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.

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

References:


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.

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.

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.

References:

Eisenberg L. Psychiatry and society: a sociobiologic synthesis.N Engl J Med. 1977 Apr 21;296(16):903-10.

© Copyright Adrian Preda, M.D.

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.

The Medical Model of Psychiatry



"Twelfth-century Byzantine manuscript the oath written out in the form of a cross, relating it visually to Christian ideas" from the Folio Biblioteca Vaticana. The source is page 27 of Surgery: An Illustrated History by Ira M. Rutkow, M.D.

Felix qui potuit rerum cognoscere causas.

Virgil

A psychiatrist who practices within the confinements of the medical model thinks of psychiatric symptoms as indicative of a pathological process. In other words, there is an underlying structural or functional deficit that manifests through a cluster of signs and symptoms, with a certain course and prognosis that will unfold over time.

From this perspective, brain pathology and mental illness are inter-changeable terms, as any brain pathology with necessarily produce mental/psychiatric symptoms, and any mental illness also necessarily implies an underlying brain pathology.

The implicit assumption at work here is that even though the underlying deficit might be hidden, its existence is certain and proved by unchanged pattern of events that unfold either at the same time and/or over a given period of time.  Ideally one would hope to understand what is the underlying deficit and how it translates into symptoms, however such understanding is neither necessary nor sufficient to inform assessment and intervention.

Huntington disease is a type of mental illness where directly looking at the brain tissue under the microscope is neither necessary to make a diagnosis (for a patient with a family history and specific symptoms) nor in any way informative for an intervention, which at this time remains palliative and supportive, not etiological.

On the other hand, bipolar disorder is a type of mental illness where a lack of understanding of the underlying brain pathology does not preclude a clear diagnosis and intervention.

Medicalized psychiatry (in lack of a better name) main effort is to build an ideal nosology made of discreet categories, where different levels of description (molecular, genetic, cellular, circuitry, brain, mind, behavior) come together based on discernible patterns. Medical psychiatry operates in an essentially descriptive manner, where the most important classification criterion is temporal relatedness of events. I.e. events that occur together belong together; where "occur together" might mean either an horizontal, synchronous temporal relationship or a vertical, longitudinal, sequential relationship. As a result, for same category data, medical psychiatry would collapse different data levels and tend to see correlation as causation.

For example, a medicalized psychiatry formulation would conclude that a consistent succession of events, such as administering a dopamine antagonist followed by improved auditory hallucinations, is evidence that excess dopamine is the cause of auditory hallucinations. Consistent temporal correlations would be seen as strongly indicative of causation. The lack of understanding of how a perceptual experience (or any other mind function for that matter) emerges from a soup of molecules and action potentials is not seen as either problematic or a subject worth of further inquiry in the eyes of medicalized psychiatry.

This pragmatic approach allows the medically-minded psychiatrist to efficiently categorize things, make recommendations, and quantify outcomes; in other words, operate in a sensible manner in an environment where sheer size and complexity, if properly sized, would otherwise overwhem and paralyze.

In summary, the strength of this medical model type of approach is its power to simplify. That is true for medicine in general and psychiatry in peculiar.

But it is in this very strengh that the perils and limitations of medicalized psychiatry also lie.

While simple is informative, simplistic is misleading; this is the first temptation that an excesively medicalized psychiatrist should avoid at all costs.

Second, clusters of data, no matter how complex, lack meaning. Reducing human experience to data clusters, as proposed by the medical model, regardless of how valid the clustering operation might be, inherently implies taking the meaning out of the equation. The inherent tension here is that no matter what philosophical approach one favors, at the end of the day, moving  away from meaningless and emptiness and toward meaningfullness is as much part of the job description for a medicalized psychiatrist as it is for a logotherapy-existential analyst. The second temptation then is to fall back on meaningless biological explanations at the cost of sacrificing meaningfull explorations.

In conclusion, as long as the medicalized psychiatrist abides by the principles of cultivating a simple, but not simplistic, human and meaningfull practice, a medicalized interpretation of mental health and distress will continue to add an informative and pragmatic perspective on mental health and disease.

© Copyright Adrian Preda, M.D.

Philosophy Based Psychiatry

Medicine nowadays has an increased appreciation of evidence-based theory and practice.  Naturally, psychiatry, as any other medical specialty, follows suit.

Ganditorul de la Hamagia
Romania, cca  5250/5200 BC

But is psychiatry just another medical specialty?

