Welcome to the seventh international conference on brain disorders and therapeutics held in September 2019 in Brussels.
My name is Sam Vaknin. I'm the author of Malignant Self-Love, Narcissism Revisited, and a series of other books about personality disorders. I'm a professor of psychology in Southern Federal University in Rostov-on-Don, Russia, and a professor of finance and a professor of psychology in SIAS-CIAPS, the Centre for International Advanced and Professional Studies.
Today I would like to make a video presentation about mental illness. Is it indeed a myth, as the anti-psychiatry movement claims, or is it a clinical entity or a series of clinical entities which can objectively be described, measured, and tackled?
This is an open debate that's been going on for well over three or four hundred years, and I don't presume to resolve it single-handedly in this video presentation, but I hope to raise a few interesting points which may lead to some provocation of thought.
Ever since Freud and his disciples, the process of medicalization of what was until then known as sin or wrongdoing started. As the vocabulary of public discourse shifted from the religious to the scientific, offensive behaviors that constituted transgressions against the divine or against the social order, these behaviors have been relabeled, pathologized, and medicalized.
Self-centredness and dysentopic egocentricity have now become pathological narcissism. Criminals have been transformed into psychopaths, and their behavior, though still described as antisocial, now came to be the almost deterministic outcome of a deprived childhood or a genetic predisposition to a brain chemistry, gone awry.
And of course this process of medicalization cast doubt the very existence of free will and free choice between good and evil.
The contemporary science of psychopathology now amounts to a godless variant of Calvinism with a kind of predestination by nature or by nature.
But before we delve into this deep philosophical, deep and unresolved philosophical issues, it behooves us to try to define who is mentally ill.
For someone who is mentally ill, if his conduct rigidly and consistently deviates from the typical average behavior of all other people in his culture and society that fit his profile, it's immaterial whether his behavior is conventional or moral or rational.
The test is a test of comparison. A mentally ill person, his judgment and grasp of objective physical reality is impaired, so there's a problem with reality testing. His conduct is not a matter of choice and is innate and irresistible, his behavior causes him or others discomfort and it is dysfunctional, self-defeating and self-destructive even by his own yardsticks and standards.
But these are all descriptive criteria.
What is the essence of mental disorders? Are they merely physiological disorders of the brain or some disturbances in the brain's chemistry? Are mental health disorders, can they be cured by restoring the balance of substances and secretions in this mysterious organ, the human brain cortex, neocortex?
Once a equilibrium is reinstated in the brain, is the illness gone or is it still lurking there under wraps waiting to re-erupt? Are psychiatric conditions inherited, rooted in faulty genes, though amplified by environmental factors here in the formative years? Or are they brought about by abusive or wrong nurturance and upbringing?
These questions are the domain of the medical school of mental health, but there are other schools. Other mental health practitioners cling to the spiritual view of the human psyche. They believe that mental ailments amount to the metaphysical discomposure of an unknown medium, the soul. Theirs is the holistic approach taking in the patient in his upper entirety, as well as the patient's view.
Of course, there's a compromised school, the dualistic school, which is both medical and spiritual.
And finally, there's the functional school. Its members regard mental health disorders as disturbances, perturbations in the proper statistically normal behaviors and manifestations of healthy individuals.
This functional school regards mental illnesses as dysfunctions, by definition.
The second individual, he let ease with himself because his stomach or making others unhappy with his deviant behavior, this individual is mended, fixed, healed, when rendered functional again by the prevailing standards of his social and cultural frame of reference.
In a way, all three schools, the medical, the spiritual and the functional, are akin to the trio of blind men who rendered disparate descriptions of the very same elephant.
Instead, the three schools share not only the subject matter, but counterintuitively to a large degree, a faulty methodology.
As the renowned anti-psychiatrist, Thomas Szasz, of the State University of New York, noted in the article, The Lying Truths of Psychiatry, mental health scholars, regardless of academic predilection, infer the etiology of mental disorders from the success or the failure of treatment modalities. This is a form of reverse engineering. The same form of reverse engineering of scientific models is not unknown in other fields of science, nor is it unacceptable if the experiments meet the criteria of the scientific method.
The theory must be all-inclusive, analytic, must be consistent, must be falsifiable, biologically compatible, monovalent, or harmonious, etc.
