This is an interesting perspective, but it really is wrong. Several psychiatric conditions do support common pathway models and have other validity evidence that makes them concerning. For several conditions, they are adequate representations of commonly caused conditions and we often have treatments for them, as is the case for schizoph…
This is an interesting perspective, but it really is wrong. Several psychiatric conditions do support common pathway models and have other validity evidence that makes them concerning. For several conditions, they are adequate representations of commonly caused conditions and we often have treatments for them, as is the case for schizophrenia, where the meds work.
I have never seen any reason - from Tversky on - to think of the better-defined mental illnesses as individual differences in preferences. Preferences do not behave like traits, but mental illnesses do, and that affects treatment options. Take a page from Kahneman & Tversky (1979, pp's 289-290).
I don't disagree with you, but it does seem like you're using "do the meds work" as the key criteria of whether its a trait or an illness. But I guess I don't understand why that matters, apart from "how should we socially judge this person?" There are a large number of mental and physical illnesses that can be improved (by the judgement of the patient) by a wide range/combination of meds, actions, choices, etc...
If I have schizophrenia and I treat it without meds and I get better, that doesn't prove you wrong. If I treat it exclusively with meds and get better, that doesn't prove Caplan wrong. Because it doesn't matter to me! What matters is: "by my standards and accounting for the cost of treatment, did I get better?" If you want to say "schizophrenia that you can treat without meds doesn't count" then I am 100% fine with that - but I think you (and Caplan) are fighting over definitions instead of reality.
"Do the meds work" isn't a good criterion for whether something is a disease because 1) many illnesses are untreatable, and 2) you can use drugs to stop non-disease behaviors and preferences easily (chemical castration of homosexuals).
Agreed, with the addition that may also be an indication that determining if something is a disease or not isn't that helpful (where I define helpful as "helps make the patient better of).
In my example, the key criteria was "is there an associated common pathway model?"
Whether the meds work or not cannot tell us about whether a trait is real, but it can lend evidence to the idea if we see that there is a treatment effect and it is not heterogeneous (ex: https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2776610). Homogeneous treatment effects are unrealistic for many traits because treatment is generally not targeted at the etiology of a disease comprehensively, so this can only be used to provide positive, not negative evidence wrt whether a psychiatric diagnosis tags an actual trait.
The concerns raised by PercyPrior have to do with measurement invariance, which is often tenuous, rather than etiology, which I was concerned with.
The DSM counts you as being schizophrenic if you have 2 or more of the following for more than 2 months:
1) Delusional beliefs (Oxford Dictionary: "a false belief or judgment about external reality, held despite incontrovertible evidence to the contrary, occurring especially in mental conditions") Bryan's objection: what counts as "incontrovertible evidence to the contrary?" If the standard is "certainty," there isn't incontrovertible evidence that we aren't brains in vats, so it must be something more like "really really good evidence to the contrary." But what about religion? Many (most?) religious folks are happy to acknowledge that their beliefs are taken on faith, in full knowledge of the lack of evidence. Maybe Bryan's objection fails because religious beliefs are not subject to incontrovertible evidence *to the contrary,* just lacking in positive support.
Bryan also objects that incentive programs at psych wards have caused people to stop attesting to their delusions. I don't find this convincing because it's too easy for a patient to simply lie about their beliefs for rewards.
2) Hallucinations (usually auditory). Problem: most people have an internal monologue. You could say it has to be a voice heard from the outside, but the DSM considers a voice which can only be heard "on the inside" to count, assuming one does not identify with or control the voice. I'm not sure what to make of that either, though, because many of my thoughts are spontaneous and uncontrolled (just try to control what your next thought will be, and notice how often it comes to you unbidden), and I don't necessarily identify with my thoughts either. (I'm not entirely sure what it even means to "identify" with a thought. To think the thought is you? I am more than any thought I have. Does it mean "to think the thought is a part of me?" Why wouldn't hallucinations be "a part of" a schizophrenic?)
3) Disorganized speech (incoherence, frequent derailment). I don't know if Bryan has an objection to this, and Scott says in his experience this doesn't respond to incentives. That is, he will offer a patient who wants to be released the opportunity to be discharged if they can just string together an even slightly coherent sentence without their medication, and even still they cannot do it.
4) Grossly disorganized or catatonic behavior: IDK what Bryan says about this criterion either, maybe there's a study somewhere where this responds to extreme incentives too.
The takeaway: you could plausibly meet the criteria for schizophrenia despite being mentally healthy if you fit items 1 and 2 for more than two months (by being religious and having an internal monologue). But maybe the solution isn't to jettison the concept of schizophrenia as a disease, but to refine the diagnostic criteria?
Yeh thats why diagnosticians are taught to use clinical judgement and not use the diagnostic criteria as a checkbox.
Hence the years of training on interview technique (assuming the symtpom , open ended etc) and thousands of patient encounters.
You dont fill out a dsm form and send it to the dsm police when you diagnose someone , you do an in depth interview and take into account the entire case and the patient as a whole. You get collateral. You examine if subjective and objective line up and if its causing dysfunction or damage to the persons well being.
No ones out their trying to "gotcha" people into a diagnosis if the treatment would be of no utility.
A broken medical system with poor incentives isnt psychiatrys fault , they use the same criteria in countries that sont have for profit healthcare systems, the criteria werent designed to buttress US inpatient hospital numbers , insurance companies and governments dont want to pay for that and have a lot more money and power than all thr psychiatrists combined.
