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  Apr 29, 2012                  
     

me+ME+DSM-5: P.S. to my answers to Question 1 about psychiatry


Yesterday I uploaded DSM-5: Question 1 of "The six most essential questions in psychiatric diagnosis" which you also find by way of this or the above Previous and which is over 500 Kb of html, that contains all of the texts relating the orginal Question (which you'll also find on the Philosophy, Ethics, Humanities and Ethics site in several editions), together with my criticisms of and comments on the psychiatric commentators on this Question 1.

I wanted to do it well or not at all, and think I did it well - which means that I probably will be ignored, as this is the common faith of those who can write and think but don't publicly sport currently socially popular points of view - but doing it well, according to my own criteria, means taking up and answering most arguments and all fallacies (that are not self-evident as fallacies).

Also, I took the trouble of providing a table of internal links at the beginning of the text, that allows readers to easily pick and choose from the text and skip the rest.

I could say rather a lot more about my text, the difficulties of composing it with ill health (I always - at least since age 14 or so - could write down whatever I thought that interested me in what seemed to others an extremely fast pace, but this long review was rather exhausting with my disease, and indeed until a few months ago I spent several years I simply could not have done it and would not even have started on it) but will leave it but for the remark that I nearly always write to please my own intellectual conscience and standards, in the first place, rather than pleasing others or becoming popular.

So what's in this PS? The parts I did not do in yesterday's text, which are the replies of dr. Frances to his commentators 4 to 8 inclusive.This is mostly "for completeness' sake" and also to do justice to the one good point dr. Frances made in the whole discussion of Question 1, namely about dr. Pincus.

So here goes - and I'll repeat the texts I comment on - and note that these are dr. Frances' responses to his commentators that I did not treat yesterday, which you need to read to get most of what follows.

It may help that the titles of the replies contain links to the starts of the text of their authors, and my responses to them, that in any case are a lot longer than the responses of dr. Frances, and usually do not agree with him. And as in yesterday's text, what I quote is indented and in blue while my text is in black without extra indentation.


Reply to Dr Cerullo

How comforting to be a first umpire. I admire the magisterial confidence of Dr Cerullo's statement, "Most working scientists and philosophers would be classified as modern realists who believe there is an independent objective external reality". I wish I could feel so firmly planted in a "real" world and possess such naive faith in mankind's capacity to apprehend its contours. Alas, as I read it, the enormous expansion of human knowledge during the last hundred years is enough to make umpire 1's head spin with confusion. The more we learn, the more we discover just how much we don't (and perhaps can't) know. Einstein gave us a four dimensional world that even physicists have trouble visualizing. Then the string theorists made it exponentially more complicated by expanding the dimensions into double figures and introducing conceptions of reality that may or may not ever be testable. The quantum theorists describe a "spooky" (Einstein's term) and inherently uncertain world that lends itself to extremely accurate large n prediction, but totally defies our intuitive understanding of the specific mechanics. It also turns out that we are pathetically limited in our sensory capacities, even when they are extended with our most powerful sensing instruments. Evolution allows us to detect only 4% of our universe, the rest of energy and matter being "dark" to us. Indeed, there may be a vast multiplicity of multiverses out there and we may never know them. So I don't see human beings as having great status as judges of reality- we are like mice describing the proverbial elephant- having available only fallible and very temporary constructs.

To get back to our umpires, the connections between brain functioning and psychiatric problems are definitely real, but they are so complex and heterogeneous as to defy any simple "realist" faith that we are close to seeing them straight on, much less solving them.

Dr. Frances' an artificial opposition between two kinds of realists that does not apply to real science, that you find discussed yesterday. Here I am mostly concerned with dr. Frances' opinions and suppose yesterday's text known.

First then, I am a bit amazed to read

I admire the magisterial confidence of Dr Cerullo's statement, "Most working scientists and philosophers would be classified as modern realists who believe there is an independent objective external reality". I wish I could feel so firmly planted in a "real" world and possess such naive faith in mankind's capacity to apprehend its contours.

