The dark matter of psychiatry
May 16, 2021 8:08 PM Subscribe
The "p-factor" may be the invisible, unifying force behind a multitude of mental disorders. While other specialities of medicine have drastically reduced mortality rates from heart disease, cancer and stroke, there haven’t been similar successes in mental healthcare. As a paper from 2013 put it, ‘mortality has not decreased for any mental illness, prevalence rates are similarly unchanged,... and there are no well-developed preventive interventions.’ Psychiatry appears to be stuck. Perhaps it’s because the diagnostic system is faulty.
As a person who has dealt with a life-time “mental disorder” since I was 17 and cycled thru every marketed medication with no benefit — I think they are looking in the wrong place. I think the research into gut biome and mental illnesses is absolutely 100% on the right track.
And while you researchers are figuring that out, for the love of god please legalize psilocybin for therapeutic or self-directed use.
posted by Silvery Fish at 9:01 PM on May 16, 2021 [35 favorites]
And while you researchers are figuring that out, for the love of god please legalize psilocybin for therapeutic or self-directed use.
posted by Silvery Fish at 9:01 PM on May 16, 2021 [35 favorites]
the existence of that correlation doesn’t mean that g actually reduces to a single biological factor.
The reification fallacy, much discussed in Stephen Jay Gould’s The Mismeasure of Man.
posted by chrchr at 10:22 PM on May 16, 2021 [9 favorites]
The reification fallacy, much discussed in Stephen Jay Gould’s The Mismeasure of Man.
posted by chrchr at 10:22 PM on May 16, 2021 [9 favorites]
Celiac here. When I eat gluten, my entire personality / outlook / mental health take a drastic nose-dive for a couple of weeks. Before I knew I was celiac, my mental health was a mess. Now that I'm managing my disease, my mental health tracks how my guts are doing basically in lockstep -- when my gut is happy, my brain is happy.
So yeah, Silvery Fish is right. At least in my own body, gut health and the gut microbiome is key to mental health. The differences are so drastic that I wouldn't believe it except that I've lived it.
posted by cnidaria at 10:36 PM on May 16, 2021 [19 favorites]
So yeah, Silvery Fish is right. At least in my own body, gut health and the gut microbiome is key to mental health. The differences are so drastic that I wouldn't believe it except that I've lived it.
posted by cnidaria at 10:36 PM on May 16, 2021 [19 favorites]
It sounds a whole lot like (is perhaps inspired by, even?) the concept of the g-factor in intelligence testing.
They indeed state as much in the article where the p-factor is introduced, and I agree that it probably suffers from similar problems. I also agree that the author of the article struggles with the reification fallacy.
I also took issue with this statement: Whereas bodily immune disorders are variable in their symptoms and locations in the body – whether it’s the gut (Crohn’s disease), the liver (pancreas), the joints (rheumatoid arthritis) or the skin (psoriasis) – all psychiatric disorders are primarily disorders of the brain. I really don't think that holds any water, and some of the paragraphs around this push into "not even wrong" territory.
All that being said, I still think it's a really thoughtfully written piece, which is wrestling with some really difficult topics. In my experience, when new methodologies become over-hyped in science (e.g. fMRI or Deep Learning) there's usually still a core of researchers who are applying the method thoughtfully, whose research should not be dismissed. If the p-factor helps deconstruct dogmas in clinical psychiatry that sounds like a good thing to me. My own personal experiences with psychiatry were actually positive and I'm thankful for them, but I know that's not true for many or even most people, and often times psychiatric methods look like trying to hammer a nail with a fish.
posted by Alex404 at 12:44 AM on May 17, 2021 [4 favorites]
They indeed state as much in the article where the p-factor is introduced, and I agree that it probably suffers from similar problems. I also agree that the author of the article struggles with the reification fallacy.
I also took issue with this statement: Whereas bodily immune disorders are variable in their symptoms and locations in the body – whether it’s the gut (Crohn’s disease), the liver (pancreas), the joints (rheumatoid arthritis) or the skin (psoriasis) – all psychiatric disorders are primarily disorders of the brain. I really don't think that holds any water, and some of the paragraphs around this push into "not even wrong" territory.
All that being said, I still think it's a really thoughtfully written piece, which is wrestling with some really difficult topics. In my experience, when new methodologies become over-hyped in science (e.g. fMRI or Deep Learning) there's usually still a core of researchers who are applying the method thoughtfully, whose research should not be dismissed. If the p-factor helps deconstruct dogmas in clinical psychiatry that sounds like a good thing to me. My own personal experiences with psychiatry were actually positive and I'm thankful for them, but I know that's not true for many or even most people, and often times psychiatric methods look like trying to hammer a nail with a fish.
posted by Alex404 at 12:44 AM on May 17, 2021 [4 favorites]
cnidaria: "the gut microbiome is key to mental health". Very low level support for this [and it may well be a haddock-hammer]: A couple of years ago, I supervised an undergraduate bioinformatics project tasked to scan the genomes of known denizens of the dark human gut to see if these bacteria had the biochemical capability for making neurotransmitters. There are a lot of species down there but ace student discovered the genes necessary for converting available amino acids into, at least, dopamine and serotonin. Prebiotics [diet which encourages the happiness of already present microbes] have a brighter future than probiotics [diet of actual microbes often of the lactic acid bacteria LAB variety].
posted by BobTheScientist at 12:59 AM on May 17, 2021 [4 favorites]
posted by BobTheScientist at 12:59 AM on May 17, 2021 [4 favorites]
It does seem psychiatry is on a dead track, and I will offer my best wishes to anyone who tries a new angle. The other day I was talking with a friend about how all of medicine has locked itself onto "evidence" as the methodological cure-all, even when the concept of evidence makes no sense in the context.
I think this approach is historically a response to the political and economic restraints on medicine. If you can say that a treatment is "science-based", which often means "evidence-based", then it is politically hard to dismiss it.
