November 14, 2007

The Extent Of Psychiatric Knowledge


Question of the Month

Test your knowledge with this question from our editors
Medscape from WebMD

Which of the following statements is true of childhood (vs adult) mania?

A.  Irritability tends to be more prominent
B.  The decrease in sleep is more pronounced
C.  Changes in appetite are less noticeable
D.  Racing thoughts are less common

If you got the right answer, you've wasted your life.  If you got the answer wrong but then learned the correct answer, you are wasting other people's lives.

The answer:

Answer: Irritability tends to be more prominent
In mania, classic DSM-IV symptoms, such as changes in sleep and appetite and racing thoughts, occur in children, adolescents, and adults. The key developmental difference between youth and adults is that in the presentation of mania, irritability is more prominent.

This is an example of how a) psychiatry has lost its way; b) multiple choice questions are useless.

First, the context of the bipolar question is a CME quiz based on an article: pass the quiz, get CME credits, which the State Board requires doctors to get.  I don't have to take this quiz; but this quiz is accredited as a legitimate means of getting CME, i.e. it is educational.

What multiple choice questions test is synthetic judgments.  It tests, "what is the universe like, actually?"


An analytic proposition is definitional; a synthetic proposition connects two independent parts that are not contained within one another.

A synthetic truth is one which its opposite can be conceived.  The opposite of an analytic truth is illogical.  So "humans have one head" is synthetic; "humans" and "head" are independent parts, connected.  It's possible humans might have two heads, or none.  "Bald men have no hair" is analytic.  "Bald" means "no hair."

The sentence, "adult AML has higher lethality than childhood AML" is synthetic because "AML" means something concrete that does not contain the notion of higher lethality in adults vs. kids.  "AML has more myelocytes than lymphocytes" is analytic because myelocyte perdominance is contained within the definition of AML.

Saying childhood bipolar has more irritability than adult bipolar isn't synthetic; it isn't additional information about "bipolar."  It is the definition of childhood bipolar.


Consider the relationship "if p then q."  Therefore, if not q, then not p (contrapositive.)

So which is it:

"If you see X symptoms, it's bipolar."


"If it's bipolar, he has X symptoms."



"If he has X symptoms, then he has bipolar" is logically equivalent to "If he is not bipolar, then he does not have X symptoms."


"If he has bipolar, then he has X symptoms" is logically equivalent to "If he does not have X symptoms, then he does not have bipolar." 

It's obvious that both pairs of statements are invalid, because on the one hand we are agreeing to label a collection of symptoms as "bipolar" (analytic), but on the other hand we are secretly allowing that we can intuit "bipolar" regardless of a previously agreed upon definition, i.e. the symptoms (synthetic).

Cleverly, we allow ourselves another opening: use the definition to make analytic judgments (he has bipolar therefore he will have manias) and use our experience to make synthetic judgments which alter to the definition (manias may indeed be absent, replaced by irritability), simultaneously.

And we do this because the real meaning of the term isn't what is meant by it, but how we intend to use it.


"If we had to name anything, we should have to say that it was its use."  When a mathematician sees something that resembles "irritability" what does he call it?  But when a psychiatrist sees something that resembles "irritability," what could he call it?  The mathematician finds the dictionary word "irritability" quite suitable for his purposes; but the psychiatrist can do nothing with the word "irritable" except use it to imply something else.

The sly move is to consider "irritability" to be a modifier of the more general construct "bipolar."  But "bipolar"is actually the modifier of irritability. 


Maybe you are confused, because your mind is stuck on viewing bipolar as a term independent of the agent who observes it; a term that we learn things ABOUT.  But the meaning of "bipolar" is recursive.

It's pornography, impossible to define except as "I know it when I see it."  But that statement does not mean pornography is "very hard to define, but easy to identify."  It means it is defined, ad lib, by me. 

Synthetic propositions can be learned to be true (or false): "the majority of married men are happier than the majority of single men."  But what can be learned about pornography that is independent of the one experiencing pornography?  "The majority of pornography depicts nudity."  Even the word "majority" is useless since it qualifies a word which is itself a personal judgment.   This is neither a true nor false statement; while I know what "nudity" is, we still don't know what pornography is except that you are now defining it as containing nudity.  But once you choose a definition, can you change it?  Well-- what about a magazine devoted to stocking fetishists that has no nudity-- indeed, possibly no actual people?   Statements about pornography can not be found true or false because the term pornography requires an active subject.  It isn't a noun, it is a judgment about its use.

You mean "community standards." No-- a nude woman in Playboy is "porn--" but the exact same photo in a Soho art gallery seen by the same people may be something else.

