Sunday, September 11, 2016

The unexamined life is not worth living

This post is a re-posting of a previous post on the PLoS Mind the Brain blog. As part of my re-focusing on this blog I will bring here relevant posts that I've published elsewhere. The goal is to have this blog as a one stop station for all my more philosophically flavored musings on psychiatry.

... states Socrates [through Plato] in his Apology. You might think this is a metaphorical statement. And thus the surprise when Socrates chooses to drive this most important point home by proceeding to drink the poison that literally ends his life.

From the psychiatrist's corner this looks a bit like suicide by cop. Socrates has the ability but not the willingness to save his life; one may argue that he effectively leads the jury to condemn him to death and then carries out his own sentence.

Is this a reasonable decision and course of action? Or alternatively, did Socrates have capacity?

For starters, Socrates' view of life as being worth living under a certain set of circumstances [but not others] is at odds with the view of modern [read Western] psychiatry which emphasizes the absolute value of life regardless of its circumstances.

Arguably, the majority view nowadays is that the ideal mental health is a state where the drive to live prevails no matter what. As a consequence, those who are ideally "mentally fit" would have the potential to overcome and survive whatever circumstances and challenges life would throw in their way. Which pretty much means they will make the choice to live regardless or they would prize life above anything else.

This view of life as having an absolute value is at odds with moral systems that consider life's value as contingent on the fulfillment of other norms and values. In middle age Europe chivalry valued bravery above living, in Japan the samurai Bushido code recommends suicide by seppuku as preferable to living without honor. And of course Socrates argues that is better to die than to life an un-examined life.

Along this line of thinking, choosing an honorable death over a shameful life can be understood as the logical consequence of subscribing to a clear moral code - and as such can be accepted as proof of competency in making life/death decisions.

However Socrates reaches his final decision following a moral code that is dictated by his daemon, in essence an auditory hallucination.

There is ample evidence that Socrates experienced auditory hallucinations in addition to what might be considered as a very specific set of compulsions. In his De Genio Socratis Plutarch states that...

"Socrates' sign was a sneeze, his own and others; thus, when another sneezed at his right, whether behind or in front, he proceeded to act, but if at his left, desisted; while of his own sneezes the one that occurred when he was on the point of acting confirmed him in how he had set out to do, whereas the one occurring after he had already begun checked and prevented his movement".

Now,  in the context of concurrent psychiatric symptomatology, when one's life/death decision follows the prompting of an auditory hallucination - even if in accordance with a pre-specified moral code - does it meet criteria for capacity?

Or would the consulting psychiatrist recommend starting a neuroleptic and holding off on proceeding with the execution until the medication will take effect?

© Copyright Adrian Preda, M.D.

Notes on Jaspers

Jaspers in quotes:

"The question of what underlies all phenomena in general used to be answered in the old days by the notion of evil spirits. These later turned into disease entities that could be found by empirical investigation. They have proved themselves however to be mere ideas’.

The mere ideas of evil spirits or neurotransmitter abnormalities are explanatory models based on [to date] insufficient evidence. Such models serve as temporary organizing models for mental disorders until enough evidence accumulates against the model to demonstrate its inadequacy. Enough experimental evidence has accumulated to convincingly demonstrate that the evil spirits model is inadequate; almost enough evidence has accumulated to demonstrate the neurotransmitter model is inadequate. Looking at the relationship between theoretical models and their translation in practice, it appears that most of the time, until a conceptual model is invalidated, the model tends to be seen as valid and used as if it is valid in day to day practice. Psychiatry is no exception to this rule.

‘We have intuitions of a whole which we call schizophrenia but we do not grasp it; instead we enumerate a vast number of particulars or simply say “ununderstandable”, while each of us only comprehends the whole from his own experience of actual contact with such patients’.

Our understanding of the unintelligible is filtered through the lenses of our own experience. While what is clear is clear to everyone in the same way, what is unclear is unclear to each individual in a individual way. 