True story to explain why this can be problematic: some years ago, doctors here stopped treating concussions with rest and avoidance of stimuli. Immediately, the number of patients with long term after-effects from concussion sky-rocketed. I asked my doctor why they had skipped the age-old recommendations and his reply was "there is no evidence". The reason there was no evidence was that almost no-one does research into concussions in this country, because there is no funding. So given the almost religious belief in evidence-based treatment, there can be no treatment for concussion. It looks like a joke, but it wasn't.
For psychiatry, this approach to medicine is catastrophic. How can you develop an evidence-based medicine where there are no clearly defined diagnoses or cures? Add in the social stigma. Mental health issues present differently across cultures, and need different therapeutic approaches. And therapies that do seem to work across cultures, like garden- or nature-therapy, are hard to measure in a manner that fits with the norms of evidence based medicine. Or, you can do some numbers, but quantitative research can seem silly in a field where there is still a ton of qualitative research to be done.
The gut microbiome thing seems promising, my personal experience is good. But anyone who has experienced mental health issues also knows that healthy eating is hard to do when you are struggling, specially with some of the really hard diagnoses, like schizophrenia or bi-polar.
(I was supposed to do research on the spaces of mental health when I had a serious breakdown, which has only now been diagnosed as complex PTSD, five years later. Ironic or something).
posted by mumimor at 1:54 AM on May 17, 2021 [28 favorites]
I think this approach is historically a response to the political and economic restraints on medicine. If you can say that a treatment is "science-based", which often means "evidence-based", then it is politically hard to dismiss it.
True story to explain why this can be problematic: some years ago, doctors here stopped treating concussions with rest and avoidance of stimuli. Immediately, the number of patients with long term after-effects from concussion sky-rocketed. I asked my doctor why they had skipped the age-old recommendations and his reply was "there is no evidence". The reason there was no evidence was that almost no-one does research into concussions in this country, because there is no funding. So given the almost religious belief in evidence-based treatment, there can be no treatment for concussion. It looks like a joke, but it wasn't.
For psychiatry, this approach to medicine is catastrophic. How can you develop an evidence-based medicine where there are no clearly defined diagnoses or cures? Add in the social stigma. Mental health issues present differently across cultures, and need different therapeutic approaches. And therapies that do seem to work across cultures, like garden- or nature-therapy, are hard to measure in a manner that fits with the norms of evidence based medicine. Or, you can do some numbers, but quantitative research can seem silly in a field where there is still a ton of qualitative research to be done.
The gut microbiome thing seems promising, my personal experience is good. But anyone who has experienced mental health issues also knows that healthy eating is hard to do when you are struggling, specially with some of the really hard diagnoses, like schizophrenia or bi-polar.
(I was supposed to do research on the spaces of mental health when I had a serious breakdown, which has only now been diagnosed as complex PTSD, five years later. Ironic or something).
posted by mumimor at 1:54 AM on May 17, 2021 [28 favorites]
Celiac here. When I eat gluten, my entire personality / outlook / mental health take a drastic nose-dive for a couple of weeks.
I have it too, and it is a terrible disease. The pernicious anemia my hematologist thinks I developed because of it almost killed me, and I had frank delusions for several days after spending a night in the hospital for the PI. For years I attributed that to gluten in the contrast dye I took for a scan (two out of three of the best-selling barium contrast dyes were thickened with it when I looked into that a few years ago), but it also could have been a case of 'ICU delirium', which could be caused by the barium in contrast dye in my opinion.
An elegant Mayo Clinic study found a more than fourfold rise in CD since the 50s to its current level of 1%, and also a fourfold higher death rate for people with undiagnosed 'gluten intolerance".
But there seems to be a rising tide of autoimmune diseases in general, and if there is a final common pathway for a "multitude of mental disorders" I think it's more likely to be autoimmunity than anything else -- and viruses and bacteria in the gut and elsewhere are past masters at inducing autoimmunity.
posted by jamjam at 1:54 AM on May 17, 2021 [8 favorites]
I have it too, and it is a terrible disease. The pernicious anemia my hematologist thinks I developed because of it almost killed me, and I had frank delusions for several days after spending a night in the hospital for the PI. For years I attributed that to gluten in the contrast dye I took for a scan (two out of three of the best-selling barium contrast dyes were thickened with it when I looked into that a few years ago), but it also could have been a case of 'ICU delirium', which could be caused by the barium in contrast dye in my opinion.
An elegant Mayo Clinic study found a more than fourfold rise in CD since the 50s to its current level of 1%, and also a fourfold higher death rate for people with undiagnosed 'gluten intolerance".
But there seems to be a rising tide of autoimmune diseases in general, and if there is a final common pathway for a "multitude of mental disorders" I think it's more likely to be autoimmunity than anything else -- and viruses and bacteria in the gut and elsewhere are past masters at inducing autoimmunity.
posted by jamjam at 1:54 AM on May 17, 2021 [8 favorites]
This is exactly as much a statistical myth as g. To recap the best exposition of why g is crap, I defer to Cosma Shalizi:
posted by pmb at 2:02 AM on May 17, 2021 [5 favorites]
the finding that positively correlated variables are all correlated with a linear combination of each other, and why this becomes no more profound when the variables are scores on [...] testsfrom g, a statistical myth (http://bactra.org/weblog/523.html) from 2007
posted by pmb at 2:02 AM on May 17, 2021 [5 favorites]
Reading the article, I don't think they're falling into the trap of postulating p to explain statistical correlations, and assuming that's the job done. There are two other big questions that they go on to discuss:
posted by vincebowdren at 4:05 AM on May 17, 2021 [5 favorites]
- whether the existing categories and disorder names do a good enough job of mapping to statistical correlations between symptoms, or as the article puts it: "Either mental disorders really do tend to aggregate or, perhaps more likely and more worryingly, our classification system is drawing lines in unnatural places, carving nature far from its joints."
- what we know and don't know about underlying mechanisms, and what clues we get about that from taking a broader view of mental disorders as all inter-related
posted by vincebowdren at 4:05 AM on May 17, 2021 [5 favorites]
"....we cannot succeed if we use DSM categories as the “gold standard.” The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories. Imagine deciding that EKGs were not useful because many patients with chest pain did not have EKG changes. That is what we have been doing for decades when we reject a biomarker because it does not detect a DSM category."
