Misunderstanding Psychiatry (and Philosophy) at the Highest Level
Misunderstanding Psychiatry (and Philosophy) at the Highest Level
Recent book reviews by Marcia Angell, MD1—the highly esteemed, former editor in chief of The New England Journal of Medicine—have stirred great controversy within psychiatric circles, as evidenced by the heated exchange of letters published in The New York Review of Books.2-4 Perhaps—to paraphrase a line from the film Cool Hand Luke—“What we got here is a failure to communicate!”
Certainly, when someone of Dr Angell’s sophistication gets psychiatry (mostly) wrong, our profession has a daunting problem on its hands. I do not intend to explore the many erroneous claims proffered in Dr Angell’s reviews and letters, most of which have been rebutted by several prominent psychiatrists.2-4 (For a magisterial de-bunking of the “antidepressants are just expensive placebos” myth, I recommend the splendid monograph by Davis JM et al.5) Instead, I want to focus on one particularly troubling passage in Dr Angell’s rejoinder to Drs Richard Friedman and Andrew Nierenberg. She states therein that
“[Drs Friedman and Nierenberg] are simply wrong in asserting that psychiatry, in using drugs to treat signs and symptoms of illness without understanding the cause of the illness or how the drugs work, is no different from other medical specialties. First, mental illness is diagnosed on the basis of symptoms (medically defined as subjective manifestations of disease, such as pain) and behaviors, not signs (defined as objective manifestations, such as swelling of a joint). Most diseases in other specialties produce physical signs and abnormal lab tests or radiologic findings, in addition to symptoms. Moreover, even if the underlying causes of other diseases are unknown, the mechanisms by which they produce illness usually are, and the treatments usually target those mechanisms . . . [italics added].”2
In my view, Dr Angell’s assertions reflect both a serious misunderstanding of psychiatric diagnosis, and—equally important—a failure to address the core philosophical issues involved in her use of the terms “subjective,” “objective,” “behaviors,” and “signs.” The bright lines of separation drawn by Dr Angell—eg, between “behaviors” and “signs,” “psychiatry” and “general medicine”—are in fact far fainter than she acknowledges. But this is not surprising. Dr Angell’s analysis is part of a long-standing narrative—alas, sometimes embraced by psychiatrists themselves—that has had the effect, if not the intent, of marginalizing and denigrating psychiatry.6
Let’s focus on the linguistic and philosophical issues that underlie Dr Angell’s claims regarding psychiatric diagnosis. First, let’s dispatch the demonstrably erroneous claim that psychiatric diagnosis does not involve “signs.” To be sure, most psychiatric diagnoses are made primarily on the basis of the patient’s self-expressed reports, experiences, and complaints—in effect, his or her “symptoms.” And, unfortunately, DSM-IV itself contributes to the confusion by calling any feature of psychiatric illness a “symptom.” The framers should have been more precise in their terminology!
However, using the definition of “sign” common in general medicine—ie, “Any abnormality indicative of disease, discoverable on examination of the patient; an objective indication of disease, in contrast to a symptom, which is a subjective indication of disease”7—we find that a number of “signs” are indeed part of the criteria sets for several DSM-IV psychiatric disorders:
• Significant weight loss (major depressive episode, anorexia nervosa)
• Psychomotor agitation or retardation “. . . observable by others, not merely subjective feelings of restlessness or being slowed down” (major depressive episode)
• Increase in goal-directed activity . . . or psychomotor agitation (manic episode)
• Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli) (manic episode)
• Motoric immobility as evidenced by catalepsy (including waxy flexibility) or stupor (schizophrenia, catatonic type)
• Stereotyped movements, prominent mannerisms, or prominent grimacing (schizophrenia, catatonic type)
• Avoidance of eye-to-eye gaze (autistic disorder)
• Delay in development of spoken language (autistic disorder)
I have deliberately omitted signs of cognitive disorders (impaired recent memory, impaired calculation, etc), such as Alzheimer disease, so as to head off the objection that “those are really neurological conditions.” And I have listed only those findings I believe are unambiguously “signs,” according to the definition provided. However, one could make a credible argument that many other determinations made by psychiatrists are in fact observations of “signs,” eg, pressured speech, loose associations, and markedly elevated affect. Then there are the many cognitive functions we assess, such as the patient’s ability to perform calculations, recall words, and draw a clock face, all of which enter into our diagnosis of delirium, dementia, and the amnestic disorders.
Of course, in addition to data obtained from the mental status examination, psychiatrists routinely assess a variety of external (non-subjective) validators of diagnosis—eg, the patient’s vocational function, prior hospitalizations, substance use, suicide attempts, family psychiatric history, and comorbid medical disorders. Finally, although not yet a part of routine clinical assessment, several biomarkers of psychiatric illness show considerable consistency across many studies—eg, enlarged cerebral ventricles and abnormal smooth pursuit eye movements in schizophrenia.8
“Philosophical problems begin when language goes on holiday.”
