There’s something odd about how psychiatry defines mental disorders—namely, by their symptoms. It’s to be expected, on some level. After all, how else could doctors diagnose psychiatric disorders, if not, in part, by their symptoms? The problem, though, is that in medicine, a cluster of symptoms isn’t usually what defines the disorder. Illnesses are identified by the underlying condition that causes the symptoms. And for good reason.
What is it
The Diagnostic and Statistical Manual is the primary reference catalog for mental health illnesses. But whereas a medical textbook will show you the picture of a broken bone or a tumor, leaf through the DSM and you will find just one thing: lists of symptoms. Who creates these lists, and based on what criteria? Do such lists really capture the nature of a mental illness? What does it mean to be a disease of the mind versus a disease of the body? Does our classification system construct mental illness, or does it reveal underlying facts from genetics or neuroscience? John and Ken diagnose the issues with Jerome Wakefield from NYU, co-author of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder.
John and Ken begin the show by discussing the field of psychiatry and how, if at all, it can be called a science. John contends that it’s something rather different than is medicine because it describes disorders by their symptoms rather than by their causes. Pushing back, Ken suggests that the mind is yet opaque to us and that as a young field, maybe symptoms are the best psychiatry can do right now. It’s gotten things wrong from time to time, sure, but we can’t throw out the baby with the bathwater. But John sees it differently. Influenced by insurance companies, drug companies, and the like, he sees the DSM as much as a political document as a scientific one.
The two are joined by Jerome Wakefield, co-author of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder and Professor of Social Work and of the Conceptual Foundations of Psychiatry at NYU. Wakefield shares that his interest in the field began at the time of the anti-psychiatric revolution of the ‘60s and ‘70s. He set out then to defend the field from attacks of being an instrument of social control, but also to make a framework to be able to critique its overuse.
Describing what he calls the hybrid approach, Wakefield explains how his conception combines the value-judgment and scientific-judgment views of psychiatry. For him, a disorder is such only when a person is experiencing some harm from it and when it is caused by a dysfunction, where something inside the mind isn’t functioning as it was evolutionarily designed to. The three then consider some examples, probing the strength of Wakefield’s “evolutionarily designed” criteria. All agree that there is a fine balance to be found between the scientific and social perspectives.
In the final segment of the show, John and Ken turn over to Wakefield the DSM’s editorial reins. His plan, he tells us, would be to perform a conceptual analysis of each disorder’s criteria to identify how they differ from things that may look very similar but in reality are quite normal. He also says that he would involve context. You can’t tell what’s going on inside without looking at the context within which it’s occurring. Though Ken is left with even more skepticism about psychiatry’s standing as a science, referring to it more as a Tower of Babel between psychiatrists, caller Chris prompts Wakefield to share his main takeaway, ending the show on a good summary note: context.
Roving Philosophical Reporter (seek to 6:07): Speaking with author Ethan Watters, Shuka Kalantari finds that after much media attention to the ‘80s death of an anorexic girl in China, Chinese reporters’ focus on western accounts of anorexia shifted the population and symptoms of those diagnosed with anorexia in China. Waters reports that for American, the current “fad” is PTSD. It’s difficult for Americans to realize that something can be very real and at the same time shaped so heavily by culture.
60-second Philosopher (seek to 46:50): Unshaven and wearing a bathrobe, Ian Shoales thinks out loud about what his neighbors or loved ones might judge of his mental health after seeing his daily ways at home.