He is confusing several things, just as he also did in posing Question 1 as he did. In any case: The logical point here is that one may be a scientific realist while being quite skeptical about some realistic hypotheses, and in general one's rational confidence in theories will vary with the specific evidence and research that exists for them (as far as one knows).

Thus, one may be firmly convinced of the existence of a real world - and I think it is very wise if a medical doctor is, and will turn quite skeptical when meeting a doctor who is a solipsist or a relativist about facts - while doubting much of contemporary real science, at least if this were offered as "this is how it really is - science has uncovered all there is to be known about this matter".

Besides... if dr. Frances is so very skeptical about "mankind's capacity to apprehend its contours" he should be proportionally far more skeptical about the abilities and achievements of his kind of purported "scientist" and the abilities and achievements of physicists and bio-chemists, say.

But he doesn't seem to understand, or is waffling:

Alas, as I read it, the enormous expansion of human knowledge during the last hundred years is enough to make umpire 1's head spin with confusion. The more we learn, the more we discover just how much we don't (and perhaps can't) know.

He just manages not to mention the wisdom of Socrates, and seems to entirely forget or miss that "the enormous expansion of human knowledge during the last hundred years" (1) is not one a single mind achieved - not even one of the qualities of the average psychiatric mind, hard as this may be to accept - but the work of several tenthousands or hundreds of thousands of the best human mind (none psychiatrists, as it happens) and that (2) the key difference with what real sciences find in their research and experiments and what a pseudoscience like psychiatry claims to have "evidence-based science" about is that real science allows the creation of new human technology, the making of real artefacts Mother Nature did not supply ready made.

I'll skip dr. Frances' opinions on Einstein, quantum mechanics, and string theories: I know psychiatrist like to suggest they understand anything and seem to believe they can discuss anything whatsoever with a pretension of understanding all about it, but dr. Frances either has Leibniz's quality of mind or else doesn't know much physics. (In the former case, he really wasted his enormous talents. In the latter case, it may console him to know that he probably dies richer than Leibniz, and with more pall bearers.)

But I will take up this silly bit:

So I don't see human beings as having great status as judges of reality- we are like mice describing the proverbial elephant- having available only fallible and very temporary constructs.

Then how come humans can destroy most of the world by atomic weapons? Or warm up the world? Or asphalt a large part of Europe to drive cars on it? Or communicate with billions of others through the internet? Whence all the very many amazing technologies and artefacts discovered and created the last century? Or must I here suppose that dr. Frances is so much of a mock philosopher that he wants to insist that we do not really know any of that - the discoveries and technologies the real sciences produced the last hundred years - as all of it is at least as doubtful as "The Great Freud's" notions about "Moses and monotheism" or about when a cigar is just a cigar, and not a penis symbol? (Answer: When "The Great Freud'" sucks it.)

Dr. Frances concluding statement is also misleading:

To get back to our umpires, the connections between brain functioning and psychiatric problems are definitely real, but they are so complex and heterogeneous as to defy any simple "realist" faith that we are close to seeing them straight on, much less solving them.

The "umpires" were a silly-clever contraption to start and misdirect a discussion about fundamental issues, and the rest of the statement is a fallacy or misleading: A genuine scientific realist has no problem whatsoever with admitting he does not know enormous amounts of things he would like to know, that the current state of the real sciences cannot as yet unriddle. And if dr. Frances only meant to convey he is not convinced there will be a biologically or bio-chemistry founded psychiatry within the next 5 to 25 years, he should have said that.

Drs Wakefield and Pouncey have made many of the same important points. Dr Wakefield's "humble realism" (associated with an honest and flexible willingness to admit fallibility and the possibility of error) works for a great baseball umpire and is not a bad model for a psychiatric diagnostician. The difference between umpire 2 and umpire 1.5 depends on how close you think our field is to understanding the reality of psychopathology. I am even more humble than Dr Wakefield and will stick with umpire 2.

My own impression was that Dr Wakefield was mostly waffling, and that "umpire 1.5" is a typical instance of what The Great Freud's fellow Austrians might have described as "falsche Spitzfindigkeit".