—Ludwig Wittgenstein, Philosophical Investigations
Now, I am (painfully!) aware of the kind of argument often marshaled against my list of putative psychiatric “signs.” It goes something like this:
Oh, come now, Doctor! With the exception of weight loss, you have really listed behaviors, not signs—at least, not as that term is understood by other medical specialties. In fact, you are really talking about certain “disapproved of” behaviors, such as an “increase in goal-directed activity.” Really, now! You are just making value judgments! Who is to say what degree of goal-directed activity is or is not normal? Don’t psychiatrists really just mean, “I don’t like how much social or sexual activity this guy is carrying out!”? And who is to say that there is anything pathological in maintaining certain postures for long periods? If you watch a group of people performing tai-chi, you could call them all “catatonic”! No—in general medicine, a “sign” is something objective, like swelling or pallor or hypoactive reflexes. And, these bona fide signs are usually reflected in abnormalities we can pick up in lab tests, imaging studies, nerve conduction studies, etc.
This essentially “positivist” view of medical diagnosis6—and of the distinction between signs and behaviors—has the ring of superficial plausibility. Indeed, I would guess that a number of psychiatrists would nod (somewhat ambivalently) in general agreement with it. But in my view, this analysis is quite wrong-headed. It creates a spurious distinction that, on closer examination, is not supported by the way several other medical specialties function in clinical practice. It also employs a sense of the term “objective” that harks back to the largely discredited school of logical empiricism (or logical positivism) that my colleagues and I have addressed elsewhere 6,9
Why, for example, does the neurologist’s statement, “The patient’s handgrip is weak,” describe an objective finding, whereas the psychiatrist’s statement, “The patient’s psychomotor activity is abnormally decreased,” entails a subjective judgment? (Could it be that neurologists simply don’t “approve of” certain degrees of muscle weakness? And that in a society that “valued” myasthenia, a weak handgrip would not be deemed pathological?) Why does the claim, “The patient’s finger appears swollen,” represent an objective finding, whereas the statement, “The patient’s speech is pressured,” represents merely a subjective judgment? Is there some scientific or epistemological principle that privileges visual or tactile over auditory data in deciding what counts as “objective”? One philosophically coherent meaning of “objective” stipulates 2 main requirements: careful and repeated observation and concurrence among multiple observers. On this view, psychiatric diagnosis is, to a considerable degree, an “objective” process.10,11
True: a swollen finger might well be correlated with, say, an elevated white blood cell count, whereas there may be no abnormal lab test associated with pressured speech. But it is not clear why that difference ought to render the determination of pressured speech merely “subjective.” (No general physician would dismiss a swollen finger as inconsequential or “merely subjective,” even if all the lab tests came back within normal limits.)
As for the objection that “you can measure the swelling in a finger, whereas pressured speech is just a judgment call,” I would reply thus: If psychiatrists wanted to devise a sophisticated recording device that computed the number and volume of words per minute spoken by the patient, we could easily do so. And, after all, how many general physicians “measure” their arthritic patient’s fingers before declaring that they are swollen? Of course, in our pathologizing of both terms—“swelling” and “pressured speech”—there is an irreducibly non-objective judgment. This is because each term requires general agreement on what degree of deviation from the norm constitutes “pathology.” This is not something that observation alone can tell us; it is ultimately an existential judgment, based on very broad concepts of “health,” “disease,” “impairment,” “suffering,” etc.
Furthermore, critics of psychiatric diagnosis need to acknowledge that a number of well-recognized medical and neurological disorders are essentially symptom-based constructs that do not necessarily or consistently “. . . produce physical signs and abnormal lab tests or radiologic findings.” Nor are the “mechanisms by which they produce illness” necessarily well understood. Consider the diagnosis of migraine headaches by our colleagues in neurology. As one recent review put it:
Migraine is a very common disabling brain disorder with unclear pathogenesis. . . . It is now generally accepted that the primary cause of migraine lies in the brain, but the nature and mechanisms of the primary brain dysfunction that leads to activation of the meningeal trigeminal nociceptors remain incompletely understood and controversial.12
Well, it’s good to know that the brain is involved! The International Headache Society criteria are the basis for migraine diagnosis, and these criteria are entirely symptomatic and “subjective” in nature, eg, complaints of unilateral, pulsating headache, often accompanied by nausea or photophobia.13 There is no “lab test” or neuroimaging study that is diagnostic of migraine headaches (although such tests may rule out a brain tumor or other pathology). Indeed, unless the physician witnesses the patient during an acute migraine attack, one could argue that the migraine diagnosis is made solely on the basis of a normal neurological examination and the patient’s verbal behavior, ie, the patient’s narrative history of symptoms.
