All In Your Head Excerpt: Psychiatry and The Isolated Demand for Rigor

Freddie deBoer

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All In Your Head Excerpt: Psychiatry and The Isolated Demand for Rigor<br>disorders without objective tests and medicines that work despite a lack of understanding of their physiological mechanism are perfectly common

Freddie deBoer<br>Jul 31, 2026

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preorder!<br>Hello folks, I’ve been waiting to read this Emmet Rensin piece on Laura Delano for The Lamp for a long time. I highly recommend you check it out. Its publication has given me a kick in the ass to share with you the first of several excerpts from my forthcoming book, All In Your Head: Illness as Identity, Trauma as Fashion, and the Desire to be Disordered. I’m going to give you guys a nice long one a month out from pub date, subscribers only, but before that I want to publish a series of smaller chunks that give you a sense of what I’m up to. This is the first of those chunks.<br>In this brief passage, I address one of Delano’s must constant critiques, that psychiatric diagnoses involve no objective tests and that we don’t know how or why various psychiatric medicines function. This is supposed to be damning, but in fact, that condition is remarkably common across medicine, including in the “hardest” of specialties and for all manner of disorders and treatments. This selection addresses that condition. Note that there are many more conditions that have no objective test that I could have listed, such as interstitial cystitis, and medications that are effective even though we don’t know how they work, such as levetiracetam for epilepsy. Then, I give you a snippet on the concept of the “chemical imbalance” and how unhelpful the rush to declare them nonexistent has been. I hope you enjoy this excerpt, and that if you do, you’ll consider preordering a copy. Preorders are massively important for a publishing house’s perception of a book’s success, and their opinion about this book will determine whether I’ll get to keep writing books. Thanks.<br>The denial of mental illness as “real illness” depends on the false premise that disease must always be visible through gross pathology, like tumors or lesions seen in an autopsy. But many recognized diseases, including epilepsy, most migraines, multiple sclerosis, various chronic fatigue syndromes, or early-stage Parkinson’s disease, often present without any clear macroscopic signs and are diagnosed by clinical symptoms, sometimes supported by imaging or biomarkers. A headache is one of the most common and oldest medical maladies known to the human species; texts from antiquity are rife with descriptions of what we would all recognize as conventional headaches. (See, for example, The Hippocratic Corpus from the fifth or fourth century BCE or references on ancient Assyrian medical tablets from seventh century BCE Mesopotamia.) And yet in most cases headaches have no pathologically evident basis, no physiological consequences that are observable to outside witnesses. I think, however, that most of us are partial to the idea that headaches are real. Psychiatry has a less complete biological toolkit than other medical specialties, but this reflects the complexity of the brain, not the invalidity of the conditions the specialty treats. To argue that mental disorders are not diseases because they cannot (yet) be pinned to a single lesion or pathogen is to apply a selectively stringent standard that no other branch of medicine is held to.<br>The story is similar when it comes to treatment. Critics of psychiatry often point to a lack of understanding for why psychiatric medications work as a sign that the field is illegitimate. But again, this is an isolated demand for rigor: many medications work without our understanding why. We don’t know how many painkillers work—acetaminophen, propofol, sevoflurane, and ketamine being obvious examples where our knowledge of the exact biochemical mechanism at play is limited. But are you really going to refuse pain killers for surgery on that basis? Are you going to claim that Tylenol doesn’t work? Nor do we really know how magnesium treats heart arrythmia, why minoxidil helps slow hair loss, why modafinil works for narcolepsy, why metformin can help manage diabetes, why naltrexone has helped treat autoimmune disorders . . . Going all the way back, the practice of medicine has entailed using treatments that we do not fully understand. To hang psychiatry for this is just yet an other example of a fundamental double standard.<br>The notion of depression as a chemical imbalance emerged from a particular context regarding a particular disease, and yes, the influence of drug companies was at play. Serotonergic theory is flawed and deserves critique, but we ought not throw the baby out with the bathwater. It’s one thing to deny that a deficit of serotonin is the cause of depression and the prevention of the reuptake of serotonin the cure. To deny that there is any neurochemical basis...