Scientific Pluralism and the Evolution of Psychiatric Classification with Dr. Awais Aftab

[00:00:00] Welcome back to the podcast, Dr. Awais Aftab. So first of all, I want to congratulate you on all of your success since our first conversation four years ago. Your work has been so meaningful to me personally, and more importantly, I think you've been a thought leader. That has pushed the entire field of psychiatry to think deeply about existential issues in our field and to always keep our patients at the center of research and clinical practice.

I saw that you were profiled in The Lancet in 2025, so I was glad to see that you are getting some of the recognition in the field that you really, truly deserve. And I think you're an inspiration to so many of us. And I'll also say that. For me, reading your work provides me great protection against disillusionment and burnout, and I think that, one of the reasons that you're so popular in our field is that a lot of us feel that when we're in the trenches of clinical psychiatry and are refreshed [00:01:00] to come into contact with your work.

So that's my introduction of you, but I will ask you to introduce yourself to our audience. Thank you, mark. I appreciate that and it's great to be on podcast. Again, I'm a mess of tha I'm a psychiatrist in the Cleveland area in Ohio. I'm clinical associate professor of psychiatry with Case Western Reserve University.

Kind of my academic and public facing work focuses on conceptual and critical issues in psychiatry. That's what I've been. Interested in for many years I've published in academic journals. I've written for kind of, you know, public outlets like the New York Times. I have a Substack newsletter called Psychiatry at the Margins that I've been writing for more than three years now.

And for many years I did an interview series for Psychiatry Times called Conversations in Critical Psychiatry that in 2024 was published in the form of a book adaptation by Oxford University Press. Imagine, almost no one listening to this podcast is hearing your name or being introduced to your work for the first [00:02:00] time.

But if that describes you, listener, you are so welcome. My first question for you kind of relates to that, so I feel like you have a lot of big fans. I'm a big fan. What I have found in talking about some of your ideas with people who are also readers of yours is that you're a bit of a roar shock test in psychiatry.

Like I feel like you have a very wide array of people that read you and have different ideas about what psychiatry should be. So I kind of want to ask you globally, what is your personal mission? Why do you do the work that you do? Yeah, it's interesting that you kind of mentioned how different people, I think, interpret and understand where I'm coming from differently and sometimes I think of my place in the current, you know, landscape of psychiatric discourse as being like a, partial agonist, you know, like Abilify, you know, a amidst kinda poly agonist and antagonist.

I think the reason is that I think traditionally the intellectual landscape has been very much polarized. It's been [00:03:00] divided, it's been kind of split between a traditional medical, mainstream psychiatric kind of view, which has very much emphasized kinda neuroscience, pharmacology, you know, bio-psychosocial model to a certain extent.

And on the opposite side of what is, what tends to be called critical psychiatry, you know, ha has can also has overlaps with, with Antip psychiatry. That tends to deprioritize the role of diagnosis tend to reject kind of dis disorder concepts, tend to kind of understand, take a more skeptical view towards role of medications and neurostimulation, et cetera.

And the way I kind approach these debates, I'm relying on a lot of work that has been done in philosophy of science and philosophy of psychiatry in recent decades. The way these traditional debates have been framed and conceptualized, I think doesn't make a lot of sense. I think once we examine those fundamental assumptions, it turns out the very assumptions guiding that polarized debates were wrong to [00:04:00] begin with.

So think of a lot of the work that I do as being in, in the middle, are taking the middle road. although that's not, you know, a, very apt metaphor, it's more, problematizing the current discourse. So what happens is that different people who are approaching. My work through different back kind of background assumptions, you know, and sympathies, the more mainstream oriented, they, they are, they, tend to see me as being more critical versus you know, people who are full fledged in the critical psychiatry camp.

They tend to see me as being more mainstream. So it ends up being an interesting, you know, kind of RA test you said. The other thing I think has to do with the format. A lot of the writing that I've done in recent years has been through my blog and newsletter. So I'm tackling a topic one chunk at a time, and I'm not devoted to an overarching.