Space limitations prevent discussion of conditions such as atypical facial pain and Meniere disease, but I would contend that these, too, are essentially symptom-based, clinical diagnoses. Even idiopathic epilepsy is regarded, to this day, as a clinical diagnosis, made primarily on the basis of the patient’s history. As neurologist Dr Anthony Marson puts it, “Epilepsy is a clinical diagnosis. . . . the diagnosis is not based upon the results of tests, but upon an accurate description of the attacks.”14 Furthermore, even a witnessed tonic-clonic seizure is, arguably, a series of “behaviors”: the patient falls to the floor, moves his limbs in a certain manner, bites his tongue, becomes incontinent, etc. In what fundamental sense do these behaviors differ from those of the patient with the catatonic subtype of schizophrenia, who assumes uncomfortable postures for prolonged periods and shows waxy flexibility, stereotypy, and automatic obedience?
If it is argued that the patient with catatonia is “producing” catatonic behaviors, whereas the person with epilepsy is involuntarily “experiencing” epileptic behaviors, I would reply that this amounts to a metaphysical speculation and a certain “theory of mind”—not a scientifically verifiable claim. Indeed, the distinction between “behaviors” and “signs” in both epilepsy and catatonia is largely semantic. Behaviors are, in effect, a subtype of “sign,” and conform to the definition of “Any abnormality indicative of disease, discoverable on examination of the patient.”7
As Dan J. Stein, MD, recently noted, “. . . both medicine and psychiatry rely on clinician-observed signs and patient-reported symptoms in order to reach a diagnosis” (personal communication, August 17, 2011). I would not go so far as to claim that psychiatry is “no different” from any other medical specialty. And, to be sure, most of the non-psychiatric conditions I have discussed here fall under the rubric of neurology. The data psychiatrists collect often do differ from those collected by, say, orthopedists or infectious disease specialists. We are less interested than these specialties in x-rays or urine cultures. We are more interested—as we must be—in the patient’s phenomenology: the structure and contents of his “inner world.”15 But the wall of separation implied by Dr Angell’s comments is, in truth, riddled with holes. Indeed, psychiatry bears more similarities to other medical disciplines than many clinicians either understand or acknowledge.
References
References
1. Angell M. The Illusions of Psychiatry. The New York Review of Books. July 14, 2011. http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry. Accessed August 18, 2011.2. Oldham J, Carlat D, Friedman R, Nierenberg A; reply by Angell M. ‘The Illusions of Psychiatry’: An Exchange. The New York Review of Books. August 18, 2011. http://www.nybooks.com/articles/archives/2011/aug/18/illusions-psychiatry-exchange. Accessed August 18, 2011.
3. Kramer PD. In Defense of Antidepressants. New York Times. July 9, 2011. http://www.nytimes.com/2011/07/10/opinion/sunday/10antidepressants.html?pagewanted=all. Accessed August 18, 2011.
4. Ghaemi N. Do antidepressants work? Asking the right questions. Psychiatry/Mental Health, 11:45AM Aug 3, 2011. Medscape Connect. http://boards.medscape.com/forums?128@49.4tMIab3F9mH@.2a0c9dc7!comment=1&cat=All&pa=3886333T1313530940564_13135309405641313530940568. Accessed August 18, 2011.
5. Davis JM, Giakas WJ, Qu J, et al. Should we treat depression with drugs or psychological interventions? A reply to Ioannidis. Philos Ethics Humanit Med. 2011;6:8.
6. Pies R, Thommi S, Ghaemi N. Getting it from both sides: foundational and antifoundational critiques of psychiatry. Psychiatric Times. July 1, 2011. http://www.psychiatrictimes.com/display/article/10168/1895157. Accessed August 18, 2011.
7. MediLexicon. Medical Dictionary, Medical Terminology. http://www.medilexicon.com/medicaldictionary.php. Accessed August 18, 2011.
8. Pies R. Beyond reliability: biomarkers and validity in psychiatry. Psychiatry (Edgmont). 2008;5:48-52.
9.Pies R. How “objective” are psychiatric diagnoses?: (guess again). Psychiatry (Edgmont). 2007;4:18-22.
10. Pies R. Psychiatry clearly meets the ‘objectivity’ test. Psychiatr News. 2005;40:17.
11. Sen A. Objectivity and position. http://www.globalhealth.harvard.edu/hcpds/wpweb/90_01.pdf. Accessed September 28, 2007.
