False Binary

Back in the 1600s, in the time of Descartes, the prevailing belief was that the body and soul were one thing. Diseases were considered spiritual or moral failings. And because of this, the body couldn't be studied as just a body and diseases weren't something to be just scientifically understood, they were to be understood spiritually as well. And remember that back in those days theology and law were far more intertwined than they are today. The church dictated what was and wasn’t allowed. Which meant that people weren’t allowed to study disease and physiology outside of the orthodoxical framework of the time.

To fully illustrate the authoritative reach of the church, and what happened when you spoke out against their beliefs, let's look quickly at Galileo. In 1633, Galileo claimed that the earth moved around the sun, which was contrary to the belief at the time that the earth was at the center of everything. And because of this assertion that went against their beliefs, he was condemned by the Catholic Church and was sentenced to house arrest for the rest of his life. He died there nine years later at the age of 77. And René Descartes, who had just finished writing a book defending the very same idea, seeing the church's reaction, immediately withdrew his book from publication.

So when Descartes published his next book in 1641, Meditations on First Philosophy, he was very careful to draw a line. The soul, he argued, was immaterial - and at that time, 'soul' meant everything we would now call 'mind': thought, consciousness, emotion, the inner life. That domain belonged to the Church and religion. But the body was something else entirely: a physical machine that operated according to mechanical laws, and could be studied by science without threatening religious authority. This let him carve out space for scientific inquiry while appearing to leave the Church's domain intact. He even sought the Church's approval by dedicating the book to theologians. While some theologians were suspicious, the conceptual divide had been introduced: body and mind were separate substances, operating by different rules, belonging to different authorities. When they eventually did ban his works in 1663, it was too late; the separation had already started formalizing on the institutional level, and was too hard to reverse. And the split he created to protect science from the Church became the framework that would shape science for the next four hundred years.

At that time medicine, finally free to conduct business as they saw fit without church oversight, understandably ran with it. Over the next two centuries, what started as a philosophical framework to enable scientific study, transformed into a complete institutional separation between "diseases of the mind" and "diseases of the body," as though they were fundamentally different categories requiring entirely different systems of care.

The separation evolved gradually through a series of institutional decisions that seemed perfectly practical and reasonable at the time. In the early 1800s, as cities grew and industrialization accelerated, European societies had to figure out what to do with people who were acting strangely, who couldn't work, or were disruptive or distressed. The answer, arrived at more or less independently across multiple countries, was to create specialized institutions to house them. Britain passed the County Asylums Act in 1808, leading to the first public asylum opening in Nottinghamshire in 1812, and similar institutions began sprouting up across Europe and America.

So now there were these asylums filled with sick patients who needed care, including needing doctors who could attend to them, but regular physicians didn't want to work there. The work didn’t feel 'medical' in the way medicine was coming to understand itself in the germ theory era. There were no clear diseases to identify, or pathogens to kill, and there were no surgical procedures to perfect. So to fill this clear gap, a new specialty emerged, initially called "alienists" - doctors who specialized in treating people whose minds had become "alienated" from reason. And by the late 1800s, this specialty had evolved into what we now call psychiatry. Because these asylums were pretty much completely separate from regular medical hospitals, the psychiatric doctors who worked in them were separately developing their own theories, and treatments, and even their own professional organizations, deepening the structural divide.

In 1871, the Association of Medical Superintendents of American Institutions for the Insane, essentially the early psychiatric professional organization, was invited by the American Medical Association to merge together into one umbrella organization, but they declined. Their meetings were focussed solely on the care of the insane, and they didn't feel like regular doctors were very interested in that, so why should they merge and muddy the waters with people who were so separately focussed? It seemed better to stay separated so they could each focus on their domains. And so asylum psychiatry was developed in complete isolation from the rest of medicine. They weren't attending the same conferences, reading the same journals, or training in the same institutions.

By 1894, the separation had become so complete that American neurologist Silas Weir Mitchell stood before a gathering of asylum physicians to tell them that they had isolated themselves from the rest of medicine, their medical records were inadequate, and their research was nonexistent. Because the diseases didn’t look the way medicine had defined what diseases should look like, and it wasn’t being studied the way medicine had decided disease should be studied, the divide became a hierarchy system where medicine saw itself as superior.