Physician that, you know, can immediately be tagged as mine. And I'm more interested in understanding things in a thoughtful manner, [00:05:00] trying to work through different details. So what happens is that someone may read, you know, one blog post I've written on, let's say, issues around autism and another one that I've written on issues around involuntary psychiatric treatment.

And they might get a very different snapshot of what my overall philosophy is just from reading that one, one post. So to step back a little bit, I think my, the. Overall ideas and goals and values animating me are twofold. First is kind of more abstract and conceptual, is that, you know, my perception as a psychiatrist is that the field is very conceptually muddled.

A lot of practicing psychiatrists, both. Clinicians and researchers, they don't have a good grasp of the basic ideas that they're relying on. You know, issues around diagnosis, disorder, judgments, issues around psychiatric explanation, you know, role of values, role of theory, and so, so I've been advocating what I call conceptual competence.

To better understand the assumptions inherent in [00:06:00] psychiatric practice, in psychiatric research, to have the appropriate vocabulary and philosophical ideas to talk about them. And ha then having kind of like the right intellectual, frameworks for those debates and having the right kind of conceptual humility.

For that. So I've been promoting conceptual competence in psychiatric training and in other contexts too. the other part of it is clinical, is that I'm dissatisfied with various aspects of psychiatric clinical practice, and I think the clinical care that the average person receives, you know, in the US but also in many other parts of the world, is.

Very impoverished in, in different ways and, I, think it is lacking in the kind of humanistic relational quality that psychiatry at its best has to offer. So the other strand of my work is more kind of practical and clinical and hoping to improve the state of affairs. Second Strand, I join you in that.

That is exactly the mission of why this podcast was [00:07:00] started, and kind of what we're aiming to do is provide some of that more humanistic approach. I think it makes sense to me that you're saying the way people interact with your work is based on perspective. I can imagine being someone firmly in the critical psychiatry camp and saying, oh, how refreshing to have this establishment psychiatrist, this practicing clinical psychiatrist who was profiled in the Lancet.

Listening to our ideas and analyzing our ideas and appreciating our perspective. And I can tell you, as someone who first encountered your work, when I was going through formal medical training, it was very refreshing to see someone thinking about these deeper issues from a critical lens when I felt like what I was learning was overly simplistic in a lot of ways.

I really enjoyed diving through your whole body of work. Preparing for this episode. I'm gonna pitch you a few different concepts, kind of from all over the map on your substack. The first is the repenting psychiatrist and the repressing psychiatrist. I think that when you describe those various groups that are reading your work, you started to paint [00:08:00] maybe a slight caricature of each of these theoretical people.

So theoretically speaking. Who is the repenting psychiatrist? Who is that character? Who is the repressing psychiatrist? So, so you're referring to a piece that I wrote a while back. It's called Psychiatric Psychodrama, and that piece is based on a philosophical work by the philosophical Liam Kofi Bright.

And what Bright was doing in his paper was titled, white Psychodrama, and it was about kind of culture wars and especially kind of, you know, culture of wars around racial issues. Bright's thesis was that. A lot of the underlying issues and dynamics around the culture war are sustained and generated by material inequalities, kind of socioeconomic material inequalities.

A lot of the, work that is going into the culture work is kind of tangential to those socioeconomic inequalities. It is, not addressing them, but it's. The kind of like, you know, it's perpetuating it, I mean, that kind of generates its own kind of [00:09:00] dialectics and contradiction. So I, took that idea and I felt that there was a similar kind of thing going on in, in psychiatry too, that psychiatry prides itself on pluralism.

We have a long tradition of the bio-psychosocial models. Psychiatry kind of prides itself on humanistic care. Prides itself on relational care. It, prides itself on, on, on thoughtful use of pharmacology and other medications. It prides itself on kind of patient agency, but if you look at kind of what's happening on the ground, there is.

A very heavy emphasis on diagnosis and pharmacology. A lot of people are dissatisfied with the care they're receiving. A lot of people have had very negative, dramatic experiences with psychiatric care. One of the reasons for this is that there are these. Larger kind of healthcare inequalities, and then the conditions in which psychiatrists are doing their work, you know, is impoverished.

