Reification in mathematics and medicine

Can you bring an object into existence just by naming and describing  it?  Well, no one has created a unicorn yet, but mathematicians and docs do it all the time. Let’s start with mathematicians, most of whom are Platonists.  They don’t think they’re inventing anything, they’re just describing an external reality that is ‘out there’ but isn’t physical. So is any language an external reality, but when the last person who knows that language dies, so does the language.  It will never reappear as people invent new languages, and invent them they do as the experience with deaf Nicaraguan children has shown [ Science vol. 293 pp. 1758 – 1759 ’01 ]. Mathematics has been developed independently multiple times all over the world, and it’s always the same.  The subject matter is out there, and not only a social construct as some say.  

A fascinating book, “Naming Infinity” describes a Russian school of mathematicians who extended set theory beyond the work of the French and Germans. They literally believed that describing a mathematical object and its properties implied that the object existed (assuming the properties were consistent).  The mathematicians involved were also very devout mystical Christians, who were called “Name Worshippers”.   They thought that repeatedly invoking the name of Jesus would allow them to reach an ecstatic state.  The rather contentious theory of the book is that their religious stance allowed them to imbue all names with powerful properties which could bring what they named into existence and this led to their extensions of set theory. Naturally the Communists hated them, and exterminated many (see p. 126).  People possessed of all absolute truth dislike those possessed of a different absolute truth.

Docs bring diseases into existence all the time simply by naming them.  This is why the new DSM-V (Diagnostic and Statistical Manual of  Mental Disorders) of the American Psychiatric Association  (APA) is so important.  Is homosexuality a disease?  Years ago the APA thought it was.  If your teenager won’t do what you want, is this “Adolescent Defiant Disorder”?  Is it a disease?  It will be if the DSM-V says it is.

There are a lot of things wrong with what the DSM has become (297 disorders in 886 pages in DSM-IV), but the original impetus for the major shift that occurred with DSM-III in the 70s was excellent.  So it’s time for a bit of history.  Prior to that time, it was quite possible for the same individual to go to 3 psychiatric teaching hospitals and get 3 different diagnoses.  Why? Because diagnosis was based on the reconstruction of the psychodynamics of the case.  Just as there is no single way to interpret “Stopping by Woods on a Snowy Evening” (see the previous post), there isn’t one for a case history.  Freud’s case studies are great literature, but someone else would write up the case differently.  

The authors of the DSM-III decided to be more like medical docs than shrinks.  In a state of ignorance, docs define diseases by what they do —  the symptoms, the physical signs, the clinical course.  So the DSM-III  abandoned the rather literary approach and started asking what psychiatric patients looked like — were they hallucinating, did they take no pleasure in things, was there sleep disturbance, were they delusional etc. etc.   Now no individual fits any disease exactly.  There are always parts missing, and additional symptoms and signs added to confuse matters.  The net result was that psychiatric diagnosis became like choosing from a menu in a Chinese restaurant, so many symptoms and findings from column A, so many from column B. 

This led to a rather atheoretical approach, but psychiatric diagnoses became far more consistent.  Docs have been doing this sort of thing since the beginning.  Different infections were classified by how they acted, long before Pasteur proved that they were caused by micro-organisms.  Back when I was running a muscular dystrophy clinic, we saw something called limb girdle muscular dystrophy , in which the patients were weak in muscles about the shoulder and hips.  Now we know that there are at least 13 different genetic causes of the disorder.  So there are many distinct causes of the same clinical picture.  This is similar to the many different genetic causes of  Parkinson’s disease I talked about 2 and 3 posts earlier.  At least with limb girdle muscular dystrophy it is much easier to see how the genetic defects cause muscle weakness — all of the known genetic causes involve proteins found in muscle. 

Where DSM-IV (and probably DSM-V) went off the rails, IMHO, is the multiplicity of diagnoses they have reified.  Do you really think there are 297 psychiatric disorders?   Not only that, many of them are treated the same way — with an SSRI (Selective Serotonin Reuptake Inhibitor).  You don’t treat all infections with the same antibiotic. This makes me wonder just how ‘real’ these diagnoses are.  However in defense of them, you do treat classic Parkinsonism pretty much the same way regardless of the genetic defect causing it (and at this point we know of genetic causes of less than 10% of cases).  

There is a fascinating series of articles in Science starting 12 Feb ’10 about the new DSM-V.  The first is on pp. 770 – 771.  One of the most interesting points is that 40% of academic inpatients receive a diagnosis of NOS (Not Otherwise Specified — e.g. not in the DSM-IV — clearly even 297 diagnoses are missing quite a bit). 

But insurance companies and the government treat this stuff as holy writ.  Would you really like your frisky adolescent labeled with “prepsychotic risk syndrome” which is proposed for DSM-V.  Also, casting doubt on the whole enterprise, are the radical changes the DSM has undergone since it’s inception nearly 60 years ago.  We’ve learned a lot about all sorts of medical diseases since then, but strokes and heart attacks back then are still strokes and heart attacks today and TB is still TB.  Do these guys really know what they’re talking about, and should we allow them to reify things?

That being said, cut psychiatry some slack.  Regardless of theory, there are plenty of mentally ill people out there who need help. They aren’t going to go away (or get better) any time soon.  Psychiatrists (like all docs) are doing the best they can with what they know.

That’s why it’s nice to be retired and reading stuff that it is at least possible to understand — like math, physics, organic chemistry and molecular biology.  But never forget that it is trivial compared to human suffering. That’s why the carnage in the drug discovery industry is so sad — there goes our only hope making things better.

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