Concepts to compare and contrast:

  • psychopathology of "the sick human individual" vs. psychopathology of "human sickness" [Musalek 2013]
  • superficial checklists of diagnostic criteria vs. understanding of a patient's experience of his illness [Musalek 2013]
  • professional, authoritarian, expert monologue vs. therapeutic, democratic dialogue [Musalek 2013]
  • expert opinion vs. genuine curiosity
  • see patients as they are vs. "through the distorting prism of our own preconceptions" [Sims 2013]

Wednesday, September 25, 2013

On being a psychiatrist: Is an MD sufficient?

Sigmund Freud LIFE
Freud argued that a psychoanalyst did not necessarily need to have a background in medicine. One might argue that to properly understand the dynamics of the psyche one might be better served by studying anthropology, sociology, history and, of course, the proper way to think about things, i.e. philosophy.

At odds with this view, like it or not, psychiatrists are physicians first.  Following graduation from medical school they enter a one year internship, followed by a three years residency in psychiatry. During internship, a psychiatrist typically splits his time between medicine and neurology (for six months) and six months of inpatient psychiatry. For the next three years, the future psychiatrist gains experience in treating a variety of patient populations (inpatient and outpatient, patients with major mental illness such as schizophrenia, bipolar, major depression or Alzheimer's dementia, illicit drug users, or severe personality disorders). As a trainee, a psychiatric resident learns how to use a variety of psychotropic medications and psychotherapeutic interventions.

It is a lot to master and that leaves relatively little time for anything else.

At the same time, psychiatry is so much more than just making a diagnosis in accordance with the medical model and then prescribing an evidence-based intervention. When it comes to psychiatry, an evidence-based appraisal of data should be the beginning, not the end of a psychiatric assessment, formulation and plan.

By allowing itself to be reduced to a medical model only perspective, psychiatry loses the ability to meaningfully translate and enrich the complexity of human experience. This is a complex discussion (HERE for a link) but the point is fairly straight forward.

I would like to propose that psychiatrists should aspire to be more than just evidence-based physicians.

We agree that a psychiatrist's expertise in describing a mental illness and then offer an evidence-based intervention should be equal to the expertise of any colleague in any other medical specialty. But while the study of philosophy is irrelevant to the outcome of an appendectomy, philosophy plays an organic part in understanding and treating any form of mental illness.

Critical thinking, good humor, perspective, skepticism, and a dialectic understanding of complex facts are as essential to good psychiatric practice as the skills of carrying a psychiatric review of systems and mental status examination.

Thus, a good psychiatrist, always a physician first, also needs to have a working knowledge of philosophy. Which should exude throughout the course of a visit with a patient.

You are not sure where your psychiatrist stands on the above issues? Not a problem.

Email this post and ask for an opinion. If you get a response, please bring it back here.

Discussing, debating, trying to understand each other's perspective will make us all better patients, better doctors, better fellow beings.

© Copyright Adrian Preda, M.D.

Philosophy of Psychiatry 101 Part 1

I received a number of interesting comments in response to my Psychology Today "Psychiatry on Trial" article.

One of these comments in particular makes for a good summary statement for some of the more important issues in the ongoing debate about psychiatric classification/nosology and intervention. I decided to present both the comment and my response as a separate article on my blog with the hope this will serve not only as a good introduction but also stimulate a discussion about values and ethics in psychiatry.

I will present my response over a series of shorter articles as the comment is rather complex and as I do plan to split hairs a bit in my discussion. If you are interested in following this please look for the response over a numbered series of future posts under the title "Philosophy of Psychiatry 101". All articles will be linked together for easier navigation.

First, here is the text of the comment in its entirety:

Submitted by Amused Reader (AR) on March 23, 2012 - 11:39pm.

"The reality is more complex..

I am not one of those who believes that psychiatry invented mental illnesses.  Of course, there are many mentally disturbed people out there and we cannot deny this reality if we want to be honest. 

I think what psychiatry is rightfully criticized for calling any kind of emotional disturbance an "illness" and offering a drug for each kind.  Currently, psychiatry doesn't do anything more than merely managing unwanted behaviors and emotional states and it's not even clear whether this is due to the effects of the chemicals in the drug or a placebo effect.  The illness can't be cured if the cause of it is not known but this is what psychiatry tries to do. It pretends that it could cure mental disturbances while not knowing what causes them which by definition is a fraud.