And it's subject to all sorts of negative [00:10:00] incentives. There's scarcity of resources. You know, a lot of people don't have adequate health insurance. They don't have access to the right kind of treatments that they need. Different forms of psychotherapy, residential care, long-term psychotherapy, et cetera.

So some of. Of the negative care that people are receiving and some of the impoverished conceptual frameworks that they're encountering are driven by that. But a lot of the, what, you know, what we can call psychiatric culture war is tough, is focused on superficial issues. It's focused on issues around diagnosis, around classification, around.

Efficacy of SSRIs are you know, this or that kind of stuff. and they're kind of like very heated and polarized camps around that. And so, I kind of, the repenter and the repressor, I think emerges from that. So when people in the field encounter this reality of poor clinical care, impoverished, conceptual thinking, there is one group that tends to, Internalize that and take it very seriously. [00:11:00] But they do it in a manner that is very exaggerated, and it becomes performative in a, certain kind of sense where they just basically start condemning the field. They start lamenting the lack of progress. They start saying this or that. What the various ways in which the field has stalled or is disappointing.

patients. It's almost a kind of self-flagellation that is happening in the repenter side of what you can call the critical side versus. Presser one, the tendency there is to try to minimize or suppress the issues. It's, and it's like, hey, you know, sure there are a lot of problems, but if you go back, you know, 50, 60 years, things are at least better than that.

You know, we're, you know, evidence-based and this are that way. We at least we have these inter interventions, et cetera. Things are not so bad. We're, not doing so poorly. Sure. But sure we can make some progress and, that. Kind of tendency to minimize the prob, the extent of the problems of kind of further fuels, discontent and resentment are that I think some of [00:12:00] the aligned healthcare professionals, you know, social workers as well as I think many patients, they have this force on them to align with.

Either the Repenter or the, repressor. So they, tend to kind of get wielded or co-opted for one of those other purposes. So that's why, you know, we, we have certain patient lobbies that are very much mainstream medicine, mainstream psychiatry. They're very much pro involuntary, kind of hospitalization for example, or pro new medications or, you know, medications.

Even when, you know, efficacy may be doubtful versus there are other. Patient groups that are very much aligned with the critical camp and very skeptical of, you know, treatments may harm patient movement, et cetera. And then there's the, there's a kind of fourth group, bright calls, the non-aligned, which are trying to bypass this culture war debate and tension.

And then instead trying to focus on how can we kinda, you know, meaningfully improve things. how can we kinda, you know, improve the state of affairs? How can we make progress [00:13:00] that doesn't get. Stuck in this polarized, you know, dynamic between their rep Appenders and their oppressors. So I was talking about how some of the ways in which people are taking that non-aligned stance, you know, I, one, one researcher I mentioned was Nev Jones, kind of who has done wonderful work on phenomenology, wonderful work on, kinda healthcare service delivery.

Wonderful work on, you know, various forms of involuntary commitment. I presented Nev Jones work as an example of someone you know, who can be in the non-aligned category within this broader psychiatric psychodrama. And, you know, also I think models like the Tris model in Italy, I think they bypass some of that inherent tension, you know, between their pento oppressor and try to find a productive way forward.

So it was basically a, plea for, hey, we're stuck in this psychiatric culture wars. We need. it's taking up a lot of our attention. It's, you know, sucking up a lot of the oxygen and there is [00:14:00] meaningful work to be done to reduce the actual, you know, inequalities. I have definitely seen both types of mental health professionals.

I've seen the caricature of the repenting psychiatrist. I've seen more of the caricature of the repressing psychiatrist. And I also wanna point out that in this non-aligned caricature, you're not saying this person is detached. You're saying that this person is rejecting the binary and trying to think creatively about how to maybe work together or see the truth in both sides.

Maybe call out the falsities on both sides in order to keep us focused on our patients and keep us focused on getting people healthier. Yeah, there's a, there is a certain detachment, but it's the detachment from the culture war rather than a detachment from the philosophical arguments or the clinical necessities.