In any case: The whole "umpire" talk managed to make nearly all of the discussion of Question 1 a metaphorical mess with lots of posturing

I agree.

As the reader may find by following the last underlined link, I do not, but Dr Pierre did flatter Dr Frances, and does know how to slickly twist and turn through an argument like a psychiatric pro, and also knows how he may convey anything by subtle abuse of "may" and "might".

In defending Umpire 3, Dr Greenberg assumes a grandly, neutral view of man's place in the world and makes clear how limited are our abilities in naming and classifying its manifestations. Greenberg rightly suggests that the distinction between a broken branch and a broken femur may be extremely meaningful to the patient and his doctor, but is really trivial in the grand scheme of an indifferent nature. He might equally have pointed out that from a bacteria's perspective, pneumonia is not a disease- it is just an opportunity for a good feed. Diseases, according to Greenberg's argument, are no more than human constructs made up de novo by us as inherently self interested third umpires.

From Greenberg's lofty perch, mankind's attempts to label do seem pathetically self referential and solipsistic, extremely limited in their apprehension of reality (even assuming that there is a graspable reality ready to be apprehended). But it seems to me that his level of philosophic detachment works only in the exalted theoretical realms, and contrary (to his statement) fails badly to do justice to the needs and opportunities of our everyday, "common sense" world.

As the reader may find by checking my response to Dr Greenberg, I think that his argument is partially mistaken, but also is not what dr. Frances makes of it.

Greenberg and I do agree completely on several points: 1) if mother nature had the gift of speaking our language and the motivation to do so, she would probably indicate she couldn't care less about our names and that she doesn't feel particularly well described by them; 2) our categories are no more than tentative approximations and are subject to distortion by personal whims, cultural values local to time and place, ignorance, and the profit motive; and, 3) psychiatry's names should be used with special caution because they lack strong external validators, carry great social valence, and describe very fuzzy territorial boundaries.

I think this not very subtly misses the moral points of Dr. Greenberg.

Where my umpire 2 position differs from Greenberg's umpire 3 is in our relative estimations of how closely our names and constructs can ever come to approximating an underlying reality. My umpire 2 position is skeptical about umpire 1's current ability "to call them as they are" and advises modesty in the face of the brain's seemingly inexhaustible complexity. But I remain hopeful that there is a reality and that, at least at the human level, it will eventually become more or less knowable. We may never fully figure out the origin and fate of the universe or the loopy weirdness of the quantum world. But the odds are that decades (or centuries) of scientific advance will gradually elucidate the hundreds (or thousands) of different pathways responsible for what we now crudely call "schizophrenia".

This is not easy to consistently combine with dr. Frances' response to dr. Cerullo.

Greenberg is more skeptical than I about the progress of science and is, at heart, a platonic idealist who finds life cheapened by excessive brain materialism.

He might be, but I didn't see the slightest whiff of evidence for this stance in his prose.

He sees psychiatric disorders as no more than human constructs - metaphors, some of which are useful, some harmful. His umpire 3 does not does not believe the glory and pain of human existence can or should be completely reduced to the level of chemical reactions or neuronal misconnections. This is a fair view for poets and philosophers (and Greenberg is both), but I see a ghost in his machine and dispute that allowing it in makes "common sense".

I don't think Dr Greenberg thinks or said or suggested what Dr Frances attributes to him. I grant Dr Greenberg was confused by Dr Frances' metaphors, but then these really are confusing.

But rather than being concerned with the ultimate knowledge of reality, I took it that Dr Greenberg's real concern was the moral insufficiency of psychiatry as is to do the sort of paid job it pretends to be able to do, because it lacks the requisite knowledge to do it as pretended.

Thank you for inventing the fourth umpire. Dr Pincus is the most practical of men and he has created a handy metaphor for describing the ultimate goal of any DSM- to be useful to its users. 