12.Pietrobon D. Insights into migraine mechanisms and CaV2.1 calcium channel function from mouse models of familial hemiplegic migraine. J Physiol. 2010;588(pt 11):1871-1878.
13. IHS Classification ICHD-II. http://ihs-classification.org/en/02_klassifikation/02_teil1/01.01.00_migraine.html. Accessed August 18, 2011.
14.Marson A. What is epilepsy? Based on a text by Dr Per Rochat and Dr Jørgen Alving. http://www.netdoctor.co.uk/diseases/facts/epilepsy.htm. Accessed August 18, 2011.
15. Pies R. The anatomy of sorrow: a spiritual, phenomenological, and neurological perspective. Philos Ethics Humanit Med. 2008;3:17.
We will have to agree to disagree over the popularity of antidepressants. By number of prescriptions in 2010, antidepressants but no other psychiatric drugs occupy 2 of the top twenty spots (see here http://www.pharmacytimes.com/media/pdf/26babf64401fed80734dbf8dce471e26.pdf). I interpret from the fact that most of these are prescribed by non-psychiatrists, anti-depressants' wide acceptance as effective, safe, and desirable.
I am not sure Jaspers promoted a pluralistic model of psychiatry, rather, he promoted an atheoretical and anti-fadist model. The main point of my reply, if I was not clear, is that Angell's skepticism is part of a historical tradition of psychiatric skepticism, she is on the losing side of the battle historically speaking even though there is much to criticize in modern anti-depressant development and marketing, and that we as psychiatrists should focus on avoiding doctrine or fads (no "biopsychosocial" approach battered into new trainees for example) but continue to reinforce the progress we have already made.
I appreciate Dr. Bresch's taking the time to write. If I understand the thrust of his comments, he agrees with much of the content of my article, but doubts it is the right strategy in responding to Dr. Angell's denigrating remarks about psychiatry. Dr. Bresch opines that such provocations should be ignored. Unfortunately, it is difficult to ignore a prominent medical writer whose remarks were already the object of rebuttals by equally prominent psychiatrists, by the time I wrote my piece. And, I am not convinced that ignoring attacks on psychiatry (for such was the tenor of Dr. Angell's remarks) does anything more than encourage further such attacks.
Regarding Dr. Bresch's suggestion that "...medical psychiatry, biological psychiatry, has been more widely embraced than psychoanalysis was in the early part of the century. Angell is on the losing side, patients love antidepressants and MDs love prescribing them", I am more than a bit skeptical. For example, I am not sure by whom "medical psychiatry"(whatever that term means) has been "widely embraced." I am also not sure many patients "love" their antidepressants (though they may request them with initial enthusiasm); and the vast majority of antidepressants are not prescribed by psychiatrists in the first place.
I do agree with Dr. Bresch that psychiatry must "look within", and find a way to avoid the internecine feuding that characterizes so much interchange these days. Dr. Bresch alludes to this with his "two minds" phrase, recalling Tanya Luhrmann's famous work, "Of Two Minds"; in that book, she describes the warring factions of biological and psychosocial psychiatry. I believe that genuine reform of our field will occur only when the members of our profession, under strong national leadership, embrace and promulgate an integrated, holistic, but evidence-based model of care. This would certainly include the "medical" aspects of psychiatry, but would also encompass humanistic and psychosocial approaches. This pluralistic model--described by Glen Gabbard, Nassir Ghaemi, and, historically, by Karl Jaspers--seems to me the best hope for our beleaguered profession.
Ronald Pies MD
I very much appreciate Dr. Bresch's taking the time to write. If I understand the thrust of his comments, he agrees with much of the content of my article, but doubts it is the right strategy in responding to Dr. Angell's denigrating remarks about psychiatry. Dr. Bresch opines that such provocations should be ignored. Unfortunately, it is difficult to ignore a prominent medical writer whose remarks were already the object of rebuttals by equally prominent psychiatrists, by the time I wrote my piece. And, I am not convinced that ignoring attacks on psychiatry (for such was the tenor of Dr. Angell's remarks) does anything more than encourage further such attacks.
Regarding Dr. Bresch's suggestion that "...medical psychiatry, biological psychiatry, has been more widely embraced than psychoanalysis was in the early part of the century. Angell is on the losing side, patients love antidepressants and MDs love prescribing them", I am more than a bit skeptical. For example, I am not sure by whom "medical psychiatry"(whatever that term means) has been "widely embraced." I am also not sure many patients "love" their antidepressants (though they may request them with initial enthusiasm); and the vast majority of antidepressants are not prescribed by psychiatrists in the first place.