I'd like to ask you to give a brief definition of pluralism. You mentioned pluralism there. I think that's a thread that is weaved through a lot of your longitudinal work and after you define pluralism for us. Could you name [00:15:00] maybe two or three concrete steps that you think we as a field need to take to more effectively wield pluralism to get better results for our patients?

So, pluralism by itself, it's a. Pretty loaded cash, you know, kind of buzzword and catchphrase that, you know, has different meanings in, in different contexts. So in, in, some ways, you know, you can be pluralistic about pluralism and, I tend to use it as a shorthand for the idea that when it comes to medicine, when it comes to psychiatry, mental health care, we're dealing with a wide variety of perspective.

And approaches and explanative frameworks. And it's not the case that one of these is obviously true, but rather it's often a case of each perspective has different kinds of advantages or disadvantages and it's about negotiating the values and other kind of advantages, disadvantages offered by each.

That's the general idea and and that's where you often use it. We can then use that to [00:16:00] specify different. Specific types of pluralism or specific applications of pluralism? So in philosophy of science, there has been a lot of work on what is called scientific pluralism in the early 20th century.

Philosophers of that time were heavily influenced by a movement known as logical positivism, and one of the hopes behind logical positivism was that there's a unity to the scientific method that all of the worst sciences we have. There is something that all these sciences share. So there is such a thing as a unitary scientific method.

And the second idea was that there is a kind of hierarchy of scientific disciplines such that higher order scientific disciplines can be theoretically reduced. To kind of lower order scientific disciplines. So biology can be reduced to physics and chemistry, and, psychology could be reduced to biology, you know, that kind of hierarchy.

Economics could be reduced to kind of psychology, that sort of thing. But by the second half [00:17:00] of the 20th century, it had become apparent to. Many in the philosophical community that hope for unity of science was misplaced. That, that there was just no valid way in which higher order sciences could be reduced to lower order sciences.

instead the emerging view was that we have this really kinda messy diversity of scientific theories, and some of them are at times even. You know, incompatible or inco, measurable, and they cannot be linked or inter integrated together into one big unified theory of sign. So. So there was this recognition that we are stuck with a plurality when it comes to science.

There, there is no single scientific method. There is no single unity of science. Instead, the worldview that we have is one of the words that should use in philosophical context is dappled. you know, that instead of having one [00:18:00] seamless theoretical description, we have. Statute description of the reality that we are working with.

So this is the idea, this is the idea of scientific brutalism that even within the domain of science we're dealing with all of this kinda I ideas. You can extend that to non-scientific perspectives as well. So for example, when it comes to mental health problems, we have different. Scientific theories and scientific disciplines understanding that.

But we also have non-scientific perspectives that we can use to understand mental suffering. There, there's still a role for, you know, religious and spiritual explanations, or there's still a role for example, you know, social explanations or cultural and explanations that don't technically fit within the domain of science.

So there's this broader term called harmonical parallelism by the philosopher Bennett Knox. That includes scientific as well as non-scientific respect. Within scientific pluralism applied to psychiatry, there's this idea that kinda we're dealing with multiple levels of organization, of [00:19:00] multiple levels of explanation.

Traditionally, these are often known as the biological, psychological, and social levels, but these are biological, psychological, social, are not. Rigid ontological levels that reality is built into, but rather just ways we are talking about how different things get together and we can splice it up differently.

So, for example, some other, theorists, they instead talk about the physiological and the experiential and social, cultural and the existential. So we can describe these levels in, in, in different ways. But, the idea is that we're dealing with different levels of explanation and levels of organization.

Because smaller components interact with each other in ways that produce new emergent properties. You know, you can have a bunch of chemicals and depending on how they're arranged in a biological system, you can have very different kinds of biological organizations. And then those biological organizations can, they can produce all sorts of behavioral [00:20:00] manifestations and you know, when it, when, different.

People are kind of, you know, an organisms, they interacting with each other. They can produce all kinds of social configurations, et cetera. So the idea that units can interact in different ways and produce new properties and exhibits, new behavior comes in. So sometimes when people are talking about pluralism, they're talking about.