Psychological theories, even the medical ones, for example, the theory about the role of serotonin and dopamine in mood disorders, all these theories are usually none of these things.
The outcome is a bewildering array of ever-shifting mental health diagnosis, expressly centered around Western civilization and its standards.
For example, Western civilization objects ethically to suicide, so anyone who tries to commit suicide is depressed, is pathologized. Neurosis, a historically fundamental condition, vanished after 1980. Homosexuality, according to the American Psychiatric Association, used to be a pathology prior to 1973, and a year later, became a methodically acceptable behavior. Seven years later, narcissism was declared a personality disorder almost seven decades after it had been first described by Sigmund Freud. Prominent psychiatrists have taken to accusing the committee of the Diagnostic and Statistical Manual that is easy writing the text, of pathologizing large swaths of the population.
Internet addiction is now a pathology, even coffee consumption.
In an article published in New Scientists entitled Psychiatry Civil War, December 2009, you could find this paragraph.
Two eminent retired psychiatrists are warning that the revision process is fatally flawed. They say the new manual, to be known as the Diagnostic and Statistical Manual 5, Edition 5, has been published already in 2013, will extend definitions of mental illnesses so broadly that tens of millions of people will be given unnecessary and risky drugs.
Leaders of the American Psychiatric Association, which publishes the manual, have been accusing the care of psychiatrists of being motivated by their own financial interests, a charge which they, of course, deny.
Perhaps the two tests of whether a set of cognitions and notions and behaviors constitutes a clinical entity should be, one, invariance. Is it considered a mental illness across all cultures, all periods of history, all societies? If it is, chances are that we are dealing with an objective ontological, immutable diagnosis.
And the second test is, is it the outcome of an egosyntonic personal philosophy or ideology?
In other words, does the patient feel utterly comfortable with his so-called condition? Is it happy? Is he functional?
If he is, chances are that this is a culture-bound syndrome, not a mental illness, that it is the judgment of society, that it is the result of social mores which are ever shifting and ever changing.
Consider, for example, personality disorders. Personality disorders are an excellent example of a kaleidoscopic landscape of so-called objective psychiatry.
The classification of Axis II personality disorders deeply ingrained, maladaptive, lifelong behavior patterns in the Diagnostic and Statistical Manual, the fourth edition text revision, which was published in the year 2000.
This classification has come under sustained and serious criticism from its inception in 1952 in the first edition.
The Diagnostic and Statistical Manual, including the fifth edition, adopted a categorical approach postulating that personality disorders are quantitatively distinct clinical syndromes.
This is widely doubted. Even the distinction made between normal and disordered personalities is increasingly being rejected.
The diagnostic thresholds between normal and abnormal are either absent or very weakly supported.
The polythetic form of the DSN's diagnostic criteria, in other words, the fact that only a subset of the criteria is adequate grounds for diagnosis, these generate unacceptable diagnostic heterogeneity.
In other words, we can have two people diagnosed with the same personality disorder, but they share almost nothing in, they have nothing in common except a single diagnostic criteria.
Imagine two people with tubercleosis who have nothing in common except coffee. It's utterly unacceptable.
The Diagnostic and Statistical Manual, edition five, adopted the language of edition four. It suggests, it proposes alternate models, which are dimensional, but still the categorical diagnostic criteria are there.
The Diagnostic and Statistical Manual fails to clarify the exact relationship between Axis two and Axis one disorders and the way chronic childhood and developmental problems interact with personality disorders.
The differential diagnosis are vague. The personality disorders are insufficiently demarcated.
The result is, of course, excessive comorbidity, multiple Axis to diagnosis in the same patient.
The DSM contains little discussion of what distinguishes normal character, normal personality, personality traits, or what Millon called personality styles from personality disorders.
And there's a dearth of documented clinical experience regarding both the disorders themselves and the utility of various treatment modalities.
The end result is that numerous personality traits and behaviors, so-called disorders, are not otherwise specified, the catch all basket category.
A way of saying we don't know what we're talking about.
And cultural bias is evident in certain disorders, such as antisocial, schizotypal, or histrionic personality disorders.
And so the emergence of dimensional alternatives to the categorical approach is acknowledged even in the Diagnostic and Statistical Manual edition four.
It says, an alternative to the categorical approach is a dimensional perspective.
