Medicine Psychiatrists Do Not Know What They Are Treating The mysteries of the mind are harder to unravel than psychiatrists pretend. Jacob Sullum | From the January 2023 issue Share on FacebookShare on XShare on RedditShare by emailPrint friendly versionCopy page URL Add Reason to Google Media Contact & Reprint Requests <img src="https://d2eehagpk5cl65.cloudfront.net/img/c800x450-w800-q80/uploads/2022/11/book1-800x450.jpg" style="max-width: 100%; height: auto" width="1200" height="675" alt="book1 | Illustration: GeorgePeters/iStock" /> (Illustration: GeorgePeters/iStock) Schizophrenia: An Unfinished History, by Orna Ophir, Polity Books, 224 pages, $35 Desperate Remedies: Psychiatry's Turbulent Quest to Cure Mental Illness, by Andrew Scull, Belknap Press, 512 pages, $35 The Mind and the Moon: My Brother's Story, the Science of Our Brains, and the Search for Our Psyches, by Daniel Bergner, Ecco/HarperCollins, 320 pages, $28.99 As a boy, especially while lying in bed or suffering a fever, I was periodically troubled by harshly critical voices that vaguely charged me with misconduct and failures of character. As I grew up, the murmuring Greek chorus was replaced by a single voice, which by then I recognized as my own. If those seemingly external voices had persisted into adolescence and adulthood, I might have qualified for a diagnosis of schizophrenia. Instead, I became a garden-variety neurotic, assailed by self-recriminations that undermined my confidence and interfered with my happiness. Are these two states of mind categorically distinct, or do they occupy different spots on a continuum of mental health? Is one properly classified as a brain disease requiring biomedical treatment while the other is a psychological condition amenable to talk therapy? Or are we talking about a difference in degree rather than kind? The renegade psychiatrist Thomas Szasz, a longtime Reason contributing editor, argued that "mental illness" was a metaphor that should not be taken literally. In his view, the patterns of speech and behavior that are seen as symptoms of schizophrenia, like less severe and more common disturbances of thought and emotion, could be traced to "problems in living" rather than an identifiable neurological lesion or biochemical defect. Less radical critics of psychiatry's scientific pretensions tend to dismiss Szasz's take as implausible, clinically naive, and cruelly indifferent to the suffering of people diagnosed with schizophrenia. At the same time, they emphasize that psychiatry has never managed a satisfactory account of what schizophrenia is, let alone what causes it or why the treatments du jour can be expected to work. That ongoing failure with regard to schizophrenia, which Szasz called "the sacred symbol of psychiatry," epitomizes the field's broader crisis of credibility, which extends to the medicalization of nearly every human folly and foible. In Schizophrenia: An Unfinished History, psychoanalyst Orna Ophir traces the concept's evolution since the 19th century, culminating in contemporary debates about its validity and usefulness. Swiss psychiatrist Paul Eugen Bleuler, who introduced the term schizophrenia, perceived a group of diseases characterized by "the four As": autism, ambivalence, and abnormal affect and associations. DSM-5, the latest version of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, defines schizophrenia based on a list of symptoms: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, and "negative symptoms" such as flat affect. A diagnosis requires just two of those symptoms, including at least one of the first three, persisting for a month or longer, plus impairment of a major life function and one or more signs lasting for at least six months. Prior to the 2013 publication of DSM-5, Ophir notes, members of what was then known as the International Society for the Psychological Treatments of the Schizophrenias and Other Psychoses argued that schizophrenia was "an idea whose very essence is equivocal," a "category without natural boundaries, a barren hypothesis." They "condemned it [as] 'yesterday's diagnosis,' 'a construct with little reliability or predictive validity,' precisely because the symptoms used to diagnose it can be understood as extreme versions of normal human experience." Even critics who saw value in Bleuler's original concept agreed that the existing diagnostic criteria were "arbitrary and pseudoscientific." As sociologist Andrew Scull notes in Desperate Remedies, that dissent came from a faction of mental health specialists who had dominated organized psychiatry for decades before losing control to academics and clinicians with a biomedical orientation. But if objections from once-regnant psychoanalysts don't give you pause, the blunt observations of Thomas R. Insel, a neuroscientist and psychiatrist who directed the National Institute of Mental Health (NIMH) from 20...