Thomas Insel, Director of NIMH (2002-15), in 2013.
And the problem with DSM definitions has not improved since then.
posted by Pouteria at 4:25 AM on May 17, 2021 [9 favorites]
Thomas Insel, Director of NIMH (2002-15), in 2013.
And the problem with DSM definitions has not improved since then.
posted by Pouteria at 4:25 AM on May 17, 2021 [9 favorites]
James Hillman spoke to this issue more meaningfully than I can here. See his "We've Had 100 Years of Psychotherapy- And the World's Getting Worse". He argues that good literature speaks to people more than therapy does. Also lacking are the soul and mythological dimensions needed to revive a moribund method of healing.
posted by DJZouke at 5:08 AM on May 17, 2021 [4 favorites]
posted by DJZouke at 5:08 AM on May 17, 2021 [4 favorites]
Can't you basically reduce what they're saying about the p-factor to "There's a ton of stuff we don't know about mental illness, let's call all of that stuff 'p'"?
posted by mmoncur at 5:24 AM on May 17, 2021 [3 favorites]
posted by mmoncur at 5:24 AM on May 17, 2021 [3 favorites]
‘More showbiz than science,’ replied another (who didn’t want to be named), before adding: ‘There are some common pathways that link disorders to each other, but that’s like saying that there are a lot of physical disorders that involve inflammation and are related to each other through that common mechanism. It’s true but only a tiny piece of the story.’That's an interesting analogy. What makes inflammation a symptom which unites many diseases isn't the diseases, but our immune system response.
posted by clawsoon at 6:22 AM on May 17, 2021 [4 favorites]
For those interested in the gut-depression relationship, I highly recommend Gut Feminism by Elizabeth A. Wilson. It's an academic book but super interesting.
posted by EllaEm at 6:23 AM on May 17, 2021 [3 favorites]
posted by EllaEm at 6:23 AM on May 17, 2021 [3 favorites]
Can't you basically reduce what they're saying about the p-factor to "There's a ton of stuff we don't know about mental illness, let's call all of that stuff 'p'"?
I'd rephrase that a little, to reflect that there is new evidence that the theorists are trying to take into account. Maybe "There's a lot more connections between different mental illnesses than we thought before; we don't understand the connections yet, but we're going to measure how correlated the different diagnoses are and call that p."
posted by vincebowdren at 7:00 AM on May 17, 2021 [4 favorites]
I'd rephrase that a little, to reflect that there is new evidence that the theorists are trying to take into account. Maybe "There's a lot more connections between different mental illnesses than we thought before; we don't understand the connections yet, but we're going to measure how correlated the different diagnoses are and call that p."
posted by vincebowdren at 7:00 AM on May 17, 2021 [4 favorites]
DSM DSM
So categorical.
Same with the p-factor--
Best to avoid.
Ditch territorial
Psychopathology!
Build you a war machine;
Get back to Freud.
posted by Richard Saunders at 7:43 AM on May 17, 2021 [5 favorites]
So categorical.
Same with the p-factor--
Best to avoid.
Ditch territorial
Psychopathology!
Build you a war machine;
Get back to Freud.
posted by Richard Saunders at 7:43 AM on May 17, 2021 [5 favorites]
It's all good questions to raise and investigate. I hope researchers and reporting and understanding of actionable/useful discoveries keeps a very close eye on how easily people can latch onto reductive oversimplifications. The siren call of a "the" p-factor will be potent. (One of the recent spate of articles about why it took an unfortunate amount of time to accept that covid-19 has aerosol spread, partially because turns out 5 microns had/has too much significance attached to it has been on my mind, as the connection here.)
posted by Drastic at 7:45 AM on May 17, 2021 [2 favorites]
posted by Drastic at 7:45 AM on May 17, 2021 [2 favorites]
He argues that good literature speaks to people more than therapy does.
That didn't seem to work for King Lear.
posted by thelonius at 8:34 AM on May 17, 2021
That didn't seem to work for King Lear.
posted by thelonius at 8:34 AM on May 17, 2021
all psychiatric disorders are primarily disorders of the brain
Hard disagree with the amount of certainty in this statement.
posted by hypnogogue at 8:47 AM on May 17, 2021 [4 favorites]
Hard disagree with the amount of certainty in this statement.
posted by hypnogogue at 8:47 AM on May 17, 2021 [4 favorites]
The other day I was talking with a friend about how all of medicine has locked itself onto "evidence" as the methodological cure-all, even when the concept of evidence makes no sense in the context.
I think this approach is historically a response to the political and economic restraints on medicine. If you can say that a treatment is "science-based", which often means "evidence-based", then it is politically hard to dismiss it.
This makes no sense. Evidence is science, at least in the sense that science in its modern conception is empirical. If you aren't basing your treatment on evidence, then you're basing it on magic. What separates snake oil from medicine is evidence. If a treatment cannot be shown to work (which requires evidence), then the treatment should be abandoned. As a healthcare researcher and clinician myself, every failure in my field is not because we clung too tightly to evidence but because we didn't have enough evidence.
The solution to improving psychological care is not to abandon evidence but to gather more of it in better ways.
posted by Lutoslawski at 8:59 AM on May 17, 2021 [7 favorites]
I think this approach is historically a response to the political and economic restraints on medicine. If you can say that a treatment is "science-based", which often means "evidence-based", then it is politically hard to dismiss it.
This makes no sense. Evidence is science, at least in the sense that science in its modern conception is empirical. If you aren't basing your treatment on evidence, then you're basing it on magic. What separates snake oil from medicine is evidence. If a treatment cannot be shown to work (which requires evidence), then the treatment should be abandoned. As a healthcare researcher and clinician myself, every failure in my field is not because we clung too tightly to evidence but because we didn't have enough evidence.