The personality disorders represent maladaptive variants of personality traits merge imperceptibly into normality into one another.
This is a shocking piece of text. It says that we cannot clearly distinguish normality. We cannot clearly distinguish adaptive personality traits from maladaptive ones and from disorders.
The following issues, long neglected in the DSM, are likely to be tackled in future editions, as well as in current research, but their omission from official discourse is startling, shocking and telling.
What is the longitudinal course of the disorder? What is the temporal stability from early childhood onwards? No one knows. What's your genetic and biological? What are the genetic and biological underpinnings of personality disorders? No one knows with the exception of psychopathy.
The development of personality psychopathology during childhood and its emergency adolescence is not clearly described with at all.
The interactions between physical health disease and personality disorder is very unclear.
The effectiveness of various treatments, talk therapies, as well as psychopharmacology is utterly neglected.
And this is only one sub field.
And so what is the biochemistry and genetics of mental health? Can't we rely on these utterly objective markets to begin to rebuild a science rather than a set of taxonomies?
Certain mental health afflictions are either correlated with a statistically abnormal biochemical activity in the brain or are ameliorated with medications that alters this biochemistry.
Yet the two facts are not in eluded belief facets of the same underlying phenomenon.
What I'm trying to say is that a given medicine reduces or abolishes certain symptoms, but that does not necessarily mean that they were caused by the processes or substances affected by the drug administered.
Causation is only one of many possible connections and chains of events.
Remember the famous sentence? Causation is not correlation. We did not establish a causative chain in any of the mental health disorders that I'm aware of.
To designate a pattern of behavior as a mental health disorder is a value judgment or at best a statistical observation. Such designation is affected regardless of the facts of brain science.
Moreover, the chances, the correlation, and the causation, the deviant brain or body biochemistry, these do exist. There is no debate about that. They were once called polluted animal spirits.
The knowledge is very old, but are they truly the roots of the mental perversion?
This is what's not clear. No one is disputing the existence of, for example, biochemical imbalances. But is it clear what triggers what? For example, do we know if the aberrant neurochemistry, aberrant neurochemistry or biochemistry causes the mental illness? Or maybe the mental illness causes the imbalances in the brain? We don't know.
That psychoactive medications alter behavior and mood is indisputable, but so do illicit or legal drugs.
Even foods alter mood and behavior. And, of course, interpersonal interactions and connections.
The changes brought about by prescription are desirable is the core of the debate. It's debatable and it involves tautological thinking.
If a certain pattern of behavior is described as socially dysfunctional or psychologically sick, clearly every change would be welcomed as healing and every agent of transformation would be called a cure.
The same applies to the alleged heredity of mental illness.
Single genes or gene complexes are frequently associated with mental health diagnosis, with personality traits, or with behavior patterns.
But too little is known to establish irrefutable sequences of cause and effect. Even less is proven about the interaction of nature and nurture, genotype and phenotype, the plasticity of the brain and the psychological impact of trauma, abuse, upbringing, role models, fears, and other environmental elements.
We know close to nothing. It is hubris. It is vanity. It is indeed narcissistic grandiosity to claim otherwise.
Nor is a distinction between psychotropic substances and talk therapy that clear-cut words and the interaction with the therapist also affect the brain, also affect the processes in the brain, its chemistry, neural pathways, albeit more slowly and perhaps more profoundly and irreversible.
Medicines, as David Kaiser reminds us in Against Biological Psychiatry, medicines treat symptoms, not the underlying processes that heal them.
Remember the criteria that I suggested?
The first criteria was invariance. If mental illnesses are bodily, if mental illnesses are empirical, if they are clinical entities, they should be invariant both temporally and spatially across cultures, across societies in all periods of history.
And this to some degree is indeed the case.
Psychological diseases are not context-dependent, but the pathologizing of certain behaviors is culture-bound and context-dependent.
Consider, for example, suicide, substance abuse, narcissism, eating disorders, antisocial ways, schizotypal symptoms, depression, or even psychosis. They are all considered sick by some cultures and utterly normative or even desirable and advantageous in other cultures.
And this was to be expected. The human mind and its dysfunctions, it's alike around the world, but values differ from time to time and from one place to another.
Hence disagreements about the propriety and desirability of human action and inaction are bound to arise in a symptom-based diagnostic system.
