This article is a response to the article “Descriptive labels are not causes, no matter how hard you try: An answer to pies and roaches” by Jani Kajanoja, MD, PhD, and Jussi Valtonen, PhD.
We thank Jani Kajanoja, MD, PhD, and Jussi Valtonen, PhD, for their thoughtful and powerful response to our article. Although we strongly disagree with their thesis, we know that our Finnish colleagues share with us the desire to provide the best possible care to our patients. We would now like to respond to some of the important claims and conclusions in their rebuttals, with the caveat that we are providing a very brief and specific response. We hope that in time we will be able to better address their arguments.
We believe that at the heart of this debate are at least the following questions: (1) What is meant by the term analysis in psychiatry? (2) How do diagnostic criteria apply (as in DSM-5) relate to clinical conditions? (3) Of what nature causality in psychiatry? (4) What causality and explanatory power does psychoanalysis have? (5) What counts circular or tautological arguments in how mental illnesses are formulated?
First, however, we would like to clear up some confusion and misunderstandings arising from our article. Our volcano analogy has been misunderstood by several readers, including Drs Kajanoja and Valtonen (henceforth, Drs K & V). In truth, the vignette could have been presented more clearly. As most readers will recall, analogies are formally stated as “A is to B as C is to D.” In our volcano wine, the corresponding terms would be: (A) the visible, surface manifestation of a volcano is that (B) the deep structure of a volcano (the underground movement of tectonic plates) that (C) the clinical symptoms of mental illness (hallucinations, delusions, etc.) exist (D) the etiopathology/pathophysiology of the disease .
Our main aim was to show that we do not need to know the deep structure (ie the cause) of an event, condition or phenomenon – be it a volcano or schizophrenia – in order to claim that the entity has causation(ie that it can make things happen). We certainly were not to liken or liken a mental illness diagnosis or mental disorder to a volcanic eruption – although to be honest, any doctor who has witnessed a severe, uncontrolled case of mania might beg to differ!
In any case, the analogy is not crucial to our main argument, which is essentially this: diagnostic criteria such as those in DSM-5 not to be confused with clinical condition to which the criteria refer. We believe that this confusion permeates almost every argument made by Drs K and V and leads them to draw false conclusions regarding the causality and explanatory power of psychiatric diagnoses.
Diagnostic criteria for a specific DSM disorder/disease is indeed descriptive – no one disputes this – but it is not just descriptive, as Drs K and V seem to believe. The diagnostic criteria are also uniquedefined as “of, pertaining to, or resembling … the index finger.”1 The diagnostic criteria point to something external to themselves; namely, to the actual clinical condition or condition inherent in the patient.
It is trivial that it is not the diagnostic criteria that cause the patient’s symptoms – and of course no one in clinical psychiatry would argue that. The criteria are only passive words in a manual, or terms in the head of DSM committee members. Rather, it is the clinical condition indicated by the diagnostic criteria that causes the patient’s symptoms. As our colleague, Awais Aftab, MD, has put it in his brilliant deconstruction of the case (where he specifically criticizes the paper by Drs K and V)2:
“The diagnostic criteria in official manuals such as the DSM and the ICD are simply indexes, as a means suggests and admit the existence of a state, condition, syndrome, property cluster, etc. They do not constitute the condition itself (see Kendler 2017). It’s not like “depression”. nothing more than symptom criteria in diagnostic manuals. The criteria are more a way for us to recognize the state of depression.”
In a more poetic sense, as a Buddhist saying puts it, “A figure pointing to the moon is not the moon.” We believe that Drs K and V repeatedly confuse symptom role DSM diagnostic categories with the conditions they point to. To borrow 2 terms from the linguist Ferdinand de Saussure, they confuse the sign with the signified.3
Psychiatry requires more than a list of symptoms
The following is an example of how we see things very differently than Drs K and V. Two of our colleagues submit the following statement: “Alex is experiencing depression, loss of pleasure, insomnia, weight gain and psychomotor disturbances.”
Drs K and V present this as a kind of prototypical mental illness, which they define as, “…signs for conditions where given diagnostic criteria are met.” They contrast the statement above with what they call a “causal claim,” such as “Alex is experiencing depressed mood because their partner wants a divorce.”