I do agree with Dr. Bresch that psychiatry must "look within", and find a way to avoid the internecine feuding that characterizes so much interchange these days. Dr. Bresch alludes to this with his "two minds" phrase, recalling Tanya Luhrmann's famous work, "Of Two Minds"; in that book, she describes the warring factions of biological and psychosocial psychiatry. I believe that genuine reform of our field will occur only when the members of our profession, under strong national leadership, embrace and promulgate an integrated, holistic, but evidence-based model of care. This would certainly include the "medical" aspects of psychiatry, but would also encompass humanistic and psychosocial approaches. This pluralistic model--described by Glen Gabbard, Nassir Ghaemi, and, historically, by Karl Jaspers--seems to me the best hope for our beleaguered profession.
Ronald Pies MD
Well written good and faithful servant!!!
Many thanks to my friend Zvi Lothane, for his thoughtful and challenging comments. He raises some very important issues and presents some useful concepts. I promise a substantive reply soon--and readers can decide whether my argument "falls flat on its face", or--as I believe--sits quite comfortably in its chair!
Best regards,
Ron Pies
P.S. Thanks to Sharon Winters, too, for the kind comment!
Dear Ron,
thank you for your friendly and lovely response!
Best regards,
Zvi Lothane
Many thanks, Dr. Newman, for your excellent perspective from primary care/Ob-Gyn! It is very reassuring to hear that you have imbibed some of the psychopharmacology wisdom from my SUNY Upstate Medical U. colleague, Dr. Stahl. You are right that this is not always the case, either in primary care or, alas, even in psychiatry!
I also agree with you that insomnia and daytime fatigue/hypersomnolence--which are often presenting symptoms in the psychiatrist's office--may be understood as "signs" or objective findings, if the clinician wants to pursue the initial complaint via specific studies. Thus, psychiatrists can and sometimes do order a polysomnogram to evaluate the complaint of insomnia, and in some cases, order a MSLT (multiple sleep latency test) for the complaint of excessive daytime somnolence. In these ways, psychiatry overlaps with both Sleep Medicine and primary care.
I think your analogue scale is also a very good screening tool!
Best regards,
Ron Pies
Reply to Dr. Lothane from Ronald Pies, MD
Does the Patient Have a Swollen Joint When there is No Physician to Observe It?
I thank Dr. Zvi Lothane for his interesting observations, particularly his fruitful, heuristic distinction between "monadic"and "dyadic" conditions. This has already prompted me to consider doing a paper on "A Typology of Signs in General Medicine and Psychiatry"-but that will have to wait! My response now is simply a very preliminary rejoinder to Zvi's comments.
I believe my argument against Dr. Angell's position may be clearer if it is analyzed in terms of propositional logic, as follows:
Dr. Angell's argument as I reconstruct it:
1. Signs, which are "objective", differ fundamentally from both symptoms, which are "subjective", and also from behaviors.
2. General medicine and psychiatry both rely on symptoms; but whereas general medicine utilizes (objective) signs, psychiatry uses only symptoms and behaviors in its diagnostic methods and criteria.
3. Therefore: there is a fundamental difference in the diagnostic methods and criteria of general medicine and psychiatry.
My counter-argument is as follows:
1. A "sign" is any abnormality or observable manifestation indicative of disease, perceived by the physician/clinician upon examination of the patient.1,2
2. A specific behavior-that is, any discernible action or reaction- is often an abnormality or observable manifestation indicative of disease.
3. Therefore, an abnormal behavior is often a sign (along with non-behavioral signs).
4. Therefore, both psychiatry and general medicine make use of "signs", and Dr. Angell's argument fails.
Indeed, Dr. Angell's argument is a bit like one that says, "Unlike zoologists, who study animals, primatologists study apes and chimps!" Just as apes and chimps are a subset of all animals, abnormal behaviors are a subset of all signs.
Now as to my list of "signs" found in DSM-IV, I would consider all but "weight loss" to be overt behaviors, though "Delay in development of spoken language" might be considered the absence of linguistic behavior. In any case, that these are indeed behaviors in no way validates Dr. Angell's argument, since nobody (certainly not this writer) has ever contested the claim that psychiatry uses "behaviors" in its diagnostic criteria!
The critical task for Dr. Angell is showing that behaviors are distinct from signs-and I believe this claim is flatly wrong, based on conventional medical terminology and long-standing clinical tradition. Indeed, browsing through any medical dictionary under "Signs" will reveal many such signs that require a behavior on the patient's part, in order to satisfy the sign's criteria. For example, Leichtenstern's sign: in cerebrospinal meningitis, tapping lightly any bone of the extremities causes the patient to wince suddenly. Now, wincing is a behavior, and it is the doctor's judgment call as to whether a slight facial muscle movement is really a "wince"; thus, Leichtenstern's sign is dyadic in the sense Dr. Lothane describes. Many signs, of course, are neither behavioral nor dyadic-they are simply "bodily deformations", to use Dr. Lothane's term. For example, Lombardi's Sign is the appearance of venous varicosities in the cervical vertebrae, seen in early pulmonary tuberculosis. I presume this would qualify as "monadic", in Dr. Lothane's terms.
