Friday, March 30, 2012

Psychiatry and Society



Following a few prior postings about the role of psychiatry in society I received a number of comments that I would summarize as reflective of the view that psychiatric illness, maybe not in its entirely but at least to some extent, is a social construct. Also, according to this view, psychiatry is seen as possibly abusing its medical affiliation status by assigning diagnostic labels even to minor emotional and behavioral deviations. Further, such (mis)labeling is thought of as a likely direct contributor to subsequent mental problems.
In this post I will try to briefly address this very important criticism of psychiatry.

The idea that “mental illness is a myth” (championed by psychiatrist Thomas Szaz) traces its origin to abuses or mistakes that have been made by psychiatrists. Masturbation, homosexuality, drapetomania (the runaway behavior of slaves) in this country or the 'sluggish schizophrenia' diagnosed in political dissidents in USSR are examples of labels that have been thought as psychiatric disease in a specific social and cultural context. Further, we now know that chronically institutionalized patients end up displaying symptoms that are a reflection of the institutionalization process rather than of any underlying preexistent biological dysfunction. Psychiatrists should be aware of this past history and remain vigilant about the potential for social abuse that is incumbent in a diagnostic process that is not based on hard biological markers. 

However, diagnostic and therapeutic blunders are not limited to psychiatry. In the history of medicine, fevers have been lumped together for centuries under a unique diagnostic category, even though we now know that a fever might be the reflection of very different underlying biological dysfunctions. From a time span of almost 2,000 years - antiquity up to the late 19th century – doctors used bloodletting, an intervention that we now know might do more damage than good, as the preferred intervention for a variety of illnesses. The point is that the science of medicine in general, and psychiatry is no exception here, has progressed by learning from its own mistakes. Further, in the words of Leon Eisenberg in his classic “Psychiatry and Society” article published in the New England Journal of Medicine in 1977 “the fact that a concept or a technology can be misused does not prove its invalidity.”

The charge about mislabeling minor deviations of though, emotion or behavior as mental illness is a more nuanced one. First most philosophers of mind would nowadays agree that all mind functions – including emotions, thought, and behavior – are brain based. Any mental manifestation is a reflection of underlying brain activity. The question then is when one differentiates a pattern of brain activity, what are appropriate criteria to differentiate normal from abnormal?

Now, when it comes to psychiatry, this question cannot be entirely answered by science. And that is because labeling can work both ways. The current discussion about refining the diagnostic criteria for autism in DSM V is a good illustration of this issue.

On one hand, labeling might result in self-fulfilled prophecies. A mental illness diagnosis, that is not warranted, would metaphorically dis-empower a patient who might feel hopeless in wining a fight with an overwhelming biology gone astray. At the same time, a mental illness diagnosis that is warranted would metaphorically empower a patient who would realize he is not a bad person and can, with proper support, win the fight with what would otherwise be an overwhelming biology gone astray.

“Relaxed” diagnostic criteria, while they might mislabel normals as having some sort of mental distress, would also capture the entirety of those who truly suffer and offer justification for social validation and support. Strict diagnostic criteria, while reducing the risk of misdiagnosis, would increase the risk of false-negatives, or of having patients with real mental illness failing the “diagnostic cut” and ending up ineligible for social benefits or other types of support.

The psychiatrist is first and foremost a doctor to his patient. As such his primary responsibility is to help his patient feel better. Not a straightforward responsibility when it comes to patients who are a danger to self or others because of their mental illness. The psychiatrist needs then to protect the patient against himself and others, as society values are not necessarily aligned with a de-stigmatizing view of socially disruptive behavior, even when it's due to mental illness.

At the same time, the psychiatrist is a member of society at large, and thus a product of a specific set of values informed by the time and the place. The prevalent cultural view on the sick role, disability, autonomy, competence to give informed consent for treatment, among other values, will inform his practice of psychiatry alongside with his biopsychosocial assessment and plan.

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© Copyright Adrian Preda, M.D.

Friday, March 23, 2012

Psychiatry on Trial


Mens Sana in Corpore Sano. Juvenal, Satire X


 F.O.C. Darley, William L. Shepard, or Granville Perkins, 1876.
Public domain.

Psychiatry has a special place in the Hall of Fame of medical specialties. Seen as either a villain or a hero, psychiatry, for the better or worse, tends to capture the public imagination. Not unlike some controversial stars that people seem to love to hate, time and again psychiatry breaks into the news, makes its talk show rounds as a special guest, is taken to court, is set free, placed on a pedestal, only to fall again in a cycle that never ends.

Psychiatry is commonly vilified for creating bogus labels that masquerade as real medical diagnoses under the hidden agenda of reinforcing social control on the unruly and the rebellious. Often times psychiatry is seen as another face of the thought police that reinforces the rules of the powerful and the privileged on those who choose to ignore or challenge the rules of the social contract. The jury is out and states its verdict as guilty when it comes to either psychiatrists fabricating diagnoses to keep themselves and medical industry in business, or simply pushing pills or locking up people who just happen to be different.

Interestingly, other disciplines that work with the mentally ill under similar theoretical assumptions (ie, that there is such a thing as mental pain and distress which can be successfully tacked with standardized interventions) are not nearly as popular as psychiatry when it comes to public debate.

At the same time, while the psychological distress—intervention paradigm is shared between psychiatry, psychology and other counseling disciplines, psychiatry stands alone in its philosophical partisanship with brain-based theories of mental pathology. In other words, consistent with its medical affiliation, psychiatry has always been steadily invested in a view of the mind as a product of brain function.

It is this reason which places psychiatry under a different set of standards and expectations in the public eye. The public view of psychiatry is a direct reflection of the fact that the debate between materialism and idealism is still fought on many different fronts, including modern philosophical theory.

As a practicing psychiatrist I face one or another of the above criticisms on an almost daily basis.

When I chose this career I envisioned myself as working with the poorest and sickest of us all. Those who been hurt most, by demons mastering their minds to such an extent that they will end up roaming the streets, or sleeping under bridges only until choosing to go up and jump off, as their only way out of the pain and torment.

And I am grateful that I have had the opportunity to do exactly that. My accomplishments are small: helping a deeply depressed young woman to regain just enough mental strength to choose to get out of bed, or a middle-age father of three to decide to keep on living, not one day at the time, that is already too long but ten minutes at the time. These usually rank as major accomplishments.

There are those of us who treat the worried well in plush offices in Beverly Hills and the Upper East Side. But the mental illness that crosses a psychiatrist's path is usually far from its glamorous New Yorker cartoon depictions.

Psychiatry is far from perfect. But that is good, as perfection implies stagnation, and when it comes to complex relationships, such as the relationship between the brain and the mind, it's always better to take a critical stance. Instead of thinking about what we've accomplished as a completed body of work psychiatry should remain a perpetual work in progress—integrating the new data from an array of related disciplines, starting with neuroscience and ending with the philosophy of mind, and redefining itself as many times as it takes.

So while I can understand how some, including well intended journalists feel it's their civic duty to doubt the legitimacy of psychiatry as a science, the reality is there are too many among us still wounded by severe mental illness.

I hope critics understand that stating that psychiatry created mental illness also implies that people who experience mental illness are making it up (as it's not real to start with, is it?). Mentally ill patients are then only unwilling conspirators against themselves and should be able to snap out of it when psychiatry's wicked plot will be eventually revealed.

But this is simply not true. Further, in a paradoxical twist, this view only reinforces the stigma that it attempts to curtail. What it curtails instead is the foundation for advocacy work for mental illness research and care, which is already under dire straits in this country.

© Copyright Adrian Preda, M.D.