The solution to improving psychological care is not to abandon evidence but to gather more of it in better ways.
posted by Lutoslawski at 8:59 AM on May 17, 2021 [7 favorites]
This makes no sense. Evidence is science, at least in the sense that science in its modern conception is empirical.
As the comment you quoted goes on to explain quite persuasively with the example of treatments for concussion, the issue arises when certain types of evidence are not considered evidence, often for socio-political reasons and increasingly, in the last 70 years, due to corporate/capitalist corruption of the institutions of science. Consider, for example, that my doctor STILL tells me there's "no evidence" that hormonal birth control pills cause weight gain because somehow 60+ years and literally billions of women's reported experiences don't count as scientific evidence. Consider, for example, that the corn and sugar lobby has spent at least 50 years pumping money into "research" to distract away from sugar as the main culprit in the American obesity epidemic. Consider how tobacco lobbies suppressed evidence pertaining to carcinogens in cigarettes - and consider the "evidence" they selectively publicized from "studies" they funded.
Considering what we know about evidence, this statement:
If you aren't basing your treatment on evidence, then you're basing it on magic.
comes across as naively dismissive at best and dangerous at worst. You only have to look at the history of psychiatry to have every reason to question "evidence-based" psychiatric practices and psychological therapies. Science cannot be spoken of as if it is independent of the human scientists who study and theorize about and practice it - and all the egos, biases, prejudices, god complexes, profit motivated corruptions, etc. that are within those humans.
posted by MiraK at 9:35 AM on May 17, 2021 [17 favorites]
As the comment you quoted goes on to explain quite persuasively with the example of treatments for concussion, the issue arises when certain types of evidence are not considered evidence, often for socio-political reasons and increasingly, in the last 70 years, due to corporate/capitalist corruption of the institutions of science. Consider, for example, that my doctor STILL tells me there's "no evidence" that hormonal birth control pills cause weight gain because somehow 60+ years and literally billions of women's reported experiences don't count as scientific evidence. Consider, for example, that the corn and sugar lobby has spent at least 50 years pumping money into "research" to distract away from sugar as the main culprit in the American obesity epidemic. Consider how tobacco lobbies suppressed evidence pertaining to carcinogens in cigarettes - and consider the "evidence" they selectively publicized from "studies" they funded.
Considering what we know about evidence, this statement:
If you aren't basing your treatment on evidence, then you're basing it on magic.
comes across as naively dismissive at best and dangerous at worst. You only have to look at the history of psychiatry to have every reason to question "evidence-based" psychiatric practices and psychological therapies. Science cannot be spoken of as if it is independent of the human scientists who study and theorize about and practice it - and all the egos, biases, prejudices, god complexes, profit motivated corruptions, etc. that are within those humans.
posted by MiraK at 9:35 AM on May 17, 2021 [17 favorites]
Can't you basically reduce what they're saying about the p-factor to "There's a ton of stuff we don't know about mental illness, let's call all of that stuff 'p'"?
Yeah and I feel like that's kind of the genius of it.
Reading the DSM and other diagnostic manuals, it's hard not to notice just how much overlap there exists between diagnoses. Looking at real people, it's hard not to notice how rare it is for any person to suffer from just a single mental illness. Literally even the meds for anxiety and depression are the same meds, often, so *how* are these considered separate illnesses? I mean, can you imagine the common cold being treated as its own separate illness if it literally never occurred as just a cold, if it was always seen as part of a bunch of other diseases? Or to put it another way, can you imagine "blood in urine" being its own diagnosis rather than a symptom of a number of possible diagnoses?
You read through a selection of modern graduate-level psychology textbooks and it's impossible not to realize that the most "old fashioned" among them - the ones that harken back to psychoanalytical models of human psyches - are the ones that make the most sense in terms of an overarching model for how to understand mental processes and illnesses. (For example, Nancy McWilliams.) These texts are the ones that present immensely broad classifications like neuroses, borderline disorders, and psychoses, that's it, 1,2,3, bam, done. And, like, there's the paranoid-schizoids personalities and there's the depressive-obsessionals and there's the narcissistic-histrionic types. That's it. 1,2,3, bam, done. It sounds so ridiculous at first glance, but the more you read, the more you realize that only these too-broad-to-seem-useful categories make the slightest bit of sense out in the real world with real people. And oh, yes, nary a smote of "evidence" for this stuff, unless of course your scientific top brass deign to count the clinical reports of ye so many practitioners over many, many decades as real evidence...
If insurance companies are starting to use "it's gotta be ~evidence based~ TmotherfuckingM" as their latest filter for denying people coverage for mental health treatments, then why NOT use the paradigm of "OK, let's get away from the stigma of freudian/Jungian woo, reset the science-o-meter and call all our unknowns the p-factor." I think it's great. I think it's necessary!
posted by MiraK at 10:03 AM on May 17, 2021 [2 favorites]
Yeah and I feel like that's kind of the genius of it.
Reading the DSM and other diagnostic manuals, it's hard not to notice just how much overlap there exists between diagnoses. Looking at real people, it's hard not to notice how rare it is for any person to suffer from just a single mental illness. Literally even the meds for anxiety and depression are the same meds, often, so *how* are these considered separate illnesses? I mean, can you imagine the common cold being treated as its own separate illness if it literally never occurred as just a cold, if it was always seen as part of a bunch of other diseases? Or to put it another way, can you imagine "blood in urine" being its own diagnosis rather than a symptom of a number of possible diagnoses?
You read through a selection of modern graduate-level psychology textbooks and it's impossible not to realize that the most "old fashioned" among them - the ones that harken back to psychoanalytical models of human psyches - are the ones that make the most sense in terms of an overarching model for how to understand mental processes and illnesses. (For example, Nancy McWilliams.) These texts are the ones that present immensely broad classifications like neuroses, borderline disorders, and psychoses, that's it, 1,2,3, bam, done. And, like, there's the paranoid-schizoids personalities and there's the depressive-obsessionals and there's the narcissistic-histrionic types. That's it. 1,2,3, bam, done. It sounds so ridiculous at first glance, but the more you read, the more you realize that only these too-broad-to-seem-useful categories make the slightest bit of sense out in the real world with real people. And oh, yes, nary a smote of "evidence" for this stuff, unless of course your scientific top brass deign to count the clinical reports of ye so many practitioners over many, many decades as real evidence...