And once these institutional structures were in place, they became self-reinforcing. Medical schools developed separate training tracks - you either studied to be a psychiatrist or you studied to be a regular doctor. Insurance systems created separate coverage categories and different reimbursement structures. Research funding got divided into mental health research and medical research. Hospitals were either psychiatric hospitals or general hospitals, but rarely both. Professional journals specialized in either psychiatry or medicine. Even the language diverged - psychiatrists talked about mental illness, affect, and behavior, while other doctors talked about physiology, organs, and biomarkers.

But in order to be taken seriously enough to get funding and insurance reimbursement, psychiatry had to create a diagnostic system similar to medicines. The solution, eventually, was the Diagnostic and Statistical Manual of Mental Disorders, the DSM. First published in 1952, and now in its fifth edition, the DSM has become psychiatry's defining document, the authoritative guide to what counts as a mental disorder and what doesn't.

If you crack open the tome that is the DSM and really look at the diagnosis laid out for you inside, you will see that it's not made up of clearly defined diseases, but rather a collection of different expressions of distress or dysfunction, that have been grouped together and labeled. Imagine a deck of cards spread out on your table. What the DSM did is they took the cards of disease expression, and noticed common clustering patterns. So sleep issues, trouble concentrating, avoiding public places, etc, and noticed that some of these clustered together in people often enough that they gave them an overarching name. They basically picked up 5 cards and called it a disorder. Then they threw those cards back in the pile so they'd be available to the next diagnosis they were creating that might include them as well. Not because the biology suggested these clusters had clear boundaries, but because the system they were working within required them to give them concrete definitions. You need discrete diagnoses to bill insurance. You need specific disease categories to get FDA approval for drugs. You need defined patient populations to design research studies. You need clear diagnostic criteria to train psychiatrists in a standardized way. The DSM gave psychiatry all of that. But in so doing it created the same siloed problem we see in medicine, each disease or condition a discrete entity rather than a connected web of downstream shared symptoms.

Look at Major Depressive Disorder and Generalized Anxiety Disorder, two of the most commonly diagnosed conditions in psychiatry. To meet criteria for Major Depressive Disorder, you need five out of nine of their symptoms cards, and for Generalized Anxiety Disorder you need three out of six of the cards. But both include fatigue, sleep disturbances, and difficulty concentrating. So you could be diagnosed with Generalized Anxiety Disorder with just those three, but not depression because you would need two additional cards to get to play. So where exactly does one disorder end and the other begin? If someone has four symptoms from the Major Depressive Disorder list, they have nothing - no diagnosis, no treatment, no insurance coverage. But if they have five symptoms, suddenly they have a disease. The cutoff is arbitrary.

PTSD symptoms overlap massively with panic disorder, depression, and generalized anxiety disorder. Fibromyalgia, classified as a physical condition (sort of, as we discussed previously) has symptoms that overlap substantially with depression and anxiety. Chronic fatigue syndrome has a lot of overlapping symptoms with depression. Parkinson's patients commonly experience depression, anxiety, and fatigue - often years before the tremor appears. Alzheimer's patients frequently develop depression and sleep disturbances before memory problems. Heart disease patients show high rates of depression and anxiety. "Comorbidity" rates in psychiatry are so absurdly high (it's not unusual for someone to meet criteria for three, four, or five different DSM diagnoses) because we've taken one continuous phenomenon and sliced it into multiple overlapping categories.

Psychiatry also tried to find biological explanations for their DSM categories. This gave us the 'chemical imbalance' theory of mental illness - the idea that depression was caused by low serotonin, that anxiety was a GABA problem, that schizophrenia was about dopamine. Except it didn't work. Decades of research have now shown that SSRIs don't outperform placebo in mild to moderate depression, and it only looks like it works a bit better in severe depression because people with severe depression don’t respond to placebo very well so the placebo arm is lower making the active arm look more effective. A landmark meta-analysis that included unpublished trial data by Kirsch in 2008 found that the difference between antidepressants and placebo was clinically negligible. The simple chemical imbalance theory was wrong.