Just the fact that our explanations of mental health problems are going to be divided across these different levels. There was the hope in the 20th century that we'll be able to reduce that complexity and show, for example, that the biological level is superior and it provides gonna, you know, more predictive value than the other levels.

But that actually has not panned out. And what we are seeing is that the. Risk factors and causal factors and other kinds of influences for mental health problems. They're distributed along levels of explanation. So, you know, cellular, genetic brain circuitry, cognition, you know, phenomenology, social interaction, et cetera.

It's [00:21:00] all it. Kinda working together in a complex, interactive manner rather than one level having a superior kind of thing. And then one final strand that I'll say that comes to kind of, you know, issues of classification in, psychiatry, there was the hope in, the second half of 20th century that there are discreet disease entities in the realm of mental health.

In the same way we kind of have discreet entities in some other areas of medicine. And, you know, like we have, you know, discreet infectious diseases in Id like, we have, autosomal genetic disorders, some discrete illnesses like Huntington's disease, multiple sclerosis. And if there are disease, discrete diseases like that, then different risk factors would all converge onto them.

and that we would provide a kind of unified explanation of what's going on. And the goal of classification would be in that case, to identify those hidden. Disease entities, you know, so the correct classification would be the one that matches those [00:22:00] disease entities in the same way as we kind of classify the periodic table of elements to kinda kind of capture their structure and properties of atomic nuclei.

It kind of became clear in the 1990s and early two thousands that the different lines of research evidence that we have. They are not converging in a manner that suggests that we are dealing with discreet, these entities, you know, they're not aligned very well. Genetics is you know, does not correspond neatly to clinical symptoms and doesn't correspond neatly to brain circuit abnormalities and doesn't correspond neatly to treatment response, et cetera.

Right? And so there's a misalignment between all of these different things. So if. Rn discrete is entities. If there are no hidden essences, it means that there is no one true classification. It means that you can map and carve up the space of psychopathology in kind of different ways, and different ways are going to have their corresponding advantages.

You know, like one method of classification might be [00:23:00] superior in capturing genetic associations, and another method might be superior in predicting treatment response or you know, just as an example. And so you can use different classification for different purposes. But there is no one true, absolutely true classification to speak of.

So that's another way in which pluralism kind of manifests in, in the mental health area. Thank you for explaining pluralism to us and going through the way it affects our current psychiatric practice. A lot of the things that Dr. Aftab just touched on are going to inform his six suggestions for DSM six that we're gonna talk about in episode two of our two part series.

Standby. We're gonna pick up with some more of Dr. Aftab's. Very unique ideas when we come back.

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Welcome back, Dr. Aftab. In the first episode ever of Psychiatry Bootcamp, you and I talked about one of my [00:26:00] favorite topics, which is handling the moment that we impart a psychiatric diagnosis. I think giving someone a label from a place of authority, maybe when we're wearing a white coat, brandishing our credentials representing the scientific community.

Maybe we're billing for the visit. It's not a neutral. Process. It's not a casual experience. It's not something that any clinician should ever see as a routine part of their day, even if they're doing it several times a day. I think that imparting a diagnosis to an individual, placing a label on an individual is what it feel like, feels like, should be approached with reverence, because the implications of such a moment of the moment are very extensive.

So since our first conversation, you've explored an idea that you call the rumple still skin effect. Can you explain for us the Rumple Still skin effect? Yes, so, so this was an idea developed in, in conjunction with, professor Alan Leitz, who's a, professor of philosophy and religion at James Madison.

And the effect itself refers to [00:27:00] the therapeutic repercussions of diagnosis by itself. That the positive effect experienced by the mere act of receiving an official medical diagnosis. and it's intended to refer not just to psychiatric diagnosis, but to diagnosis across medicine. And we were struck by these reports as well as, you know, my own clinic experience of patients where people who have struggled with certain issues for prolonged periods and haven't quite had a name for it or from.