If insurance companies are starting to use "it's gotta be ~evidence based~ TmotherfuckingM" as their latest filter for denying people coverage for mental health treatments, then why NOT use the paradigm of "OK, let's get away from the stigma of freudian/Jungian woo, reset the science-o-meter and call all our unknowns the p-factor." I think it's great. I think it's necessary!
posted by MiraK at 10:03 AM on May 17, 2021 [2 favorites]
As far as "evidence" goes, Jonathan Shedler, a clinical psychologist, has written on the various issues with "evidence-based treatment" and indeed what even does/should constitute evidence in the world of psychotherapy/mental health treatment research. Shedler is focused on more narrowly on talk therapies and doesn't mention any pharmacological/immunological interventions, but touches on the same points that mumimor makes re: the dominant framework of mainstream psychiatry. FWIW, such critiques work in support of gathering more evidence in better ways by pointing out the kinds of evidence that are overlooked as a matter of ideology, habit, and/or institutional incentives.
"OK, let's get away from the stigma of freudian/Jungian woo, reset the science-o-meter and call all our unknowns the p-factor."
While there's a lot more to be learned, I suspect doing so will result in people reinventing much of the wheel. Neuropsychoanalysis is a thing, after all.
posted by obliterati at 10:14 AM on May 17, 2021 [4 favorites]
"OK, let's get away from the stigma of freudian/Jungian woo, reset the science-o-meter and call all our unknowns the p-factor."
While there's a lot more to be learned, I suspect doing so will result in people reinventing much of the wheel. Neuropsychoanalysis is a thing, after all.
posted by obliterati at 10:14 AM on May 17, 2021 [4 favorites]
This makes no sense. Evidence is science, at least in the sense that science in its modern conception is empirical. If you aren't basing your treatment on evidence, then you're basing it on magic. What separates snake oil from medicine is evidence. If a treatment cannot be shown to work (which requires evidence), then the treatment should be abandoned.
I was waiting for this reaction. Obviously, you are right. I agree! I jumped through tiny hoops to make my research compatible with the norms we have agreed on as the foundation of modern medicine, even though my area of research didn't always fit into the boxes. I have even contributed (in a small way) to better, evidence based treatment of a specific patient group.
BUT, and this is a huge but, there are forms of knowledge that cannot fit into those boxes and are also not magic woo. There can be all sorts of reasons for this, foremost there may be ethical reasons you cannot provide evidence in a manner that is accepted by the medical research community. Or your study may not be replicable, because there are some unique conditions.
Or you can be making theoretical propositions, based on generations of knowledge and yes evidence, but there might not yet be the instruments available to test your proposition.
In many fields, scientists know there is a wide methodological and theoretical range which is acceptable within that field. Where I work now, (a tech university) a failed full-scale experiment can be seen as an important step on the way towards the solution, but then we don't usually kill people if we fail at the experimental level. We do break machines. Within medicine, it seems to me that the methodological and theoretical range is very narrow. Also, as my friend the social science scholar pointed out: not all doctors have a full grasp of statistics.
And there isn't only an issue with statistics in medicine. There is also the problem of reading and analyzing data. The current discussion about the spread of coronavirus is a case in point, but in general, being able to parse the relevant data in any given situation is to a large extent a skill, not a science. You need to be able to see, wether it is on the epidemiological or the bacterial level. Or out there in general practice. And you need to be able to combine what you see with what is known, not just what you may know.
Related to that is how cultural knowledge can inform science. In the US, black women suffer more from preeclampsia than white women, even if they are rich and famous and have access to platinum healthcare. To be honest, I find the attempts to explain this through medical or social science pathetic -- this is not happening elsewhere. As a hypothesis, I would suggest this might have to do with racism. And I'd also suggest that the humanities might have some interesting input on how to deal with this, more so than "evidence".
Now let me return to the examples I used in my comment above. As I understand it (from my doctor), the research into long term effects of concussions has improved because of strong new patient groups and American footballers. I'm sorry for the athletes, but it is good if they brought some money into the field. However, the public policy of not treating patients because there was no scientific evidence for the treatment is IMO insane. It's true that there was no evidence for the traditional treatment, until someone made the wildly unethical and unplanned experiment of foregoing it, thus leaving thousands of people semi-invalidated for life. Now we know again that time spent in a dark room with little stimulation helps, but we know that because people suffered for knowledge we already had. And obviously, the motivation was economical. In the old days, if you had a concussion, your doctor would order a week of rest, and you would get a week of sick leave, regardless of the measurable symptoms. With no "evidence", you could be sent back to work the next day.
One of the things I was looking into in my earlier project was that a lot of psychiatrists all over the world are finding very good results with garden and/or nature therapy. They can document that it works better than drugs with patients with many different diagnoses, from schizophrenia to PTSD. That's nice. But they cannot create studies which document which types of gardens/nature work better. Because no two gardens or forests are alike, they depend on climate and culture and a multitude of other factors. And we cannot discount that the project leaders may be excellent therapists. Finally, the ethical issues with any form of tests in this field are immense. It's not like you can just traumatize some rats and give them a garden.
As part of an earlier project, I once interviewed a professor who had won several awards for leading an ICU with results (measured in recoveries) far beyond any other in Europe. He was convinced that his use of art and music in therapy was an important contribution to the success. So I got to visit the ICU, and listen to the CDs he had made, and it was all terrible. The ward was a chaotic mess with modern art randomly placed in between the beds and machines. I would personally experience his New Age playlists as torture, specially since one would be completely helpless while exposed to them. But how does one sort out what is working in such a complex environment? You can't really do double blind tests on people who are close to death.
Earlier (maybe twenty years ago), it was documented that somatic patients in hospitals with a view to plants recovered faster than patients with a view to a brick wall. Doh! Well OK, it was documented, and thus every new hospital is now required to have windows facing a garden or nature. But again, there is no evidence for how that garden should be planted or maintained. And the hospital itself can be a hell-hole of industrial construction methods and noisy ventilation systems and bad plans. With a garden.