What happened was they noticed serotonin seemed to improve people’s moods, so they started testing depressed people to see what their serotonin levels looked like. What they actually saw was that in some depressed people serotonin was elevated and in some people it was depleted, which baffled them, but if you look back at Table 1 in chapter 4, you will see that initially when we enter into acute threat our serotonin levels elevate. Over time as we get stuck in pathostasis, serotonin drops and that’s when you see chronically low levels. So researchers were testing people at different stages of pathostasis, not understanding what they were seeing, and still thought the answer was to further disrupt an already dysregulated system.

What SSRIs actually do is inhibit reabsorption of serotonin. So normally serotonin is released, it floats across the gap between neurons, it binds to receptors on the receiving neuron, and that binding becomes a signal. Then normally it gets pulled back into the original neuron to be reused.

By blocking reuptake, the serotonin stays in the synapse longer, so it has more opportunities to keep binding to those receptors, and keep signaling. By staying in the gap longer it keeps hitting the receptor over and over instead of being cleared away.

Think of it like a text message. Normally you send it and it gets read one time. What SSRIs do is more like the message keeps re-appearing in someone's inbox, so they keep reading it again and again. More signal events from the same serotonin. But just like with every other time we try to adjust the chemistry of the body artificially over the long term, the brain adapts. If you're getting bombarded with serotonin signaling, the receiving neuron goes "okay this is too much" and starts downregulating its receptors. Pulling them back. Becoming less sensitive. This is the same tolerance we talked about with insulin in diabetes. So you end up with more serotonin floating around than you started with, but this amount becomes the new normal, and the receptors adapt and now you also have fewer receptors to receive it and/or less responsive receptors.

This is the same pattern we see across medicine when they try to artificially replace decreased chemicals. It works for a while - then tolerance develops. The body adapts to the artificial supply, downregulates its own production or sensitivity, and you need more to get the same effect. Eventually the drug stops working, or you become dependent on it just to maintain a baseline.

And this keeps happening despite this clear issue because drug trials are typically conducted over 6-12 weeks. And SSRIs are no exception. The average amount of time people stay on antidepressants is 5 years, with 25% staying on them for 10 years or more, and we really only tested them as a short term bandaid. The fact that drug testing for chronic diseases is so short is worth examining. Think about alcohol tolerance. If you needed to test how drunk someone will get when they drink a specific amount of alcohol every day, and you only test them for 6 weeks, they would probably get pretty drunk off of let’s say 6 beers a day for that 6 weeks. But if someone is drinking a 6 pack every day for 5 years? We all intuitively know that at some point there is likely no effect at all on that person from those beers. This is how most long term medicine works too.

Psychiatry was looking in the brain for something specific to 'mental' illness because that's the organ they'd been assigned. They were trying to find the 'depression chemical' or the 'anxiety receptor' because the institutional framework demanded that mental illnesses be brain diseases, separate from the body.

So psychiatry hasn't been any more successful than the rest of medicine. Just like with diabetes, heart disease, and IBS, psychiatry found some mechanisms, but none of them led to cures. But despite the gaps in their understanding and ability to effectively help these patients, like medicine, psychiatry kept diagnosing, they had to in order to get reimbursed by insurance. Millions of people were given labels - Major Depressive Disorder, Generalized Anxiety Disorder, Panic Disorder - complete with narratives about chronicity, prognosis, and what to expect. And this raises a question we haven't addressed yet: if the treatments don't work better than placebo, what exactly are these diagnoses for? What happens when we give someone one of these diagnoses - medical or psychiatric? Medicine treats diagnosis as though it's a neutral act of observation - we're simply naming what's already there, documenting reality. But what if it's not? What if the act of giving someone a diagnosis is itself an intervention that changes what happens next?

In Chapter 2, we saw that expectation produces biology. When patients believe treatment will help, their bodies respond - blood pressure drops, tremors reduce, pain decreases. Real, measurable physiological changes driven by belief. This expectation effect is so strong it can even override and reverse the expected effects of a drug like ipecac. So given that we have 70 years of data proving just that in trial after trial after trial, what about the other side of that equation? If expectation can produce healing, can it also produce harm? If believing you'll improve creates improvement, does believing you're disordered create disorder? What happens when we hand someone a psychiatric diagnosis - when we tell them 'you have this condition, here's what it means, here's how it will affect you'? Are we describing a pre-existing reality, or are we teaching their nervous system how to organize itself around a new identity, creating the very patterns we claim to be documenting?