I'm not literally saying this SCID is the attributes to the DSM "PCA," or any other subspace method. I don't work with subspace methods often, so if anyone wants to fill me in on what is done in the medical world (or other high stakes domains) in practice, much appreciated. In cases of segmenting customers and then targeting each one differently, I have found that subspace methods work well for raising typical startup metrics. But the interpretability was not cut and dry in my experience, something that obviously is needed when you work with individuals like Doctors, not populations like many companies. My guess is that the DSM segments patients to different treatments though. If this is the case then it does't really matter what the name of the constellation is as long as after they send the patient there, everything is hunky dory.

jVinc 8y ago

Person comes to conclusion that objective tool doesn't work because it doesn't give him the results he wants. I'm glad he didn't get to just subjectively call people bipolar or not based on what he wants, it would just bias his research and make it all scientifically useless. Whether you like skid or not, at least "According to skid patient is in box X" has a definite meaning, and can be scientifically trusted to mean something. Opposite to that "This one specific doctor based on this one single interaction decided that the person fits in box Y" is just completely useless.

existentialhalt 8y ago

I have been diagnosed with bipolar disorder, schizophrenia, depression, anxiety, and autism. All caused by chronic mercury toxicity. The name of the disorder should be "mercury toxicity" in my case.