And there are completely different aspects of this. A scientist I know who is also a musician, has documented by using MRI scans that people who can play an instrument use different parts of the brain when they listen to music than those who cannot play themselves. I like this study. But a Phd student I advised wanted to create a similar study for art and architecture. It couldn't really work, because while you can easily bring music into the scanner, you can't bring space in there, and a photo is not the same as the actual space. So we cannot right now bring evidence that some people perceive space differently from others, while we can prove that some people hear music differently. Because of the equipment.
In other words, science is more than evidence, though evidence is an important aspect of science.
posted by mumimor at 11:06 AM on May 17, 2021 [12 favorites]
I was waiting for this reaction. Obviously, you are right. I agree! I jumped through tiny hoops to make my research compatible with the norms we have agreed on as the foundation of modern medicine, even though my area of research didn't always fit into the boxes. I have even contributed (in a small way) to better, evidence based treatment of a specific patient group.
BUT, and this is a huge but, there are forms of knowledge that cannot fit into those boxes and are also not magic woo. There can be all sorts of reasons for this, foremost there may be ethical reasons you cannot provide evidence in a manner that is accepted by the medical research community. Or your study may not be replicable, because there are some unique conditions.
Or you can be making theoretical propositions, based on generations of knowledge and yes evidence, but there might not yet be the instruments available to test your proposition.
In many fields, scientists know there is a wide methodological and theoretical range which is acceptable within that field. Where I work now, (a tech university) a failed full-scale experiment can be seen as an important step on the way towards the solution, but then we don't usually kill people if we fail at the experimental level. We do break machines. Within medicine, it seems to me that the methodological and theoretical range is very narrow. Also, as my friend the social science scholar pointed out: not all doctors have a full grasp of statistics.
And there isn't only an issue with statistics in medicine. There is also the problem of reading and analyzing data. The current discussion about the spread of coronavirus is a case in point, but in general, being able to parse the relevant data in any given situation is to a large extent a skill, not a science. You need to be able to see, wether it is on the epidemiological or the bacterial level. Or out there in general practice. And you need to be able to combine what you see with what is known, not just what you may know.
Related to that is how cultural knowledge can inform science. In the US, black women suffer more from preeclampsia than white women, even if they are rich and famous and have access to platinum healthcare. To be honest, I find the attempts to explain this through medical or social science pathetic -- this is not happening elsewhere. As a hypothesis, I would suggest this might have to do with racism. And I'd also suggest that the humanities might have some interesting input on how to deal with this, more so than "evidence".
Now let me return to the examples I used in my comment above. As I understand it (from my doctor), the research into long term effects of concussions has improved because of strong new patient groups and American footballers. I'm sorry for the athletes, but it is good if they brought some money into the field. However, the public policy of not treating patients because there was no scientific evidence for the treatment is IMO insane. It's true that there was no evidence for the traditional treatment, until someone made the wildly unethical and unplanned experiment of foregoing it, thus leaving thousands of people semi-invalidated for life. Now we know again that time spent in a dark room with little stimulation helps, but we know that because people suffered for knowledge we already had. And obviously, the motivation was economical. In the old days, if you had a concussion, your doctor would order a week of rest, and you would get a week of sick leave, regardless of the measurable symptoms. With no "evidence", you could be sent back to work the next day.
One of the things I was looking into in my earlier project was that a lot of psychiatrists all over the world are finding very good results with garden and/or nature therapy. They can document that it works better than drugs with patients with many different diagnoses, from schizophrenia to PTSD. That's nice. But they cannot create studies which document which types of gardens/nature work better. Because no two gardens or forests are alike, they depend on climate and culture and a multitude of other factors. And we cannot discount that the project leaders may be excellent therapists. Finally, the ethical issues with any form of tests in this field are immense. It's not like you can just traumatize some rats and give them a garden.
As part of an earlier project, I once interviewed a professor who had won several awards for leading an ICU with results (measured in recoveries) far beyond any other in Europe. He was convinced that his use of art and music in therapy was an important contribution to the success. So I got to visit the ICU, and listen to the CDs he had made, and it was all terrible. The ward was a chaotic mess with modern art randomly placed in between the beds and machines. I would personally experience his New Age playlists as torture, specially since one would be completely helpless while exposed to them. But how does one sort out what is working in such a complex environment? You can't really do double blind tests on people who are close to death.
Earlier (maybe twenty years ago), it was documented that somatic patients in hospitals with a view to plants recovered faster than patients with a view to a brick wall. Doh! Well OK, it was documented, and thus every new hospital is now required to have windows facing a garden or nature. But again, there is no evidence for how that garden should be planted or maintained. And the hospital itself can be a hell-hole of industrial construction methods and noisy ventilation systems and bad plans. With a garden.
And there are completely different aspects of this. A scientist I know who is also a musician, has documented by using MRI scans that people who can play an instrument use different parts of the brain when they listen to music than those who cannot play themselves. I like this study. But a Phd student I advised wanted to create a similar study for art and architecture. It couldn't really work, because while you can easily bring music into the scanner, you can't bring space in there, and a photo is not the same as the actual space. So we cannot right now bring evidence that some people perceive space differently from others, while we can prove that some people hear music differently. Because of the equipment.
In other words, science is more than evidence, though evidence is an important aspect of science.
posted by mumimor at 11:06 AM on May 17, 2021 [12 favorites]
Lot's of interesting stuff here to consider. I find myself most interested in the possible environmental factors discussed toward the end of the article. As someone who works occasionally with adolescents bound for inpatient psych hospitals, I can anecdotally report that I often find myself drawing a direct line between a patient's symptoms/diagnosis and factors/relationships inside the patient's home environment.
posted by WhenInGnome at 11:16 AM on May 17, 2021 [1 favorite]
posted by WhenInGnome at 11:16 AM on May 17, 2021 [1 favorite]
muminor, I think that’s a great example of a particular hardliner stance in “evidence based medicine” that the only way to know things is through a randomized controlled trial. The viewpoint was famously parodied in a couple of BMJ papers about parachutes.