Diagnosis. So often in middle age when they receive diagnosis such as a DHD or diagnosis such as autism, sometimes depression, they report this feeling of tremendous relief. They feel that something valuable has been given to them. Some new explanative perspective has opened up to them and they can see their own life and the years they have spent suffering in a new way.

And it offers them clarity. So some people even kind of. Cry, you know, in, in a good way, on, on receiving a diagnosis of a DH, ADHD or autism. [00:28:00] So, so we were struck by that phenomena and we wanted to analyze and talk about it further. And the curious thing was that all of this has been recognized and noted and commented on.

No one had formally. Kristin had given it a name and no, no one had formally defined it or theorized about why these kind of things are happening. So, so we wanted to remedy that and, the reason we went with Rumpel Still Skin as the choice of name is that it refers to one of the folk stories in kind of Grimm's folk stories and.

Story goes that there was this woman and, she makes a deal with a person that she would give that person her first born child in return for the ability to spin strong to gold. And in using that ability, the woman generates a lot of money and her life's turned around. And years later when she has her first son, the man comes to collect.

The woman at that point, you know, she's hesitant to do so and she wants to get out of that bargain in some way. So the person gives her the option. He, he says [00:29:00] that if you can guess by real name then you'll be free from this requirement and you don't have to give me, gimme your son. So she tries.

She tried to guess, you know, all kinds of name. any name German, you know, you know, it's a German story, so she tries to think of any German name she could think of, but none of that is successful. And eventually one of the servants tracks down the obscure real name of that person, which is Rumpel Sill skin.

And the woman says that, and she's released from that difficult situation. So it refers to this idea that there are these obscure characterizations of conditions. That have a certain legitimacy that commonsensical descriptions don't, and they come with certain kind of benefits. So, you know, in many sci-fi stories and fan fantasy stories, this idea comes in that in order to tap into the magic of something, you have to either, recognize or capture their true name.

You know, you, see that kinda idea and it also. Plays a role in [00:30:00] different kind of shamanistic practices where it's not just ordinary knowledge, but it's special technical knowledge in, in, in some sense. So what is happening in some ways in medicine is that it's not just the case that the doctor is describing their problem to them in ordinary language, but it they're presenting their problem to them in using a language that is divorced from our ordinary language that is technical in some way, specialize and contains some kind of institutional.

Authority or cultural authority. So for example, someone saying that they struggle with focus difficulties and sitting skill and paying sustained attention. That description doesn't have the same value as a doctor saying, do you have attention deficit hyperactivity disorder, you know, a formal diagnosis, you know, in similar kind of situations.

Same thing with kinda autism, you know, with chronic fatigue. And what was curious is that. This happens even with descriptive diagnosis, which don't otherwise offer an [00:31:00] explanation. There's a, kind of analogy here with the placebo effect. It's not a, it's not a perfect analogy, but I think it can be drawn, is that when people take medications, they experience benefit and, you know, some of the benefit is because of the active ingredients in that medication.

But some of the benefits is from just the act of taking a medication expecting you'll feel better. And so we can think of. Diagnosis in certain situations as being inactive diagnosis that are conferring benefit simply by virtue of a medical professional giving an official sounding, you know, diagnosis in the context of a medical ritual.

You know, the per the person is coming to the doctor, going through a systemic and assessment. So our culture. Places a lot of value in this kind of medical ritual and medical authority and that shows up in this way. There are probably other mechanisms as well. I, think one of the mechanisms is simply a switch between ordinary language and medical language.

I think our ordinary way of [00:32:00] talking about problems is often very lain with personal responsibility. It's often lain with, blame in some way, you know, up. Parents saying that their, child struggles with attention has often connotations of being lazy or being undisciplined, not exerting enough effort versus medical language is usually divorced from blame and shame.

And it, it focuses much more on mechanisms and kind of trying to understand what's going on in, in the brain and in the mind and trying to intervene on that. So simply it's, some of it is, I think a shift from ordinary language and its relationship with kind of agency and blame. To, kind of like a more medical language that has, that is agnostic towards that.