That said, there is a philosophical argument to be made-in a longer paper!-to the effect that all signs are fundamentally "dyadic", in this sense: they all require an interaction between (1) an observed patient; and (2) a clinician who holds to some theory of disease or pathology, as developed by the prevailing medical culture and science. On this view of signs, the patient does not have a "swollen" joint when there is no clinician to observe it! The patient merely has a joint which-in a "realist" account of the world-contains a certain volume of fluid exudate, a certain number of neutrophils, plasma proteins, etc. (Readers will be reminded, of course, of that old epistemological conundrum: Does a falling tree make a noise, when there is no one in the forest to hear it?).
These Talmudic arguments may seem like picayune, metaphysical quibbles--and, of course, when set against the poignant suffering and incapacity of our patients, they are just that. However, when someone of stature attempts to marginalize the profession of psychiatry from the rest of general medicine, there is sufficient reason to take language "off holiday" and put it back on the job!
And again, my thanks to Zvi Lothane for a stimulating exchange!
Regards, Ron Pies
1. See Dorland's Medical Dictionary, 25th edition:
Sign: "an indication of the existence of something; any objective evidence of a disease; i.e., such evidence as is perceptible to the examining physician, as opposed to the subjective sensations (symptoms) of the patient."
2. See MediLexicon. Medical Dictionary, Medical Terminology. http://www.medilexicon.com/medicaldictionary.php. Accessed August 18, 2011.
Ken Thompson, MD, of the University of Pittsburgh writes:
Dear Dr Pies,
I very much appreciated your piece on signs and symptoms. From my perspective, what I have learned in psychiatric practice is the capacity to help people reveal the patterns of their lives and their way of being; to see these patterns as they emerge and help the person in their efforts to change patterns that they wish to change.
I use the language of patterns and emergence because I think the language of signs and symptoms in itself does not capture the dynamism and complexity of the human mind-- and here I use mind instead of brain to connote the interaction between the inside of a person and that which is outside-- including language and all of human culture. (The brain is often not appreciated as being the organ that is specifically permeable to the outside- and that what is created by inside and outside coming together is an emergent pattern of being-- more than the brain).
So we have few fixed signs and symptoms... we have fluid patterns, like the pattern created by flowing water. The patterns can be seen-- but they are not fixed-- they ebb and flow and shift (and the very utility of metaphor helps capture this!)
It's time psychiatry adopted complexity theory.
Happy to expand on this if it's of interest.
Dear Dr. Thompson--
Many thanks for your cordial note, and for the alternative way of looking at our patients. I very much like your focus on "patterns"and "complexity", which does help break down some of the sclerosed dichotomies conventional medicine often uses. For example, even the time-honored distinction between "symptoms" and "signs" begins to fray at the edges, when you examine many of the classical "signs" in general medicine [see my response to Dr. Lothane, below]. I also like your concept of the brain as the "permeable" organ, which is reminiscent of Merleau-Ponty's "embodied mind" that is always interacting with the word; and I agree that "what is created by inside and outside coming together is an emergent pattern of being." All of this has affinities, I think, with various Zen Buddhist concepts, with which I am in sympathy. None of this, in my view, contradicts the major arguments I advanced against Dr. Angell's claims; rather, your perspective provides a complementary way of seeing the issues. Thanks again!
Best regards, Ron
I enjoyed reading this article and I wish that theoretical discussions were presented more often. You make a good argument in support of the fact that psychiatric symptoms/signs can have the same degree of objectivity that physical symptoms have. On the other side I think that Dr. Engell argument cannot be dismissed as to the fact that no underlying specific abnormality can be found for psychiatric symptoms. She is indeed highlighting the difference between medical illness and psychiatric disorders. The problem for me originates in the fact that the difference between psychiatry and other medical fields is not stressed enough. During the last fifty years psychiatry essentially focused on the task of reducing mental illness to biochemical abnormalities in the belief that this is the only way to give a scientific basis to its body of knowledge and to make of it a medical discipline. This approach, however, is leading nowhere and is reducing man to a complicated machinery. Indeed this is leading to an impoverishment and the dismissal of psychiatry as a field in itself.
It is a blind alley and the only way out of it is indeed to claim the specifity of psychiatry and the fact that mental disease belongs to a different order of organization. Mental disease to prove itself doesn't need to be reduced to medical disease. We need to have the courage to claim the specificity of psychiatry and the fact that it is a valuable field of study and research in itself and not only because it is part of medicine. Psychiatric care is worth in itself and not because it is a form of medical care. The psychiatric leadership, however, has chosen the other path. To destroy psychiatry by reducing it to medicine.