I do believe that certain people have to take medications such as schizophrenics, anyone with a recent psychotic episode, severe OCD cases, PTSD, Bipolar I and such.  Those and only those could qualify as true mental illnesses where meds may be the only way to make those people's lives manageable. (By the way, managing the illness and curing it are two completely different things and on that basis psychiatry has not cured anyone yet.)  All other conditions are not illnesses, they are emotional disturbances created by deep inner conflicts or moral dilemmas or conflicts between the inner needs and the external pressures from the environment. When someone is depressed, it may well be because they sacrifice who they truly are for the sake of not being rejected by others and because of other reasons that have nothing to do with them.

Adverse and stressful environment could alter our brain chemistry but instead of addressing the real reason why we are depressed, which is difficult life circumstances and also inner struggles, the psychiatrist will hand us a drug prescription. This way we don't have to change anything about ourselves and our lives.  All we have to do is just take a pill that will help us cope with the unhealthy environment.  It's as if someone held your hand over fire and when you started screaming from getting burned they'd give you a pain killer instead of letting you put your hand away.

Depression may be cured without drugs if people ask themselves what they are sacrificing and why and if they get the courage to do what they want with their lives whether it's approved by others or not.  What I find insane is when an individual is labeled as mentally ill and is put on drugs only because he or she is not well adjusted to the insane society."

Amused Reader (AR) does not subscribe to the view "that psychiatry invented mental illnesses".

I hope this signals a reasonable position that can be used as a foundation for an open dialogue on the issues. AR further states that "there are many mentally disturbed people out there and we cannot deny this reality if we want to be honest".

This is an important clarification: as AR, most people actually agree that there are "mentally disturbed people". However not everyone holding this view realizes that this position automatically implies acknowledging the existence of a category of illnesses that can be appropriately classified as "mental", in other words, agreeing that mental illness is real (i.e. biologically based)- as opposed to the minority view that mental illness is a social construct summing up a set of specific cultural and social factors.

If the existence of mental illness is agreed upon, the next level of disagreement is about what can be properly defined as mental illness. The issue at hand here is about how to define illness, a concept typically anchored in physical (biological) dysfunction, in a context where there is very little if any hard physical evidence of dysfunction. The mind, essentially a function of the brain, is such a domain of inquiry. This is AR's very point next when he states that "psychiatry [can be] rightfully criticized for calling any kind of emotional disturbance an 'illness'". This and "offering a drug for each kind" is a summary statement  of the most common charges that are brought up against psychiatry

To clarify AR makes two different claims:

1. That psychiatry calls any kind of emotional disturbance an illness.

2. That after the labeling is completed, psychiatry then proceeds to offer a drug for each kind.

Both statements are false.

First, it is of essence for any psychiatric work-up and diagnosis to consider a differential diagnosis. This is no different that the process of medical diagnosis in general, where the doctor's expertise is called on to differentiate between the many different causes of the same presentation. An internist will use his skills to differentiate if a cough stems from a common cold, heart attack, or pulmonary edema. Similarly, a psychiatrist will differentiate between feeling upset because of a normal mood variation, a recent loss, depression, or maybe because of persistent auditory hallucinations.

Ruling out normal reactions (which account for the majority of "normal" or minor emotional disturbances) is part of any psychiatric diagnostic work-up and it is in fact one the operational criteria required by DSM before more severe diagnoses are given. The reason being precisely to prevent labeling "any kind of emotional disturbance as a mental illness".

Second, psychiatry's unjustified use of the label "illness", which is implied here, is equivalent with psychiatry inventing mental illness, which AR's claimed it was not the case in the first place.

The reason for which I am pointing it out is that slippery classification and rapid change of positions are unfortunately common place in today's anti-psychiatry debate. For the sake of dialogue we should all weed out any inconsistencies, especially those that we might have unintentionally committed.

[To follow.]

© Copyright Adrian Preda, M.D.

Thursday, April 26, 2012

Psychiatry and Culture

United Nations. Martin Swart. Wikipedia Commons
I have been surprised by the level of interest that my recent postings under Ethics and Morality (Psychology Today) have generated.

My first post in this series got about 1300 hits to date (the post has been up for a bit less than a month), with the two following posts also wrapping up hits pretty quickly: as of now the second post is at 600 hits and the third one (that’s been up for about a week) is already at 650.

This was an interesting and unexpected trend. My other posts, while generating enough hits, have done so over time, suggesting not nearly as high a level of interest as these more “philosophical” posts.

It seems like mental illness and psychiatry remain quite fascinating (albeit controversial at times) topics of interest for the collective imagination.

Of course, these posts were published by a popular American magazine, on a western Internet sit. I have no idea who my readers are but it’s fair to assume that the majority are from the USA or other western countries.

This being the case I thought a discussion about the intersect between psychiatry and culture would be of interest to this readership.

But first here is the context of our discussion.

The modern Western psychiatric classification of mental distress uses a descriptive approach to diagnosis. This is shared by the American Psychiatric Association DSM III onwards psychiatric diagnostic system as well as the World Health Organization ICD-10. The descriptive aspect is emphasized by both systems, meaning that current diagnoses are not meant to explain the brain deficits underlying psychiatric signs or symptoms.

However, when it comes to psychiatric practice, as discussed in numerous treatment guidelines. descriptive diagnoses do not exit in a vacuum, but instead  inform treatment together with a biopsychosocial formulation of the issues at hand.

There is an appearance of world wide agreement and homogeneity when it comes to psychiatric diagnosis and even intervention. But appearances might be deceiving. As it turns out, even within the fairly homogeneous Anglo-American psychiatry, the way similar formulations have been applied over time varies greatly, with cultural factors being an important, yet frequently under-appreciated, contributor.

For example, the influence of Adolf Meyer’s, one of the forefathers of modern American psychiatry and a pioneer of the biopsychosocial model, gathered more following in the British psychiatry than in the USA, which has been Meyer's adoptive country for most of his life. Europe, where psychoanalysis fell on harder times after the Second World War, made space for the Meyerian ideas, while in the USA the same ideas were almost wiped out by the alternating preeminence of the more extreme theoretical formulations of psychoanalysis and biodeterminism.

At the same time, the Kraepelinian backbone of American DSM III and its successors faced multiple challengers in its own homeland. A number of eminent German psychiatrists including Eugene Bleuler, Kurt Schneider and Karl Jaspers went head to head with Kraeplin's procustian descriptive approach to psychiatric diagnosis. Yet this did not deter American psychiatry to dust it off and put it back on the shelf.

To conclude, the history of psychiatric nosology seems to indicate that cultural preferences appear to inform the biological agenda of research as much, if not more, as the other way around.

Psychiatry - culture interactions also manifest in cultural differences that are not easily captured by fixed descriptions. Any constrained, pre-defined description is lousy way to capture fluid differences, which is the case with cultural factorors. For example in a typical Western culture, the fact that the lack of independence that is usually part of a depressive presentation is highly problematic will be an aggravating factor for the clinical presentation and course.Compare that with a typical Eastern culture, where because group identity and connection are valued above individual autonomy, dependence is more acceptable and thus less probelmatic.

Cultural bound syndromes further challenge the limits of a strict classification system. Panic attacks, described in the USA, and ataques de nervios, described in the Latino cultures, share a number of commonalities, but also are different in a number of important aspects. For example fainting and amnesia are associated with ataque de nervios but not with panic attacks). The complicated dynamics between cultural influences and psychopatholgy are further illustrated by the fact the Latino culture based ataque de nervios seems to reach its peak on the USA soil, in that Latinos are most likely to report ataques de nervios when they are US citizens, born in the US, have spend more of their life in the US and speak more English (Gurnaccia et al., 2010).

It’s important to remember that the human psyche is a complex construct emerging at the somewhat fluid cross between genes and memes. As we are continuing our amazing discoveries in the brain-mind field, psychiatrists as well as neuroscientists need to remember that theoretical slicing, while necessary for “cutting” the overwhelming complexity in smaller pieces, also carries the risk of producing simplistic and thus inaccurate representations of the whole


GuarnacciaPJ, Lewis-Fernandez R, Martinez Pincay I, Shrout P, Guo J, Torres M, Canino G,Alegria M. Ataque de nervios as a marker of social and psychiatricvulnerability: results from the NLAAS. Int J Soc Psychiatry. 2010May;56(3):298-309. Epub 2009 Jul 10.

© Copyright Adrian Preda, M.D.

Tuesday, April 24, 2012

Faith in Psychiatry

Van Gogh - Man in Sorrow
Public Domain
Est autem fides credere quod nondum vides; cuius fidei merces est videre quod credis.
Faith is to believe what you do not see; the reward of this faith is to see what you believe.

St. Augustine

In response to one of my prior posts one of my readers commented that “in [the] American society doctors are treated like prophets and religious deities.”

This got me thinking, as my experience as a practicing physician in this country has been quite unlike being treated as a god or a prophet.

Let me set some facts straight.

I am a foreign medical graduate. As such, before coming to the US, I was used to a degree of implicit respect from my patients, which is the norm in other parts of the word. Also, while my European medical background prepared me for the overall practice of medicine in the US, it did leave out a couple of important things. Specifically, it was during my US internship when, for the first time in my professional life, I was exposed to learning about malpractice suits and defensive medicine, learned that physicians fall under one of the many categories of health care practitioners, and heard about patients “firing” their doctors.

Elsewhere the doctor-patient relationship is not just another business contract, essentially no different than the contract that a customer makes with his car mechanic or plumber or traveling agent etc. Elsewhere, the physician is not just another contractor or consultant but has a special role as someone whose intimate knowledge of one’s body and mind lessens one’s pain or nurses one back to health. This implies a certain “magic” to seeing the doctor that often results in the patient’s feeling better the moment they see their physician, which “magic” is both palpable in the medical examination room and acknowledged by the society at large. That is why being a doctor, in many places around the world, tends to have a special social status, even when doctors are not as financially prosperous as other professionals in the same society.

In the Western culture we tend to forget that healing was once part of a sacred relationship between the healer, the sufferer and a god whose discontent with the sinner was the proximate cause of his illness. A healer was then a hierophant and mediator of one’s relationship with God. And to this day, tribal societies see their healers as working with one’s spirit or soul. Arguably this sacred dimension might be at the origin at the “magic” that we now call a placebo effect.

Regardless of its origins the placebo effect turns out to be an essential ingredient in any healing process. 
At the same time it turns out the quality of the physician-patient relationship is the main predictor of the placebo response. What does that mean? The better the relationship is the higher the chance that the patient will feel better (as a result of an enhanced placebo response). It is important to understand that good doctoring will invariably increase placebo effect, while bad doctoring will invariably results in worse outcomes because of the lack of a placebo effect.

In other words, as doctor but also, and this is the most important part of this argument, as a patient, you would want the placebo effect on your side.

Unfortunately, in this day and age, when the divine is no longer part of the allopathic physician toolkit, when a medical malpractice suit can be started anytime by anyone, when patients or rather “medical customers” or “clients” engage in business medical contracts with doctors or rather “medical health care practitioners” who tend to practice defensive medicine, the odds are set against a placebo response.

It is a paradox, as the safeguards put in place to improve the quality of medical care actually hinder the changes of a good placebo response and thus result in poorer outcomes.

Which brings me to my final points.

Psychiatrists and their medications are commonly criticized for the high rates of placebo response as indicative of a lack of true biological effect for commonly prescribed psychotropics. An alternative explanation is that psychotropic medications are prescribed by psychiatrists, a category of physicians who might have a better chance of eliciting a strong placebo response because of a unique set up (longer appointments) and  professional skills that result in better engaging their patients.

We don’t know which explanation is true. But the consequences following these opposite explanations are far reaching: while the former explanation would be a reason for concern, the latter would be a reason for study and emulation.

Finally, a word of advice for the patient in all of us: the better doctor for you is the one that’s going to make your placebo response go way up. Thus the better doctor is not the one with a ton of diplomas on his walls but the one that you feel you can trust and connect with.

© Copyright Adrian Preda, M.D.