And I think second is, I think, it provides a node for storytelling and identity about these problems. I think someone who has struggled, for example, with social communication difficulties and repetitive behaviors, but had no name to talk about it now suddenly has a name they can use that. Connects them with other [00:33:00] people who have those difficulties, that connects them with research and other studies that have been done and provides them with a community as well as a source around which knowledge can be organized.

So I think that's another factor involved in this too. You know, along with some of these cultural factors around medical rituals and other things that I've mentioned. I think when you don't have that formal diagnosis and you describe the behaviors using lay language, and often this is done in non-professional relationships, you are.

Necessarily embedding moral judgment into that judgments about a person being good or bad, or right or wrong. And when you medicalize it, it's much easier to say, we're just describing a pattern of symptoms, a pattern of behaviors that we have a lot of experience with. And I think by demoralizing and saying, it's not that you're a bad person, it's that you're having these problems that.

Automatically gives the person more hope, makes them feel less helpless. And then you add that with, by the way, we [00:34:00] have a lot of experience with this problem. You can read all these research papers on it. We have these FDA approved treatments for this problem that gives a person even more hope. And so just by having that diagnosis, they might get some traction under their wheels that they may not otherwise have.

But I do wonder if in 2026 we might also be experiencing the opposite of the rumble stilson effect, right? So maybe there are times when a label isn't pardoned by giving a name to the dysfunction. We're reinforcing the dysfunction providing a script for the patient to play out, to keep them in the sick role.

Are we contributing to sort of a self-fulfilling prophecy where because someone understands their brain in a certain way. They feel compelled, maybe automatically or by nature of the way their neurons are arranged. Even if you, and I don't understand these descriptive diagnoses, to mean that their neurons are arranged in a certain way, right?

Does a person feel limited and therefore not experience healing and clarity like in the repel still skin effect, but experience a reinforcing of these. I'm [00:35:00] gonna call them pathological symptoms and behaviors.

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Yeah, you're very right. and, there's a section of our paper on the Rumpelstiltskin effect where we tackle these and you can consider them hydrogen effects of the diagnosis. You know, all the ways in which a negative, the effects of person. So that's very true. And if you look at the research that has been done on.

Psychological and social effects of medical diagnosis and psychiatric diagnosis. We see [00:37:00] positive themes emerge, you know, positive effects in self-image and all those kind of things that you know, that we talked about. But then consistently, all the qualitative research that has been done also consistently shows negative effect of medical diagnosis and psychiatric diagnosis on a, variety of different aspects of psychological and social functioning and my own kind of.

Perception is that this has to do with kind of two sorts of pathways. I think that the first one is the stigma pathway that if a condition or a diagnosis pretty heavily stigmatized, you know, receiving that diagnosis, one marks the person in terms of other people shying away from them or just stereotyping them or having negative assumptions about them.

But it all, there's also this internalized. Stigma where the person now themselves sees them in a negative light and thinks that, you know, something is deeply wrong with them, something that they're broken in some manner. So one, I think is the issue of, of stigma, including internalized stigma. The second relates to what we can call [00:38:00] essentialism most.

People, when they think of medical categories and psychiatric categories, they, tend to imagine that there is a kind of hidden essence to that category that makes that problem what it is, that is shared by all of those problems. And there's also a tendency to think that. Essence is fixed and unchangeable.

And I think when people have those kinds of ideas or when they tend to interpret a, psychiatric diagnosis or psych psychiatric re in that essentializing manner, they can have this belief that whatever problem I'm having, I am stuck. This problem, this, is fixed, this is unchangeable, this is not going away.

And I have to work around the problem rather than try to change it. So someone, for example, if someone who has generalized anxiety disorder, let's say they receive that diagnosis and they begin to think, well, you know, that's just who I am. I'm anxious. You know, and they, start avoiding social situations because they make them anxious.

They will actually get stuck in a self-sustained [00:39:00] anxiety situation because anxiety. Thrives on avoidance and you know, one of the best treatments for that is actually exposure, right? So if the behavior changes in such a manner, you can continue the problem in a self-fulfilling kind of sort of fashion.

