Just as the American Psychiatric Association’s (APA) long-delayed DSM5 was about to launch, the director of NIMH, Dr Thomas Insel, provoked a flurry of acrimony when he mentioned in his blog that his organisation intended to move away from the ideas behind DSM: “Patients with mental disorders deserve better… NIMH will be re-orienting its research away from DSM categories… we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system”1. It now seems Insel’s comments had more to do with NIMH funding needs than points of principle. After a bit of scuffling behind the scenes, NIMH and APA settled their differences2 and the DSM party went ahead. However, the affair raises a critically important issue in psychiatry
Over the past few years, NIMH has undertaken a carefully directed campaign to garner support for its new Research Domain Criteria project (RDoC). This consists of a determined effort to cast the whole of mental disorder as a problem of brain pathology: “First, the RDoC framework conceptualizes mental illnesses as brain disorders… Second, (it) assumes that the dysfunction in neural circuits can be identified with the tools of clinical neuroscience…. Third, (it) assumes that data from genetics and clinical neuroscience will yield biosignatures that will augment clinical symptoms and signs for clinical management.”3. The whole project is very long term and even initial results are not expected in under a decade but the authors were convinced of its direction: “Our expectation, based on experience in cancer, heart disease, and infectious diseases, is that identifying syndromes based on pathophysiology will eventually be able to improve outcomes.” Clearly, the validity of these three base assumptions is critical to the success of the RDoC program.
As outlined in this and a considerable number of other papers in a wide variety of journals, the RDoC program will consume the majority of NIMH budgets for many years to come. It will dominate research in mental disorder, shifting efforts away from matters of psychology to fundamental brain processes. One would therefore expect that the theoretical orientation underlying such a massive expenditure of public money, not to mention the lives of the mentally-troubled and the careers of a generation of professionals, would have been charted in very precise detail.
However, in checking a list of these papers, something became very obvious. The papers were written by a group of the most senior officers of NIMH, supported by the APA and WHO. They were also placed in a broad range of non-psychiatric journals, including Nature and the abstruse Journal of Clinical Investigations, as though aimed at the broadest possible medical/biological audience. The most remarkable feature, though, was the complete absence of anything that would amount to a justification of the (many) authors’ fundamental claim, that a full understanding of the brain will give a full understanding of mental disorder, with no questions unanswered. These papers give the strong impression that they were designed to sway opinion by appeals to authority rather than to convince by weight of evidence from the literature. This, of course, is the exact antithesis of the scientific method.
For any field that claims to be scientific, there are certain fundamental and inviolate rules to follow. They tell us where we can look, what counts as evidence, what procedures are acceptable, and so on. And one of the most important rules of all is this: In science, there is no such thing as a final authority. Where there is uncertainty, we can say that the weight of scientific opinion favours this or that conclusion but the unwavering basis of empirical science is that any opinion can be overturned by further evidence. That’s what empirical means. So in such an important matter, the future direction of the next thirty or forty years of psychiatric research, one would expect that nothing would be left to chance. Every effort should be made to ensure that, given our present state of knowledge, the validity of the chosen path is beyond question. Unfortunately, that is not the case.
My preliminary survey showed that not one of the many authors (e.g.; reference  has nine) cited anything that would amount to a justification of the basic, biological claim. This struck me as bizarre, so I rechecked the dozen or so NIMH papers, then followed each author back through the literature for about ten years, but still there was nothing. It seems that, among our ‘key opinion leaders’, the question of the ultimate nature of mental disorder is regarded as settled: it is biological, and the ordinary “…tools of clinical neuroscience, including electrophysiology, functional neuroimaging, and … data from genetics…” will tell us everything we need to know. But where is the proof?
Perhaps we should just accept this and go with the flow, as they say, but I had experience of something similar in the past. In 1998, I published a paper which showed that George Engel’s so-called ‘biopsychosocial model,’ beloved of British, Canadian and Australian psychiatrists, didn’t exist. Alerted by the way everybody used the term but nobody ever provided proper references, I trolled through practically everything Engel had ever written, plus dozens of papers that cited him, to find that he had never written the model at all. It is an urban myth so, as a justification for what psychiatrists do, it has all the authority of a fond dream. Perhaps the claims of biological psychiatrists were of the same order, a self-reinforcing belief that had simply become part of the wallpaper in the world of psychiatry, handed from generation to generation just as we hand on our notion of what is the best football team. I decided to search the literature methodically to see if anybody had ever provided anything to justify the NIMH stance.