With all due respect to our Finnish counterparts, we believe they have grossly simplified – indeed trivialized – the diagnostic process in psychiatry. To put it bluntly: anyone with sharp eyes and ears, and 15 minutes to spare, could easily find that a friend or family member has depressed mood, loss of pleasure, weight gain, and visible agitation. It is not a diagnosis! And it is far from diagnosing, say, the depressive phase of bipolar I, which requires a holistic integration of the patient’s developmental history; disease process; relevant medical history; family history; applicable medical exclusions; mental state test etc.
Once again, in our opinion, Drs K and V appear to be confused about the difference between raw diagnostic criteria and the actual clinical situations to which the criteria refer. Mental illness is a gestaltand is2:
“…not like a mere itinerary of things in isolation. This is because wholeness also involves interactions and relationships between parts that often create new properties.”
Moreover, “A detailed descriptive analysis connects an individual in the clinic with a large amount of clinical and scientific information.”2 This includes verification tools such as “… genetics, family history, personality traits, risk factors, medical history, [and] treatment response.”2 This supporting evidence is almost never included in the formal diagnostic criteria.
In short: Drs K and V minimize or completely deny the causal weight involved in the diagnosis of at least some of the most serious mental disorders, such as Bipolar I, Schizophrenia, OCD and others. (To be sure: not all mental illnesses possess this level of causality or number of verifiers – a topic for another time).
Regarding cycle and causal weight
In fairness to Drs K and V, they have now clarified that they did not claim that:
“… psychodiagnoses themselves reflect circular reasoning… There is nothing wrong with descriptive diagnoses as long as their descriptive nature is clear. Our criticism focused on falsely invoking a psychiatric diagnosis as an explanation for the symptoms, which is a logical fallacy.”
We appreciate the explanation, but we do not agree that mental illness has neither explanatory power nor content usuallyas Drs K and V suggest. Furthermore, we find no basis in logic—or in clinical reality—that would show descriptive and explanatory to be mutually exclusive or divisive properties of a set of diagnostic criteria. That’s how it is DSM-5 criteria for bipolar I disorder, for example, are certainly descriptive—no one disputes that—but are not only descriptive. They also point to a real clinical situation that has etiological implications and explanatory weight.
Accordingly, it is reasonable to assume that bipolar I is the cause of the patient’s manic or depressive symptoms. That these symptoms are also part of the diagnostic criteria for bipolar I disorder does not in any way circumvent the causal claim. As Dr. Aftab puts it2:
“There is a perfectly legitimate sense in which to say depression.” have an effect how people think, feel and behave and in my opinion it is misleading and inaccurate to suggest otherwise.”
Importantly, we add this: anything that can affect something else has a causal effect.
All this is not to say that the hon DSM diagnostic categories fully explain the patient’s condition. It is very rare that we ever fully understand all the causes of a patient’s clinical condition, which may number in the thousands, often including many psychological, psychosocial, and characterological factors. But DSM analysis is at least the beginning of a causal explanation, as Aftab points out.2
Finally, we agree with Drs K and V (and Aftab) that there is some danger in repeating a psychodiagnosis – as if there were a physical or material object sitting inside the patient causing symptoms mechanically or physiologically. But this risk can be reduced by using – and talking to the patient – the biopsychosocial approach of case preparation, which (to repeat) is a mandatory part of DSM diagnostic process.
Much more could be said in response to Drs K and V, but we must postpone that for now. We appreciate the opportunity to share our views and hope that readers will find this exchange stimulating and useful.
Dr Pies is Professor Emeritus of Psychiatry and Assistant Professor of Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry Emeritus, Tufts University School of Medicine; and editor emeritus of Psychiatric Times (2007-2010). Dr Pies is the author of several books. A collection of his work can be found on Amazon. Dr. Ruffalo is an assistant professor of psychiatry at the University of Central Florida College of Medicine in Orlando and an adjunct professor of psychiatry at Tufts University School of Medicine in Boston, Massachusetts.
Sources
1. Uncertain. Collins dictionary. Accessed August 23, 2024. https://www.collinsdictionary.com/us/dictionary/english/indicial
2. Aftab A. The explanatory value of descriptive analysis. Psychiatry on the fringes. July 13, 2024. Accessed August 23, 2024. https://www.psychiatrymargins.com/p/the-explanatory-value-of-descriptive?utm_campaign=reaction&utm_medium=email&utm_source=substack&utm_content=post
3. Dewanti D. A semiotic analysis of Ferdinand De Saussure’s structuralism on the “Energen Green Bean” advertisement. June 21, 2023. Accessed August 23, 2024. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4487450
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