"But we all agree, at least, that certain things are pornographic."  But a consensus among individuals isn't truth, it's definition: "we agree to call this pornography."  Until, of course, someone disagrees.  But what is the basis of the disagreement? It is never content, it is always intent: pornography is that which is "intended to elicit sexual arousal."  We disagree about what the purpose of the images are.


What is the intention of the diagnosis "bipolar?"  To describe something?    As a reason for something?  To imply treatment?

"But you have to agree that if I give a child with bipolar disorder bipolar meds, they get less irritable."  But why not call them "irritability" meds?  If you gave them to an irritable child without bipolar, would they not get less irritable?  Or is it that if you gave them to an irritable child and nothing happened, the child doesn't have bipolar?

"I have a map of an imaginary world in my mind; according to it, you should be able to get to my house in twenty minutes."  The map exists for him, but tells you nothing about the real state of affairs.  And can you rely on such a person to use the term "minutes" the way you expect?

 The term "bipolar"-- whether it exists (as a so far unknown physical pathology) or not-- isn't valid because it says nothing about the world; it only says what the person using it thinks about the world.


My car's engine is stumblin... (Below threshold)

November 15, 2007 1:03 AM | Posted by Glen: | Reply

My car's engine is stumbling. My Mechanic says it suffers from Stumbliositis. Personally, I don't believe him because that is not a valid construct. I know that engine stumbling is not a result of Stumbliositis but of either an electrical, fuel, intake or exhaust related problems. He did fix the problem (bad ignition coil) and for a fair price. Still, that does not change the fact that there is no such thing as Stumbliositis. Personally I think that he used to be a Psychatirst.

Seriously, Donald Hebb is rolling in his grave right now. It seems rather strange to think that an organ that has a necessity to change its morphology based on experenice would be expected to manifest abnormalities in a uniform way.

One last note, It is entirely possible for children's mania to be more irritable by the very nature of parental involvement. Us parents are pretty good at taking the 'fun' out of mania. Killjoys we are!


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What residency program are ... (Below threshold)

November 15, 2007 3:00 AM | Posted by The Pride: | Reply

What residency program are you affiliated with? I'd like to go there.

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The CME on Medscape is a jo... (Below threshold)

November 15, 2007 8:32 AM | Posted by Anonymous: | Reply

The CME on Medscape is a joke. I have played around with it and received CME for all sorts of things (without ever reading the article or questions). It takes roughly 5 minutes to guess the correct answers, and then you're done. Pathetic.

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I wasn't aware the DSM had ... (Below threshold)

November 15, 2007 10:38 AM | Posted by Steve: | Reply

I wasn't aware the DSM had a diagnosis of childhood bipolar do (but who can keep up with the DSM anyways?)

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Bipolar is the new "racism"... (Below threshold)

November 15, 2007 1:26 PM | Posted by John: | Reply

Bipolar is the new "racism" or "conservative"... meaningless words whose definitions are owned and not shared, empty vehicles for self-serving, morally superior hacks to mediate their pre-conceived vision of the world. This is why I have Akiskal, Al Sharpton and Teddy Kennedy on speed dial... to avoid foot-in-mouth syndrome.

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My guess was "C" because ev... (Below threshold)

November 16, 2007 3:38 AM | Posted by Whatever: | Reply

My guess was "C" because everyone knows that kids can be such picky eaters and when they are eating more they are obviously going through a growth spurt. Right?

See, bipolar children who get beaten up by their parents on a regular basis often fail to display this sort of irritability.

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An equation I wish were not... (Below threshold)

November 16, 2007 5:07 PM | Posted by spiritual_emergency: | Reply

An equation I wish were not true: Incompetent, drug dependent parenting + incompetent, drug dependent doctoring = children like Rebecca Riley

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RE: Rebecca Riley story. <b... (Below threshold)

November 20, 2007 1:16 PM | Posted by KWL: | Reply

RE: Rebecca Riley story.
Wow, we can certainly "structure" ourselves into the most *incredible* delusions.

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So, before modern medicine,... (Below threshold)

November 20, 2007 11:35 PM | Posted by ME: | Reply

So, before modern medicine, when people said that someone has a certain disease, were those terms also invalid, even though today they would be valid?

Suppose there is a bipolar virus that causes bipolar, that is someday found. Would "bipolar" then become retroactively valid?