It would be interesting to see if this proposed general factor is different from the Big 5 personality trait “neuroticism.” The name can seem slightly insulting, as someone who scored highly, but it does capture a general type of emotional vulnerability that sounds similar to what’s being described here. Comfortingly it does appear to change reliably in response to psychotherapy, which is good news both for patients and for the field.
I saw a study a while back that did seem to observe clustering in genetic correlations between psychiatric disorders (and migraine, but notably not other neurological disorders). It’s an interesting approach, I thought. Of course, in general, there is no “right” number of clusters for a given set of data and similar problems with g will apply here. That said I do get the sense that nobody believes there’s anything particularly magical about DSM categories, except perhaps insurance companies.
posted by en forme de poire at 3:08 PM on May 17, 2021 [8 favorites]
It would be interesting to see if this proposed general factor is different from the Big 5 personality trait “neuroticism.” The name can seem slightly insulting, as someone who scored highly, but it does capture a general type of emotional vulnerability that sounds similar to what’s being described here. Comfortingly it does appear to change reliably in response to psychotherapy, which is good news both for patients and for the field.
I saw a study a while back that did seem to observe clustering in genetic correlations between psychiatric disorders (and migraine, but notably not other neurological disorders). It’s an interesting approach, I thought. Of course, in general, there is no “right” number of clusters for a given set of data and similar problems with g will apply here. That said I do get the sense that nobody believes there’s anything particularly magical about DSM categories, except perhaps insurance companies.
posted by en forme de poire at 3:08 PM on May 17, 2021 [8 favorites]
BTW, since it came up... I would be a little cautious about interpreting the research linking gut microbes to psychiatric diagnoses. Microbiome experiments are already complicated, context-dependent, and variable across research groups. That all goes double when you bring the brain and behavior into the mix. A related problem is that so much gut microbiome research depends on mouse models. If your research is on cancer or diabetes then these are at least relatively easy to observe in a mouse -- although even then, not everything will translate to humans because our physiology is pretty different. But it's even more debatable how well any mouse models really relate to the human experiences of mental illness or non-neurotypicality. On top of this, it is very difficult to perform microbiome and behavior studies that are large, well-designed, and well-analyzed enough to reliably answer the questions people are most interested in. When all that goes wrong, you get situations like this.
I want to stress that I'm not being negative about microbiome research as a whole; there are strong reproducible effects in some areas and plenty of exciting future directions. And, while this is much less my area, it does seem like there are connections between the brain and immunity -- so it's not unreasonable to think that microbiomes could play a role, since we know they have lots of interactions with the immune system. It is just really, really complicated, and it's very difficult to do this research properly with the tools and resources we have right now. My guess is we're likely to go through several more cycles of hype and backlash before we really get to a sophisticated understanding of how strongly microbes are linked to mental health, and what mediates any of those possible connections.
posted by en forme de poire at 3:56 PM on May 17, 2021 [8 favorites]
I want to stress that I'm not being negative about microbiome research as a whole; there are strong reproducible effects in some areas and plenty of exciting future directions. And, while this is much less my area, it does seem like there are connections between the brain and immunity -- so it's not unreasonable to think that microbiomes could play a role, since we know they have lots of interactions with the immune system. It is just really, really complicated, and it's very difficult to do this research properly with the tools and resources we have right now. My guess is we're likely to go through several more cycles of hype and backlash before we really get to a sophisticated understanding of how strongly microbes are linked to mental health, and what mediates any of those possible connections.
posted by en forme de poire at 3:56 PM on May 17, 2021 [8 favorites]
I have a sort of fascination with Thomas Szasz's approach to all this, which is sort of embarrassing since I've spent a lot of my career in the orbit of psychological science. But I too find it suspicious and also unhelpful that people with one psychiatric label seem to wind up with an alphabet soup of them. I go back and forth between thinking that the relevant level of analysis is something more general than a diagnosis -- like the p-factor, or like Szasz's general conception of "problems in living" -- and thinking that the most relevant level is something more specific than the DSM gets, like individual problems that you could use some individual strategies for. And maybe it's both of these things. Maybe I think that a property like propensity to psychiatric distress is something that inheres in self-as-stable-throughout-time, whereas a property like specific symptoms is something that belongs in selves-defined-at-slices-in-time. Regardless, I am increasingly of the opinion that a diagnosis, coming inevitably from a set of categories that are themselves unstable over time, is not a helpful way to think about either of these levels of selfhood, or to improve anybody's life.
posted by eirias at 6:23 PM on May 17, 2021 [3 favorites]
posted by eirias at 6:23 PM on May 17, 2021 [3 favorites]
Thanks for the post. I don't see my perspective reflected in any of the comments above, so I'll do a sketch of it, on the chance it might be helpful to someone.
My personal experience is with depression, mania and psychosis.
I agree with the author's premise that psychiatric diagnoses are faulty but note that the author accepts without criticism the dogma that psychiatric disorders are diseases of the brain. In my view, current psychiatric diagnoses and other lore are not simply faulty, but pseudo-scientific. However, I don't believe the fix is to try to achieve better science. The problem is not bad science, but that the mainstream psychiatric community is committed to the wrong paradigm, the medical model of psychiatric disorders. I.e., they are illnesses & all illnesses are ultimately biological in character. Unfortunately, this paradigm is pretty much forced on the field by our dominant culture which is materialist and deeply invested in scientism. What's tragically fatal about the medical model -- which is the background to assertions like psychiatric problems are illnesses of the brain -- is that it completely blinds those who subscribe to it to the reality of what is happening with these disorders. (Or at least, to be cautious about extrapolating from my own experience, with mania and psychosis.)