A PubMed search yielded nothing of interest, so I searched the contents of the major English language journals for the eleven years January 2001 to December 2011, looking for papers that could possibly provide a formal justification of the claims of biological psychiatry. The task of systematically searching every paper published in that period is beyond an individual, and would constitute a serious drain on the resources of even a hundred people. I started with thirteen journals but dispensed with two of them straight away (the Canadian and Australasian journals) as I know they do not publish this kind of material. Full details of the remaining eleven journals are given in the paper4. Through a friend, I was able to obtain copies of anything interesting that was not in those journals so my coverage, while not entirely systematic, was exhaustive – and exhausting. By the end, I was doing little more than staring glassy-eyed at the thousands of pages of basic biological research.
In eleven years, these journals published some 19,234 original research papers, reviews, surveys, editorials, opinions and commentaries, filling something like 154,000 pages of 1465 issues. This did not include correspondence, historical or other topics as they seemed unlikely to be the bearers of monumental news. And be in no doubt: a proof of the claim that biology is all in mental disorder would be monumental, on a par with any major scientific discovery in the past few centuries. Trouble is, I found nothing in this extensive search of the literature that could be taken as a justification of the notion that mental disorder is fundamentally biological in nature. As of 2013, the whole edifice of orthodox or mainstream psychiatry rests on a mantra, something that has the form of a scientific statement but is factually empty, devoid of content. Instead of Insel’s claim that mental disorder can be seen as a form of brain pathology, only this fact has been established: There is nothing in the recent psychiatric literature that amounts to a formal, articulated, publically available, tested and proven biological model of mental disorder.
I concluded that the notion of biological psychiatry is no more than an ideology, supported by people who believe fervently in its truth but who cannot prove their beliefs: “As they stand, these papers represent firmly-held, highly partisan opinions with no convincing basis. They use rhetorical language to present an excessively simplified and one-sided view of a complex question in such a manner as to induce people to think that the matter has been resolved when, in fact, it has not. That is, while failing the criteria for scientific literature, they satisfy the definition of propaganda”4. Essentially, biological psychiatry is an urban myth.
Where does this leave us? Throughout the world, hundreds of millions of people are being “treated” according to a model of mental disorder that doesn’t exist. Moreover, the psychiatric establishment that controls the flow of research money has decided to commit it to a direction that lacks anything like a scientific warrant. We can be sure that junior researchers will dance to their tune on the basis that anything so important as the nature of mental disorder will surely have been sorted out by their elders and betters. They may point to the opinions of, say, the neurophysiologist, Eric Kandel5 but nothing could be further from the truth.6
The burden of proof of the claims of biological psychiatry rests with those who make them. In the absence of proof, we can say that mainstream psychiatry has failed its most basic scientific duty. I seriously doubt that there has ever been anything quite like it in the history of western science.
2 Lieberman J, 2013. DSM5: Setting the Record Straight. Medscape, May 2013. (online by subscription).
3 Insel TR et al, 2010. Research Domain Criteria (RDoC): Toward a New Classification Framework for Research on Mental Disorders. Amer J Psychiat 167: 748-751
4 McLaren N, 2013 Psychiatry as Ideology. Ethical Human Psychol Psychiat 15: 1-11.
5 Kandel ER, 2005. Psychiatry, psychoanalysis and the new biology of mind. Washington: APA Publishing.
6 McLaren N, 2008. Kandel’s ‘New Science of Mind’ for Psychiatry and the limits to biological reductionism: a critical review. Ethical Human Psychol Psychiat; 10: 109-121. Expanded version: Defining limits to biological psychiatry. Ch. 1. of McLaren N, 2009. Humanizing Psychiatry: The Biocognitive Model. Ann Arbor, Mi.: Future Psychiatry Press.
Jock McLaren is an Australian psychiatrist who worked 25yrs in the remote north of the country. He occupies himself delving into the philosophical basis of psychiatry, only to find there isn’t one. This has not helped his popularity with his colleagues, now well into negative territory. related posts: