Science, Psychiatry, and Family Practice: Positivism vs. Pluralism: Page 2 of 2
Science, Psychiatry, and Family Practice: Positivism vs. Pluralism: Page 2 of 2
Indeed, Dr Kurt Kroenke12 points out that physicians can easily overestimate the value of lab and imaging tests, noting that the patient’s history .”...typically accounts for 75% or more of the diagnostic yield when evaluating common symptoms.” The physical examination accounts for 10% to 15%, and diagnostic testing, generally less than 10% of the diagnostic yield.
Moreover, lab tests and biomarkers can never be any better than the clinical criteria that define the disorder under investigation—and useful “lab tests” or biomarkers for a disorder must always follow the development of reliable and valid clinical criteria. As Bernard Carroll succinctly puts it, “Laboratory measures are the servants of clinical science, not the other way around.”8
Diagnosis in psychiatry and family practice: lumps vs. patients
Critics of psychiatric diagnosis often argue that our disease categories do not identify or name any “ontological entity”—a real “thing” like an abscess or tumor. These critics point to medical specialties like microbiology, in which one can see a pathogenic organism under the microscope, and even isolate it from the patient’s infection site. For the critics, this makes microbiology a “real” science that treats “real” diseases, in contrast to psychiatry, which allegedly treats only “metaphorical” disease.13 I believe this “lumps and bumps” concept of disease is deeply misinformed and represents the regressive legacy of logical positivism—an early 20th century school of thought now largely discredited by most philosophers of science.4
In his Skinner Lecture of 1942,15 professor of radiology Dr Henry Cohen described “two main trends . . . in our conception of disease.” The first was that of the Hippocratic school, which, in Cohen’s words, “. . . stressed the patient—his complaints, his appearance, his habits, his work, his environment, his relatives, his sputum, urine...and the like.”15(italics added) The contrasting trend—which Cohen saw as a late outgrowth of “Platonic” philosophy—is close kin to the positivist, “lumps and bumps” school of thought. It conceived of a disease in terms of a specific ontological entity—what family physician Kirsti Malterud, MD, PhD defines as, “. . . a solid fact representing the actual pathology. . . ”16
One might have thought that a radiologist would be in sympathy with this positivist outlook, but Cohen clearly was not. Rather, he tartly observed that,
“Our textbooks describe “entities”—model and composite pictures of such diseases as typhoid fever...cancer and the like...[and] our goal has been a diagnostic penny-in-the-slot machine; for then, treatment and prognosis too follow automatically. Not a few physicians act as if, by a combination of X rays with clinical pathological reports, that goal has been achieved. From time to time, voices have been raised stressing the importance of the patient; of his environment, of the mental reaction to, and the mental components of his illness, but they have gone unheeded...”15^^
Dr Malterud observes that it is rare, in family practice, that the physician can link specific observable signs to a specific localized lesion or pathological process. On the contrary,
“The professional norm that objective signs are supposed to confirm subjective symptoms and thereby reveal monocausal disease processes falls apart in the sea of medical complexities encountered by the family physician.”16
Nevertheless, Dr Malterud notes that, ”. . . the solution of the patient’s problem can often be achieved despite the impossibility of reaching an established medical diagnosis.”16 Indeed, in psychiatry, as in family practice, we can still be of great help to the patient, even when we have not identified a specific lesion, pathophysiological process, or other “ontological entity” as the culprit. Thus, the patient may present with a puzzling mix of anxiety, depression, obsessive features, rejection sensitivity, and mild ideas of reference. No specific diagnostic “entity”, lesion, or pathophysiological process may be discernible—yet the patient is suffering and unable to function. The psychiatrist, proceeding from a Hippocratic and “holistic” perspective,17 may understand the genesis of the patient’s problem in biological, psychosocial, environmental, and even spiritual18 terms. Most important: the psychiatrist may find effective ways of helping the patient feel and function better. This, arguably, is a type of Hippocratic medicine16,17 and there is nothing “unscientific” about it—so long as the physician’s approach is grounded in careful and repeated observation; frequent testing of one’s hypotheses; and the use of well-founded somatic and psychosocial treatments.
As for those vaunted lab and imaging findings psychiatry’s critics are always demanding, Dr Malterud notes that “test results . . . are only interesting if they can support or refute a first-class clinical question.”16 (italics added)
When we elevate lab tests to the level of Supreme and Ultimate Standard, we are engaging not in science, but in scientism—“an exaggerated trust in the efficacy of the methods of natural science applied to all areas of investigation (as in philosophy, the social sciences, and the humanities).”19
Sometimes, of course, a pathophysiological approach is necessary; for example, in ensuring that a patient’s panic attacks are not the result of a pheochromocytoma; or his auditory hallucinations, the result of a temporal lobe tumor. But these examples are atypical, in both family medicine and psychiatry. Usually, our patients’ complaints are more subtle, complex, and overdetermined.16 I believe they are best addressed by maintaining a dynamic tension between what Karl Jaspers proposed as two basic methods of discernment in psychiatry: Erklären (causal explanation) and Verstehen (meaningful understanding).20 Very roughly, these modes of discernment correspond, respectively, to the pathoanatomical and patient-centered perspectives.
Neither family practice nor psychiatry is a “natural science,” like biophysics. Rather, they are medical sciences—hybrid constructs,compounded of observation and interpretation; molecules and motives; nanograms and narratives. Indeed, the core values of clinical psychiatry have always been Hippocratic, pluralistic and holistic. Even the dean of neuropsychiatry in the U.K.—Prof. William Alwyn Lishman—had this to say:
“The study and treatment of those psychiatric disorders deriving from brain malfunction must capitalize on all that psychiatry has to offer. There are psychodynamic, social and cultural aspects of neuropsychiatry to be considered; exploration of conflict must take its place alongside the physical examination in differential diagnosis; psychotherapy alongside pharmacotherapy in treatment.”21(xiii-xiv)
Such rich pluralism does not undermine psychiatry’s status as a medical science. But psychiatry is also an art,22 grounded in deeply personal human relationships. The danger to our profession comes from those who insist on stark dichotomies, as Dr Malterud explains:
“Dichotomous thinking is dangerous because it encourages the practitioner to choose one alternative and dismiss the other. Instead...physicians must be ready to merge paradoxes and opposing perspectives...the narrative structure of medical knowledge is gaining increasing recognition. Yet, an ongoing simultaneous attention to biomedical processes should never be neglected.”16
Yes, the physician’s knowledge is almost always fragmentary and incomplete--and often, “we see through a glass, darkly.” But we must not allow these limitations to deter us from diagnosing and treating our patients to the best of our ability.
Acknowledgments: My deep appreciation to Dr S. Nassir Ghaemi and Dr Bernard J. Carroll, for their helpful comments on this article. The views presented here, however, are my own.
** My colleague, Dr Nassir Ghaemi, has suggested that “in clinical diagnosis, the specific scientific criteria are the five [Robins and Guze] criteria of validity”; and that one cannot justifiably “separate science from validity when discussing nosology.” (personal communication, 8/29/13). (The Robins & Guze criteria (Am J Psychiatry. 1970 Jan;126(7):983-7) comprise clinical description, laboratory study, exclusion of other disorders, follow-up study, and family study—often considered the fundamental elements of “construct validity”). To be sure: “science” is intimately related to construct validity—but they are distinct concepts. “Construct validity” is essentially an outgrowth and subset of the long-established scientific method, which dates from Roger Bacon’s work in the 13th century. An empirical claim may be proved “invalid” yet be eminently “scientific.” For example, the “steady-state” theory of the universe was unquestionably grounded in the scientific method, but was eventually invalidated and replaced by the “Big Bang Theory.” By the same token, the DSM-5’s decision to eliminate the subtypes of schizophrenia (paranoid, disorganized, etc.) might someday be invalidated, based on new data—but it would be unfair, retrospectively, to call the DSM-5’s decision “unscientific.” (see Highlights of Changes from DSM-IV-TR to DSM-5, American Psychiatric Association, 2013).
^^These different aspects of the patient’s condition have been discussed in terms of “disease” (pathoanatomical entity) and “illness” (the patient’s subjective reaction) by Dr Arthur Kleinman.
1. Pies R: Psychiatry and the myth of medicalization. Psychiatric Times. April 18, 2013. http://www.psychiatrictimes.com/depression/psychiatry-and-myth-%E2%80%9C....
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013, p. xlii
3. Cuthbert B: Concept Clearance - First-Generation RDoC Standard Data Elements http://www.nimh.nih.gov/funding/grant-writing-and-application-process/concept-clearances/2013/concept-clearance-first-generation-rdoc-standard-data-elements.shtml?utm_source=rss_readers&
4. Carroll S: What is Science? July 3, 2013 http://www.preposterousuniverse.com/blog/2013/07/03/what-is-science/
5. Leibenluft E, Severe Mood Dysregulation, Irritability, and the Diagnostic
Boundaries of Bipolar Disorder in Youths. Am J Psychiatry. 2011;168: 129–142
6. Ghaemi SN: Requiem for DSM. Psychiatric Times, July 17, 2013. http://www.psychiatrictimes.com/dsm-5-0/requiem-dsm
7. Pies R: With Obesity, A New Disease is Born: Its Profound Implications for Psychiatry. http://psychcentral.com/blog/archives/2013/06/22/with-obesity-a-new-disease-is-born-its-profound-implications-for-psychiatry/
8. Carroll BJ. Comment on Medscape. http://www.medscape.com/viewarticle/804408?nlid=31347_421&src=wnl_edit_medp_psyc&spon=1
9. Pies R: What Should Count as a Mental Disorder in DSM-V? Psychiatric Times. April 14, 2009
10. Skudlarski P, Schretlen DJ, Thaker GK, Stevens MC, Keshavan MS, Sweeney JA, Tamminga CA, Clementz BA, O’Neil K, Pearlson GD. Diffusion tensor imaging white matter endophenotypes in patients with schizophrenia or psychotic bipolar disorder and their relatives. Am J Psychiatry. 2013 Aug 1;170(8):886-98.
11. Wittgenstein L: The Blue and Brown Books, New York, Harper Torchbooks; 1965
12. Kroenke K: Diagnostic Testing and the Illusory Reassurance of Normal Results. JAMA Intern Med 2013; 173:416-17.
13. Pies R: Mental illness is no metaphor: five uneasy pieces. Psychiatric Times, Sept. 13, 2012. http://www.psychiatrictimes.com/articles/mental-illness-no-metaphor-five-uneasy-pieces?iframe=true&width=90%25&height=90%25]
14. Pies R, Thommi S, Ghaemi SN: Getting It From Both Sides: Foundational and Antifoundational Critiques of Psychiatry Psychiatric Times, July 1, 2011 http://www.psychiatrictimes.com/display/article/10168/1895157
15. Cohen H: The nature, methods and purpose of diagnosis. The Lancet, 1943; 241: 23-25
16. Malterud K: Diagnosis—A tool for rational action? A critical view from family medicine. Atrium, Winter, 2013, pp. 26-35.
17. Ventegodt S, Kandel I, Merrick J ; A short history of clinical holistic medicine. The Scientific World Journal 2007; 7, 1622–1630
18. Pies RW, Geppert C: Ethical issues in the psychiatric treatment of the religious ‘fundamentalist’ patient. Medscape Psychiatry. March 19, 2013. http://www.medscape.com/viewarticle/780839
20. Ghaemi SN: Paradigms of Psychiatry: Eclecticism and Its Discontents. Curr Opin Psychiatry. 2006;19(6):619-624. http://www.medscape.com/viewarticle/547497_9.
21. Lishman WA: Organic Psychiatry: the Psychological Consequences of Cerebral Disorder. 3rd edition, Wiley-Blackwell, 1998.
22. Ghaemi SN: The Rise and Fall of the Biopsychosocial Model: Reconciling Art and Science in Psychiatry. Johns Hopkins University Press, 2012.
For further reading:
Pies R: DSM-5’s Validity: Non Sumus Angeli! Medscape Psychiatry. June 12, 2013 http://www.medscape.com/viewarticle/805365
Markova IS, Berrios GE: Epistemology of psychiatry. Psychopathology 2012; 45:220-227 [This paper discusses the concept that psychiatry is a “hybrid discipline” whose objects of inquiry are themselves “hybrid” constructs]