To be, however, able to maintain the autonomy and independence of psychiatry as a field of knowledge and pratice, psychiatry needs to have a specific understanding of mental illness that is not a biochemical explanation and needs to have specific forms of effective treatment that are not based on chemical and physical interventions. This is the part that is missing not because of lack of knowledge but because of the blind adherence to a paradigm and a set of believes that are leading to the dismissal of psychiatry as an independent discipline, and with the end of psychiatry to the reduction of man to a complicated machinery without emotions.
I appreciate the comments of both Dr. Bresch and Dr. Iacobello.
First, with respect to Dr. Bresch: I don't believe we are really disagreeing, so much as differing over nuances. While I am not sure patients "love"their antidepressants, I do agree that these medications are both widely prescribed, and generally accepted by most patients. (There are positives and negatives associated with wide prescription, of course, including some cases of over-prescription; on the other hand, there is also evidence of under-prescribing and under-dosing in some settings). Indeed, consistent with Dr. Bresch's point, a recent study by pharmacists (not psychiatrists) found that among monitored patients taking antidepressants:
"Fifty-seven percent of patients reported feeling better a lot of the time, and an additional 30% reported feeling better some of the time. Nearly 75% reported that the antidepressant did not bother them or only bothered them a little of the time. Being very satisfied was reported by 47% of patients, and an additional 28% were satisfied with the antidepressant." [Dara et al, J Am Pharm Assoc. 2002;42(1); viewable at: http://www.medscape.com/viewarticle/436594_7].
As for whether Karl Jaspers was "pluralistic", I will leave that to readers of my colleague, Dr. Nassir Ghaemi, who is a scholar of Jaspers. Dr. Ghaemi sees Jaspers as having embraced a kind of "biological existentialism", and indeed, pluralism in the best sense of that term. I recommend Dr. Ghaemi's paper to Dr. Bresch: Pluralism in Psychiatry: Karl Jaspers on Science Philosophy, Psychiatry, & Psychology - Volume 14, Number 1, March 2007, pp. 57-66.
I also recommend this paper to Dr. Iacobello, whose comments I appreciated, but with some reservations.
First, I completely agree that psychiatry need not "pitch" itself as being a biomedical science, in order to legitimate the illnesses and conditions we treat. In my view, disease (literally, dis-ease) is a property of persons, not of organs, minds, or brains. Disease is a state of pronounced suffering and incapacity, and we need not point to a specific physical or chemical abnormality in order to justify our identification of disease states--or to justify our care and treatment of patients. Nor should we try to "reduce" disease states to nothing more than biochemical abnormalities, since they cannot be meaningfully understood without an appreciation of how they affect the whole person.
That said, I do not believe we need to choose between being, on the one hand, a "human science" that emphasizes intrapsychic and interpersonal meaning, spiritual purpose, etc; and, on the the other hand, a medical discipline that diligently searches for biochemical abnormalities that contribute to some states of dis-ease, such as schizophrenia or bipolar disorder. Silvano Arieti's classic text, Schizophrenia, is a superb model of integrative understanding, ranging from the biochemical theories of its day to the "inner world" of the individual with schizophrenia. Arieti saw no contradiction or paradox in that approach.
Perhaps unlike Dr. Iacobello, I do not see an abdication of such pluralism, among the leaders in our field. Dr. Glenn Gabbard and Dr. Ghaemi have been urging a broad-based, pluralistic model of psychiatric practice for many years. That said, this orientation has not found its way into the DSMs to any large degree, nor has it been integrated very well into standard clinical practice, in recent decades. We do need to work much harder to bring about the kind of pluralism that Jaspers and Arieti would embrace.
Best regards, Ron Pies
Henry (Zvi) Lothane, MD, DLFAPA writes:
I do not think that Marcia Angell MD and Ron Pies are that far apart as Dr Pies claims.
Ron rightly questions Angell's claim that "mental illness is diagnosed on the basis symptoms (medically defined as subjective manifestations of disease, such as pain) and behaviors, not signs (defined as objective manifestations, such as swelling of a joint)."However, Ron does not prove that "Dr. Angell's assertions reflect ... a serious misunderstanding of psychiatric diagnosis."
Ron's shows that "a number of "signs" are indeed part of the criteria sets for several DSM-IV psychiatric disorders: anorexia nervosa, psychomotor agitation, distractibility, motor immobility, stereotyped movements, avoidance of eye to eye contact..." However, since he does list BEHAVIORS, and since Angell also states that mental illness is diagnosed by BEHAVIORS, Ron's counter-claim falls flat on its face.