When you make lists, there will be those who disagree with you. There will be cultures, societies, periods in history where these lists cannot apply, would not apply.
As long as the pseudo-medical definitions of mental health disorders continue to rely exclusively on signs and symptoms, mostly on observed and reported behaviors, they, these definitions, remain vulnerable to such discord and devoid of much sought universality and regal.
One could say that mental disorders are intricately and intimately connected to the social order.
The mentally sick receive the same treatment as carriers of AIDS or the Ebola virus or smallpox. They are sometimes guaranteed against their will and coerced into involuntary treatment by medication, psychosurgery, or electroconvulsive therapy.
This is done in the name of the greater good, largely as a preventive policy.
Preemption, prophylactic, conspiracy theories notwithstanding, it is impossible to ignore the enormous interest, enormous financial interest vested in psychiatry and psychopharmacology.
The multi-billion dollar industries involving drug companies, hospitals, managed healthcare, private clinics, academic departmentsand law enforcement agencies relying for their continued and exponential growth on the propagation of the concept of mental illness and its corollaries, treatmentand research.
When the Diagnostic and Statistical Manual was first published in 1952, it had a bit over 100 pages. Now it's nine times larger.
In Psychiatry: Civil War, the same article I quoted about in The New Scientist, there is this paragraph.
The wording used in the Diagnostic and Statistical Manual has a significance that goes far beyond questions of semantics.
The diagnosis it enshrines, what treatments people receive and whether health insurance will fund these treatments.
They can also exacerbate social stigmas and may even be used to deem an individual such a grave danger to society that they are locked up.
Some of the most eprimonious arguments stem from worries about the pharmaceutical industry's influence over psychiatry. This has led to the spotlight being turned on the national ties of those in charge of revising the manual and has made any diagnostic changes that could expand the use of drugs, especially controversial.
But you see, mental illness, though intimately connected with the social order, is also a metaphor.
You do remember that in the Soviet Union, dissidents were locked up in mental asylum, involuntarily committed by psychiatrists in order to maintain the social order and for the greatest social good.
But mental health is a metaphor across cultures and societies.
Abstract concepts form the core of all branches of human knowledge. No one has ever seen a core in physics or entangled a chemical bond with his hands or surfed an electromagnetic wave or visited the unconscious. These are all abstract concepts. These are useful metaphors, theoretical entities with explanatory and descriptive and predictive power.
Mental health disorders are no different. They are shorthand for capturing the unsettling quiddity of the other.
Useful as taxonomies, they are also tools of social coercion and conformity, as Michel Foucault and Louis Althusser observed.
Althusser actually ended up in a mental asylum.
Relegating both the dangerous and the idiosyncratic to the collective fringes is a vital technique of social engineering and social control.
The aim is progress through social cohesion and the regulation of innovation and creative destruction.
Psychiatry, therefore, is a reifies society's preference of evolution to revolution.
Worse still, psychiatry is perceived as preventing nature or anarchy. As is often the case with human endeavor, it is a noble cause.
Psychiatrists and psychologists, the vast majority of them, are committed to helping people.
And stroke is striplessly pursued with the most pure motives.
But it is dogmatic. It is doctrinaire. In decent psychiatry resembles religions, existing established religions, much more than it resembles a science.
Another useful metaphor is to consider mental illness as a kind of self-perpetuating viral organism, which injects negative statements into the mind of the patient.
And that's a nod to cognitive behavioral therapy, of course.
Like every organism, this virus known as mental illness strives to perpetuate its existence, to transfer its genes, its life-negating, dysfunctional, and self-defeating theorems, and to fend off its enemies.
Often, the patient reports feeling invaded or body snatched by his own disorders, which he experiences as alien to his core or to his essence. These are introjects.
This is what psychiatrists and psychologists tell their patients, that they should feel.
And the impact and influence of a therapist on his patient have been described long ago. Remember transference?
And so, perhaps at the very core of psychotherapy, there is an unhealthy interaction, truly unhealthy, not as a mere abstract, not as a mere social convention, but a truly unhealthy exchange of social coercion via the agency of the therapist.
When the patient tries to comply and conform to social expectations as pervade and conveyed via the psychiatrist or the psychologist, it is a process of late-onset socialization and acculturation and conformity.
Any dictatorship will be proud of it. Thank you.