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Excellent. I wonder whether... (Below threshold)

November 21, 2007 5:02 PM | Posted by DrSteve: | Reply

Excellent. I wonder whether psychiatry qualifies as a science at all. As you point out so well, definitions and lists of charcteristics can never be epistemologically anything more than tautologies. What's missing is theory (any theory which needed a book the size of DSM to exemplify it should be laughed out of court). Not that I'm a Lacanian, or anything, but are you familiar with Lacan's diagnostic model? For him there are no character disorders, axes.... No, there are three types of people, neurotic, psychotic, and perverts. Though people in each category can function well or poorly, they don't hop from one category to another. I.e. a neurotic under stress does not become a psychotic. It's really fascinating stuff - if only because there's a beefy system of thought underpinning it.

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Since you obviously know th... (Below threshold)

November 22, 2007 2:27 AM | Posted by Rose: | Reply

Since you obviously know the correct answer, I'm curious: have you wasted your life? Or are you wasting other people's lives?

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Modern psychiatry is actual... (Below threshold)

November 30, 2007 12:08 AM | Posted by Dan: | Reply

Modern psychiatry is actually a marketing branch for GlaxoSmithKline.

What you've delicately avoided mentioning (tactful of you) is that bipolar has this consensus definition because there are billions of dollars in it having this definition, and further precision and real analysis won't make anyone any money. More pills will.

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Hold up.I presume ... (Below threshold)

November 30, 2007 12:29 AM | Posted by Dan: | Reply

Hold up.

I presume you're using standard moderation, and that's why my last comment is being held, which is fine, but ...

I did some more reading here and I've found you're possibly even more cynical about pharmaceutical influence in psychiatry than I am. My previous comment reflects ignorance of the fact, and I'd like to apologize for that.

The rest of it stands, though.

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If you wanna see a complete... (Below threshold)

March 23, 2008 5:05 PM | Posted by Obdulantist: | Reply

If you wanna see a completely tautology based (and useless) diagnostic and therapeutic protocol in action, go watch the somatisation 'experts' at work.

And if you really want to have fun, ask them about their previous classification of multiple sclerosis, Parkinson's, and stomach ulcers (among other diseases) as various forms of somatisation. Then stand back and watch their heads implode trying to justify how, despite getting those completely wrong, they have really got it all figured out now, even though they are still using the same diagnostic reasoning.

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There is a virus that cause... (Below threshold)

December 25, 2008 3:17 AM | Posted, in reply to ME's comment, by Claudius: | Reply

There is a virus that causes bipolar disorder in all people who get's called borna disease...but not everyone who are bipolar have borna disease.

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Buildings are expensive and... (Below threshold)

January 14, 2011 6:42 AM | Posted by ReedFrancine34: | Reply

Buildings are expensive and not every person can buy it. Nevertheless, personal loans are invented to support different people in such cases.

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" The term "bipolar"-- whet... (Below threshold)

January 23, 2011 6:12 PM | Posted by smaro: | Reply

" The term "bipolar"-- whether it exists (as a so far unknown physical pathology) or not-- isn't valid because it says nothing about the world; it only says what the person using it thinks about the world. "

I just copied and pasted your whole sentence as I could not or did not want to understand what it means...
Unknown physical pathology, when there are differences in the size of the frontal lobes and in the amounts of the adrenaline/noradrenaline/serotonine produced?
I am not a doctor, just a patient still trying to figure out what is going wrong in my head...
I suspect the problem is more something to be taken care of an endocrinologist than a psychiatrist, I don't know why they never thought to mess with us...!
What is your opinion? I mean, hypo- and hyperthyreoeidism a (I am greek and don't know how it is written in English) also manifest with depression and mania-like symptoms...

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The problem with correlatin... (Below threshold)

January 24, 2011 5:38 AM | Posted, in reply to smaro's comment, by Rookie: | Reply

The problem with correlating physical brain differences with mental disorders (not even to mention the problem with defintions of what that disorder may be as per the article) is just that: they're correlational. No causation or direction of effect is implied and indeed, both results could be brought about by a third cause. As for neurotransmitter differences, unusual noradrenaline and seratonin activity are implicated in a number of disorders (say ADHD or unipolar depression), but as far being what bipolar IS... "a chemical difference" just doesn't have the explicit causal connection or explanatory depth to say what exactly bipolar is... And to come back to the point the article makes, such studies will only tell you what "people who match the consensus symptom list for bipolar" have different abuot their brains; bipolar remains whatever it actually is and looks like. To then take the brain differences found and modify the definition further would be circular reasoning AGAIN! Same mistake, recursively repeated.

As for Hypothyroidism (hypo is low) and hyperthyroidism (hyper is high, think hypothermia and hyperactive)... differences in levels of the various thyroid factors are what those conditions ARE. The symptoms are associated with those varying levels, not an actual definition of the problem. The symptoms remain independant and could be caused by different problems (potentially), but the actual physical problem can be tested; a doctor can examine the truee state of your body and the world... for bipolar that can't be done yet.

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