Furthermore, a swollen joint is NOT a behavior in the sense that avoidance of eye contact is. A swollen joint is a sign, or manifestation, of medical, pathophysiological disorder. A swollen joint is a bodily deformation, a MONADIC disorder.
Avoidance of eye to eye contact is a behavior. Furthermore, it is an interaction between a patient and an examining psychiatrist, arguably a replay of the patient's previous similar behaviors in social interactions with family members, co-workers, spouses, friends, strangers met in the street.
The psychiatric disorder is thus DYADIC, interpersonal one, or, as I say, a DRAMATIC encounter (see my article in PT on dramatology http://www.psychiatrictimes.com/somatoform-disorder/content/article/1016...).
It is pointless to debate spurious conundrums created by words like "objective" and "subjective," where "subjective" is often viewed as "unreal" or imagined, or, worse yet, malingered. A complaint is subjective in the sense that it is a statement made by a sufferer, a subject (ie, a person). It is objective in the sense of being a real experience for the patient.
Rather, one should keep in mind that psychiatry is a hybrid discipline -- with one foot in biology and the other in sociology and psychology.
Therefore, internists will have no philosophical or political debates about diagnosing pneumonia. But psychiatrist will be divided in making the diagnosis of paranoia, depending on the details of the social and interpersonal behavior in question.
The proper application of psychopharmacology can additionally improve outcomes of other medical conditions.
The lack of knowledge of adequate psychopharmacology is not moving into primary care. Of those treated I find many who are under treated and still suffering, increasing relapse risk.
I have been using a standard pain scale ( which is visual analogue), to have patients give an average of the following problems over the proceeding 3 weeks:
Insomnia
Daytime sleepiness/fatigue
Stress
Sadness
Worry
Guilt
Stress and worry is anxiety, sadness and guilt depression. quantifying is important and this is not all that my analysis is based upon.
Back to the point, Insomnia is an obvious objective measure, as are the others, if measured. The pain scale is used ubiquitously and is the foundation for narcotic dosing.
This is an attempt to make objective findings quickly. I am an OB/GYN but know the necessity of adequate mental health care. Unfortunately, few in primary care, and dare I say some in psychiatry, have a feel for the specialty; poor medical regimens for mood and stress are commonplace.
I recently spent 1 year doing Steven Stahls "Master Psychopharmacology" program. It was excellent and has broadened my knowledge tremendously. The average generalist has not been doing this and the vast gap between what is available and what is practiced has many patients undertreated.
Excellent article, thank you, Chevies Newman, MD
Love this! Thank you for this article....
In addition to Dr. Pies for this article, many thanks to SALVATORE IACOBELLO and SUSAN KWESKEN for their comments that reflect so much of what I feel [but have difficulty articulating].
Oops! Sorry....Instead of "Susan K."I referred to as "one" of the comments I was grateful for, it looks as though I was really referring to Dr. K. Thompson and Dr. Lothane.
I agree with Pies' tendentious reply but I disagree with his methods.
The whole conflict has the whiff of a pre-written script to which the actors are adhering extremely closely. First of all, has anyone ever noticed that these narratives of the "emptiness"of psychiatry, when they discuss medications, ALWAYS focus on modern anti-depressants?
The skepticism and condescending attitude of our internal medicine colleagues has long-standing antecedents and reflects the failure of psychiatry to integrate to allopathic medicine in the nineteenth medicine, perhaps due to England's, the United States' and France's reluctance to completely adopt Geisinger's model, as Meyer attempted at Johns Hopkins. We attribute the unification of psychiatry with the remainder of medicine to Meyer, but perhaps we should also note that the unification was only partial.
This argument is merely a perpetuation of a stigma and skepticism that has plagues mental illness forever. So long as psychiatrists treat the stigmatized, we will be stigmatized. But Pies' response ignores the fact that medical psychiatry, biological psychiatry, has been more widely embraced than psychoanalysis was in the early part of the century. Angell is on the losing side, patients love antidepressants and MDs love prescribing them.
All we psychiatrists can and should do is maintain a critical attitude towards the faddishness of psychiatric medications. We should continue to medicalize psychiatry and professionalize it, for example there are "two minds" each deeply critical and antagonistic toward the other in the psychiatric profession, this has to stop.
Most of psychiatry is based in phenomonology, codefied by Jaspers in 1913. So what? Much of medicine is also phenomological, Pies alludes to this and he is right. We have to embrace the limitations of our fledgling field and improve it. Psychiatry when defined as behavioral medicine is enormous and we possess an enormous amount of knowledge. But there is an enormous amount of progress to be made in our clinical abilities. I say we ignore provocations like Angell's and look within.