The invention was of another bit of confusing, misleading and ambiguous baloney and to read that "the ultimate goal of any DSM- to be useful to its users" manages, just like the "pragmatic" Dr Pincus managed to do, to forget everything about the patients of psychiatry. Then again, that seems a psychiatric professional sort of disease (or "disease" or even "disorder" if you insist), so I should not be amazed.

Then again, Dr Frances does have one good point:

There is only one problem with the fourth umpire's position- but it is a big one. There is no external check on his discretion, no scientific or value system that guides what is useful. Everything depends on the skill and goodwill of the umpire. 

Quite so, except for the supposed lack of a "value system": It's precisely the point - or one of them - of Dr Pincus "pragmatism" that he gets to say what is "useful" and indeed only he will have a  "pragmatic" say as to what is and what isn't (all quite miraculously - for the trained logical mind - without using "useless" notions like "truth" or "validity" that a mind of the size of dr. Pincus sees no use for, in psychiatry).

But Dr Frances has seen this also:

In the wrong hands pragmatism can have dreadful consequences- commissars who treat political dissent as mental illness or judges who psychiatrically commit run of the mill rapists to keep them off the streets. But to ignore the practical consequences of psychiatric decisions leads to its own set of abuses- most recently diagnostic inflation and excessive treatment.


So... I have done this as well and have finished what I set out to do as regards Question 1: Give my rational and informed if sometimes a bit satirical rebuttals to a lot of psychiatric posturing and nonsense, seasoned - as seems the way of psychiatry, so far, and since 100 or 150 years - with a few crumbs of sense and even with incidental real facts.

I do not yet know when I will consider the other questions in the series, but I intend to do so if my health allows it, for I have excellent personal, moral, intellectual, philosophical and legal reasons to be exceedingly angry with some psychiatric frauds, as explained in the beginning of my The six most essential questions in psychiatric diagnosis - 0 and I have meanwhile also found that psychiatry is not a real science, and that it therefore should be terminated in the way in which it is practised, because its theories are mostly bogus, bullshit or delusion, and its practicians are often very dishonest in pretending to have knowledge about the working of the human mind they simply do not have, as there simply is hardly any good knowledge how the human brain generates human experience.

Psychiatry is very much more like bad philosophy, bad religion or quackery than it is like real science. It should not be in real medicine, and should not be practised in the way it is: For money, without real knowledge, on unsuspecting patients, as unable to see through bad philosophy or religion as they are able to see through bad science.




P.S.
Corrections, if any are necessary, have to be made later.
-- April 30, 2012: Made some corrections and added some links and the last paragraph.

 

As to ME/CFS (that I prefer to call ME):
1.  Anthony Komaroff Ten discoveries about the biology of CFS (pdf)
2.  Malcolm Hooper THE MENTAL HEALTH MOVEMENT: 
PERSECUTION OF PATIENTS?
3.  Hillary Johnson The Why
4.  Consensus of M.D.s Canadian Consensus Government Report on ME (pdf)
5.  Eleanor Stein Clinical Guidelines for Psychiatrists (pdf)
6.  William Clifford The Ethics of Belief
7.  Paul Lutus Is Psychology a Science?
8.  Malcolm Hooper Magical Medicine (pdf)
9.
 Maarten Maartensz
ME in Amsterdam - surviving in Amsterdam with ME (Dutch)
10.
 Maarten Maartensz Myalgic Encephalomyelitis

Short descriptions of the above:                

1. Ten reasons why ME/CFS is a real disease by a professor of medicine of Harvard.
2. Long essay by a professor emeritus of medical chemistry about maltreatment of ME.
3. Explanation of what's happening around ME by an investigative journalist.
4. Report to Canadian Government on ME, by many medical experts.
5. Advice to psychiatrist by a psychiatrist who understa, but nds ME is an organic disease
6. English mathematical genius on one's responsibilities in the matter of one's beliefs:

7. A space- and computer-scientist takes a look at psychology.
8. Malcolm Hooper puts things together status 2010.
9. I tell my story of surviving (so far) in Amsterdam/ with ME.
10. The directory on my site about ME.



See also: ME -Documentation and ME - Resources
The last has many files, all on my site to keep them accessible.
 


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