Creating Mental Illness

Allan V. Horwitz

Reviewed by Mira de Vries

Horwitz is one of those tantalizing authors (see also: Blok, Blom, Boyle, Caplan, Thomas, Walker) in the field who exposes the folly and fraudulence of psychiatric diagnoses, yet fails to follow his own views to their logical conclusion. Below are some of his own persuasive arguments questioning the validity of the foundation of psychiatry and psychotherapy:

  • “Contrary to its definition of mental disorder, a basic principle in the DSM definitions of particular disorders is to avoid inferences about the causes of symptoms.”
  • “The reasons for the proliferation of mental illnesses lie in the historical development of the psychiatric profession over the course of the twentieth century.”
  • “[T]he grounds for inclusion of the conditions found in the DSM-III, and perpetuated in the DSM-II-R and DSM-IV, did not stem from either theory or research but from the need to maintain the existing clientele of mental health professionals.”
  • “Through discarding etiology as a means of classification, the DSM could encompass the conditions treated by all competing schools of psychotherapy.”
  • “If a professional wants to argue, for example, that there is an entity called ‘compulsive television watching’ she can easily come up with specific criteria … and train observers to measure the disorder in a consistent way.”
  • “Insurance forms, not the nature of symptoms, demand precise diagnoses.”
  • “[O]nce a drug was developed, a specific illness would have to be found that the drug would treat.”
  • “Once a diagnosis has been created, it enters professional curricula, specialists emerge to treat it, conferences are organized about it, research and publications deal with it, careers are built around it, and patients formulate their symptoms to correspond to it.”
  • “Diagnostic categories emerged in order to raise the prestige of psychiatry, to guarantee reimbursement from third parties, to allow medications to be marketed, and to protect the interests of mental health researchers and professionals.”
  • “'Frightening mental illnesses' ... help justify large research budgets for the NIMH.”
  • “[T]he most direct benefits of high prevalence estimates of depression accrue to pharmaceutical companies.”
  • “Their dependence on professionals can lead [people] to produce the kinds of symptoms their therapists expect them to have… [the symptoms] vary as professional fashions in diagnosis change.”
  • “Diagnostic psychiatry recognizes the presence of ‘culture-bound’ disorders only in other cultures.”
  • “[T]he best predictor of MPD is having a therapist who believes in the diagnoses.”
  • “[L]inkage analysis [linking psychotic disorders to particular locations on chromosomes] has to date been the source of more embarrassment than accomplishment in biological psychiatry.”
  • “[M]ethods of assessing brain structure and function… [and] the discovery of neurotransmitters …despite rhetoric to the contrary…have not led to significant advances in knowledge about the causes of mental disorders.”
  • “It does not follow from the fact that drugs produce changes in the brain that the original brain state that is changed constitutes a mental disorder.”
  • “[P]rofessionals are not more effective clinicians than nonprofessionals… No amount of coursework, training, or experience can create the qualities that lead to successful psychotherapy.”

But now comes the big surprise. In spite of all of the above, Horwitz fully believes in “the three major disorders that Kraepelin distinguished one hundred years ago: schizophrenia, bipolar disorder, and endogenous depression.” How these “real” disorders can be reliably identified, or how Kraepelin identified them, he doesn't say. On the contrary, he admits that "the distinction between people who can't function appropriately and those who won't function appropriately is far more a moral value judgment than a judgment based on psychiatric knowledge.” Nor does he postulate as to the causes of these supposedly real diseases. He only mumbles that there is a “strong possibility that these are brain-based disorders.”

The drug companies that conspire with NIMH and the APA  to convince us all that we need their poiso- I mean medications, suddenly turn into heroes when it comes to what he considers Kraepelinian diagnoses. “[T]he greatest accomplishment of modern psychiatry [is] the development of efficacious psychotropic medications,” and “Schizophrenia … responds to the phenothiazines and clozapine. Overall, there is little doubt that these medications are ‘antischizophrenic’ agents, not general tranquilizers.” Likewise, he goes on to claim that lithium is an effective treatment for “bipolar patients.” Yet when someone with a diagnosis that Horwitz pooh-poohs feels helped by a drug, this "could stem from cultural expectations for success, rather than from the biological impact of the drug itself." He doesn't say whether he means the patient's expectations or the physician's. Though Horwitz acknowledges a study which indicated that “patients [on a] placebo pill had the lowest rates of relapse,” he never entertains the idea that the drugs he lauds may be precisely the cause of a great deal of what he considers real mental illness.

Just as Horwitz fails to present evidence for the presence of somatic lesion in his three pet mental illnesses, so he fails to point out that somatic lesion can never be conclusively ruled out. He ascribes the "sensations of pain, fatigue, or distress" of "fibromyalgia in the contemporary United states" to “sociocultural processes” and "the nature of hysteria... [that] represent culturally produced symbolic entities rather than direct indicators of underlying diseases." The unsustainability of this position is given away by the fact that he makes the same claim about Lyme disease (spread by ticks and curable by antibiotics).

Why not just admit that all of psychiatry and psychotherapy is bunkum, and mental health workers don't know what they are doing?

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