They are blind to it because the most intrinsic element of the experience of mania and psychosis is an elevation of consciousness to an apperception of reality which is both more true than that of the general materialist view and involves an openness to kinds of events which the general materialist view dismisses as impossible. The problem comes when the elevation of consciousness happens to someone who lacks sufficient preparation and/or whose ego and personality structures are not solid enough to deal with the fact and the ramifications of the elevation of consciousness and who thus loses the ability to regulate their own mind. The ability to regulate one's mind is particularly important in this higher consciousness -- which some traditions call non-dual and others subject-object-identity -- because it turns out the mind is not so limited by the physical body as the empiricist materialist consciousness believes. So havoc is easier to wreak if you're getting things wrong mentally. Anyway, mania and psychosis are manifestations of this kind of inability to regulate one's mind. As purely descriptive terms they aren't objectionable. But both are secondary effects of a phenomenon that is itself extremely positive and that our psychiatrists and our dominant culture do not accept. Indeed cannot see and categorize as a species of delusion when reported to about. (Actual delusion, which can be part of psychosis and involves accepting as true groundless ideas about matters of fact, is very bad. But spiritual awareness and insight is not delusional.)
The horror and tragedy of contemporary psychiatry is, that while psychiatrists don't know what they are dealing with, or what they are doing, they do have drugs which can stop, at least mania and psychosis. And they prescribe them liberally. However the strategy of these drugs is not to remove the manic or psychotic features, but rather to suppress consciousness to such an extent that the problems of self-regulation due to higher levels of consciousness do not arise. This is, one might say, to throw the baby out with the bathwater. And the destructiveness of psychiatric drugs on the mind and the soul cannot be overstated. They are just ruinous and deprive those who take them of what seems to me a fundamental human right to personal spiritual advancement. At the doses usually prescribed they also effectively prevent any kind of reflection on one's experience with the disorders that could lead to insight into what is actually going on.
Trusting the health of one's soul -- 'psyche' means soul in Greek -- to people who are professionally oblivious, even hostile, to the full reality of the soul is utter folly. But that is what our culture and its medical model has us doing. Only a major paradigm shift is going to help the field get un-"stuck".
(re Lutoslawski's disparaging remark about magic above: if you're really interested in what's happening with the so-called major disorders, trying to practice a little Wicca -- or other magic tradition -- is not a bad way to go. Phyllis Curott's guidebook Witchcrafting is a good read and puts forth an outline of a view of mind much closer to the truth than that entertained by mainstream psychiatry. Empirical science, so useful for so many things, will here just lead you astray.)
posted by bertran at 1:35 AM on May 18, 2021 [6 favorites]
My personal experience is with depression, mania and psychosis.
I agree with the author's premise that psychiatric diagnoses are faulty but note that the author accepts without criticism the dogma that psychiatric disorders are diseases of the brain. In my view, current psychiatric diagnoses and other lore are not simply faulty, but pseudo-scientific. However, I don't believe the fix is to try to achieve better science. The problem is not bad science, but that the mainstream psychiatric community is committed to the wrong paradigm, the medical model of psychiatric disorders. I.e., they are illnesses & all illnesses are ultimately biological in character. Unfortunately, this paradigm is pretty much forced on the field by our dominant culture which is materialist and deeply invested in scientism. What's tragically fatal about the medical model -- which is the background to assertions like psychiatric problems are illnesses of the brain -- is that it completely blinds those who subscribe to it to the reality of what is happening with these disorders. (Or at least, to be cautious about extrapolating from my own experience, with mania and psychosis.)
They are blind to it because the most intrinsic element of the experience of mania and psychosis is an elevation of consciousness to an apperception of reality which is both more true than that of the general materialist view and involves an openness to kinds of events which the general materialist view dismisses as impossible. The problem comes when the elevation of consciousness happens to someone who lacks sufficient preparation and/or whose ego and personality structures are not solid enough to deal with the fact and the ramifications of the elevation of consciousness and who thus loses the ability to regulate their own mind. The ability to regulate one's mind is particularly important in this higher consciousness -- which some traditions call non-dual and others subject-object-identity -- because it turns out the mind is not so limited by the physical body as the empiricist materialist consciousness believes. So havoc is easier to wreak if you're getting things wrong mentally. Anyway, mania and psychosis are manifestations of this kind of inability to regulate one's mind. As purely descriptive terms they aren't objectionable. But both are secondary effects of a phenomenon that is itself extremely positive and that our psychiatrists and our dominant culture do not accept. Indeed cannot see and categorize as a species of delusion when reported to about. (Actual delusion, which can be part of psychosis and involves accepting as true groundless ideas about matters of fact, is very bad. But spiritual awareness and insight is not delusional.)
The horror and tragedy of contemporary psychiatry is, that while psychiatrists don't know what they are dealing with, or what they are doing, they do have drugs which can stop, at least mania and psychosis. And they prescribe them liberally. However the strategy of these drugs is not to remove the manic or psychotic features, but rather to suppress consciousness to such an extent that the problems of self-regulation due to higher levels of consciousness do not arise. This is, one might say, to throw the baby out with the bathwater. And the destructiveness of psychiatric drugs on the mind and the soul cannot be overstated. They are just ruinous and deprive those who take them of what seems to me a fundamental human right to personal spiritual advancement. At the doses usually prescribed they also effectively prevent any kind of reflection on one's experience with the disorders that could lead to insight into what is actually going on.
Trusting the health of one's soul -- 'psyche' means soul in Greek -- to people who are professionally oblivious, even hostile, to the full reality of the soul is utter folly. But that is what our culture and its medical model has us doing. Only a major paradigm shift is going to help the field get un-"stuck".
(re Lutoslawski's disparaging remark about magic above: if you're really interested in what's happening with the so-called major disorders, trying to practice a little Wicca -- or other magic tradition -- is not a bad way to go. Phyllis Curott's guidebook Witchcrafting is a good read and puts forth an outline of a view of mind much closer to the truth than that entertained by mainstream psychiatry. Empirical science, so useful for so many things, will here just lead you astray.)
posted by bertran at 1:35 AM on May 18, 2021 [6 favorites]
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posted by atoxyl at 8:44 PM on May 16, 2021 [5 favorites]