This can even be true in conditions that we tend to think of as having more newer developmental significance. So things like ADHD and autism. Core features of these conditions, they, generally persist. They generally don't go away, but the, severity fluctuates considerably over time for a lot of people and kind of like the impairment or distress they're having depends a lot of the, on the circumstances and sometimes they're also the issues of developmental maturity.

Some things get better and there's also to some degree. Modifiable using skills training. So if someone, for example, someone gets the diagnosis of A DHD and they begin to think, well that said, you know, I have this fixed problem with my [00:40:00] attention that I'm gonna have for the rest of my life. They might start kinda acting in ways that just reinforces that attention deficit instead of acting in ways that tries to help them grow and overcome.

Comes some of those aspects of it. Same thing with autism. Someone who just accepts that and says, well, you know, I'm just bad with people. I'm just not gonna, you know, this is fixed and I'm changing. Might give up on valuable social skills training that they can actually use to change the severity of it or change their functioning over time.

So I think, so this is, I think the second part is, I think ideas in which people. Tell these stories that trap themselves in a certain pattern of impairment instead of thinking of diagnosis and opportunity to try to improve things, to see to what, extent they can improve their lives. I think that we should definitely forgive any patient who is experiencing this, misunderstanding about what a psychiatric diagnosis [00:41:00] is and any patient who thinks that a psychiatric diagnosis, which I think you and I would agree, is descriptive, just describes a cluster of signs and symptoms and behaviors.

Some patients might think of them more as diagnoses that necessarily include. A causal mechanism, right? A chemical imbalance. We need to forgive those patients because the people giving them the diagnosis don't understand this. I mean, this isn't it covered in medical training. these questions don't show up on standardized board exams, and when they don't show up on standardized board exams, they don't make it into medical training, and that's high level medical training.

So I cannot thank you enough for bringing this level of complexity to the topic. I think it's just super important to say more often. Yeah, no, and I agree with you that this is not the fault of patients that they're interpreting, you know, these categories in this way, but this is, partly reinforced by the kind of public education and public communication that the medical profession has undertaken.

You know, I think a lot of the vocabulary around psychiatric diagnosis has [00:42:00] been with chemical imbalances, brain diseases, brain disorders, brain circuit disorders. And if you are a lay person and you're constantly exposed to this kind of vocabulary, you know, a around you, then it is very natural for you to have these kind of centralistic assumptions about psychiatric diagnosis.

In other areas of science, and you just described all the different forms of sciences, we demand that the public just accept what we say as gospel in terms of, let's say, infectious diseases, right? Because we don't have time to explain it all, and we sort of can't. And so it's very difficult for a patient to say, what do you mean?

Some of this public communication about psychiatry is more complicated than you have led me to believe. Yeah. Yeah. and if I think, you know, recently there has been a, wave of memoirs and other patient stories of how, you know, their negative experiences with psychiatric diagnosis. And, one common theme in almost all of them is that they had complex, multifaceted problems with a lot of relational aspects.

And they were given a [00:43:00] diagnosis early in age, oftentimes, you know, in, in teenage years. And they were told a story of it, or their, the suggestions they were given was that this is a very. Heavily biological disease that's gonna stay with you for the rest of your life, and you're gonna need medications for the rest of your life.

And they can accept that story at that early age, and it shapes their self image. But then 10 years later when that story falls apart and they realize that, you know, hey, it's actually much more complicated. And, you know, this is also modifiable to a certain way. And, you know, there are these, there were these relational factors keeping it going.

They experienced a sense of disillusion, man and a loss of trust in the, medical profession. I would say rightfully so. Dr. Aftab, thank you for this episode and we will continue our conversation in two weeks.

Thanks so much for listening this episode of Psychiatry Bootcamp. look forward to two weeks from now when we will be back with Dr. Awais Aftab to talk about six suggestions for DSM [00:44:00] six. If you're enjoying the show, we'd love to know what you think. You can connect with us on TikTok or Instagram at Psych Bootcamp.

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