This is an interesting perspective, but it really is wrong. Several psychiatric conditions do support common pathway models and have other validity evidence that makes them concerning. For several conditions, they are adequate representations of commonly caused conditions and we often have treatments for them, as is the case for schizophrenia, where the meds work.
I have never seen any reason - from Tversky on - to think of the better-defined mental illnesses as individual differences in preferences. Preferences do not behave like traits, but mental illnesses do, and that affects treatment options. Take a page from Kahneman & Tversky (1979, pp's 289-290).
I don't disagree with you, but it does seem like you're using "do the meds work" as the key criteria of whether its a trait or an illness. But I guess I don't understand why that matters, apart from "how should we socially judge this person?" There are a large number of mental and physical illnesses that can be improved (by the judgement of the patient) by a wide range/combination of meds, actions, choices, etc...
If I have schizophrenia and I treat it without meds and I get better, that doesn't prove you wrong. If I treat it exclusively with meds and get better, that doesn't prove Caplan wrong. Because it doesn't matter to me! What matters is: "by my standards and accounting for the cost of treatment, did I get better?" If you want to say "schizophrenia that you can treat without meds doesn't count" then I am 100% fine with that - but I think you (and Caplan) are fighting over definitions instead of reality.
"Do the meds work" isn't a good criterion for whether something is a disease because 1) many illnesses are untreatable, and 2) you can use drugs to stop non-disease behaviors and preferences easily (chemical castration of homosexuals).
Agreed, with the addition that may also be an indication that determining if something is a disease or not isn't that helpful (where I define helpful as "helps make the patient better of).
In my example, the key criteria was "is there an associated common pathway model?"
Whether the meds work or not cannot tell us about whether a trait is real, but it can lend evidence to the idea if we see that there is a treatment effect and it is not heterogeneous (ex: https://jamanetwork.com/journals/jamapsychiatry/article-abstract/2776610). Homogeneous treatment effects are unrealistic for many traits because treatment is generally not targeted at the etiology of a disease comprehensively, so this can only be used to provide positive, not negative evidence wrt whether a psychiatric diagnosis tags an actual trait.
The concerns raised by PercyPrior have to do with measurement invariance, which is often tenuous, rather than etiology, which I was concerned with.
The DSM counts you as being schizophrenic if you have 2 or more of the following for more than 2 months:
1) Delusional beliefs (Oxford Dictionary: "a false belief or judgment about external reality, held despite incontrovertible evidence to the contrary, occurring especially in mental conditions") Bryan's objection: what counts as "incontrovertible evidence to the contrary?" If the standard is "certainty," there isn't incontrovertible evidence that we aren't brains in vats, so it must be something more like "really really good evidence to the contrary." But what about religion? Many (most?) religious folks are happy to acknowledge that their beliefs are taken on faith, in full knowledge of the lack of evidence. Maybe Bryan's objection fails because religious beliefs are not subject to incontrovertible evidence *to the contrary,* just lacking in positive support.
Bryan also objects that incentive programs at psych wards have caused people to stop attesting to their delusions. I don't find this convincing because it's too easy for a patient to simply lie about their beliefs for rewards.
2) Hallucinations (usually auditory). Problem: most people have an internal monologue. You could say it has to be a voice heard from the outside, but the DSM considers a voice which can only be heard "on the inside" to count, assuming one does not identify with or control the voice. I'm not sure what to make of that either, though, because many of my thoughts are spontaneous and uncontrolled (just try to control what your next thought will be, and notice how often it comes to you unbidden), and I don't necessarily identify with my thoughts either. (I'm not entirely sure what it even means to "identify" with a thought. To think the thought is you? I am more than any thought I have. Does it mean "to think the thought is a part of me?" Why wouldn't hallucinations be "a part of" a schizophrenic?)
3) Disorganized speech (incoherence, frequent derailment). I don't know if Bryan has an objection to this, and Scott says in his experience this doesn't respond to incentives. That is, he will offer a patient who wants to be released the opportunity to be discharged if they can just string together an even slightly coherent sentence without their medication, and even still they cannot do it.
4) Grossly disorganized or catatonic behavior: IDK what Bryan says about this criterion either, maybe there's a study somewhere where this responds to extreme incentives too.
The takeaway: you could plausibly meet the criteria for schizophrenia despite being mentally healthy if you fit items 1 and 2 for more than two months (by being religious and having an internal monologue). But maybe the solution isn't to jettison the concept of schizophrenia as a disease, but to refine the diagnostic criteria?
Yeh thats why diagnosticians are taught to use clinical judgement and not use the diagnostic criteria as a checkbox.
Hence the years of training on interview technique (assuming the symtpom , open ended etc) and thousands of patient encounters.
You dont fill out a dsm form and send it to the dsm police when you diagnose someone , you do an in depth interview and take into account the entire case and the patient as a whole. You get collateral. You examine if subjective and objective line up and if its causing dysfunction or damage to the persons well being.
No ones out their trying to "gotcha" people into a diagnosis if the treatment would be of no utility.
A broken medical system with poor incentives isnt psychiatrys fault , they use the same criteria in countries that sont have for profit healthcare systems, the criteria werent designed to buttress US inpatient hospital numbers , insurance companies and governments dont want to pay for that and have a lot more money and power than all thr psychiatrists combined.
> Grossly disorganized ...behavior
Anti-ideological Pragmatism, eg, US domestic politics and foreign policy