Historically, psychiatry has been seen as different than other medical specialties. And of course it is: psychiatry studies the mind, while all other specialties study the body.

Due to this difference in focus, physicians entering the field of psychiatry, i.e. students of the body, tend to have a difficult time establishing a coherent professional identity that somehow needs to integrate their expert knowledge of the body with the yet to be understood realms of the mind.

For the philosopher the mind-body problem is a theoretical challenge of major importance. For the practicing psychiatrist in additional to the theoretical importance well acknowledged by countless philosophers the mind-body problem is a foundational issue; as its solution will carry clear pragmatical implications for the psychiatrist way of practicing his trade.

Not surprisingly, a number of psychiatrists end up choosing to stay with the familiar, i.e. practicing a type of psychiatry confined within a biomedical model of the mind and mental illness.  Further, the field of psychiatry as a whole, struggling with similar identify issues, has moved away from complex models and now favors a reductionist biomedical mind-brain model.

The biomedical mind-brain solution, in addition to resolving the identity crisis, has an added degree of appeal due to its simplicity.  However, while most times simplifying is good and simple solutions are desirable, one needs to remember that over-simplifying is never good and simplistic solutions are always a hindrance.

Understanding the biology of mental process has been essential in terms of both important theoretical advances and practical applications (i.e. the discovery of new treatments) in psychiatry (or more broadly put in neuroscience).  However, assuming that every mental process, starting with the building blocks of cognition and ending with consciousness, can be entirely reduced to its underlying biology, might be oversimplifying and as such counter-productive.It appears that one of the important challenges that modern psychiatry faces is separating simple from simplistic.

Thinking along this lines, one can understand why psychiatry shall require a more philosophically grounded apprenticeship and practice than other medical specialties.

To be a good physician one needs to have a solid understanding of his specialty object of study: e.g. the heart for the cardiologist, the blood for the hematologist, etc.  Similarly, to be a good psychiatrist one needs to have a solid understanding the brain.  However, while brain-expertise might be the end goal for other medically trained brain experts - such as the neurosurgeon and neurologist - brain expertise is only one of the competencies that a psychiatrist needs to master.  Specifically, a good psychiatrist, while required to qualify as a brain expert, also needs to meet equal qualifications as a mind expert.

In practical terms, the formation of the modern psychiatrist, following mastery of traditional medical disciples such as anatomy, physiology, pathology, pharmacology etc. in addition to thorough familiarity with the disciplines of psychology, cognitive sciences, and neuroscience, shall include philosophy as the sine qua non jewel of psychiatric expertise.

Why philosophy?  And more specifically, what sort of philosophy are we talking about?

Psychiatry is clearly a complex subject. As such, the modern evidence-based philosophy of practice that has become the overarching theme of modern medicine, while necessary, might not be sufficient for psychiatry. In addition to evidence-based appraisal proficiency, psychiatrists also need a philosophy of neuroscience foundation in order to bring together the apparent diverging components of modern psychiatric practice.

Similarly to psychiatry standing at the crossroads of medicine, psychology, sociology, anthropology and ethics, where body meets brain, and brain meets mind, the philosophy of neuroscience is also a subject of major philosophical confluences including epistemology, philosophy of mind, philosophy of science, and moral philosophy.

Such complexity could be overwhelming for the psychiatrist in training.  Especially when the trainee already faces a steep learning curve in the science and art of psychiatric interview, nosology-diagnosis, and a variety of interventions ranging from traditional psychotherapy to modern psycho-pharmacology.  All these in addition to keeping up with a rapidly changing field of knowledge, where mastery requires frequent learning "updates".

When the plates are already full, is it realistic to propose further increasing the number of required competencies, including a philosophy-based competency?

What we would like to propose is that training in the philosophy of neuroscience is not so much about adding more, but rather about organizing existent knowledge by changing perspective.

Think about it this way.  You need to operate a complex machine but you are illiterate.  There are many different sets of instructions and you depend on people who are literate to read you the instructions each and every time you need to operate your machine.  The instruction manuals are updated frequently and new manuals are also published on a regular basis.  You need to master all this information.  Your plate is already full.  Then your boss comes in one day.  He says that in addition to everything else you do, you are now expected to master a new task: you need to learn how to read.  You try to explain that it is quite overwhelming just the way it is, implying that you simply cannot add anything else to your already full plate.  He tells you that if you will master this new task (i.e. reading) you will find that your plate will actually be less full.  By adding reading (a tool/process/skill or active knowledge, as opposed to passive, learnt and stored knowledge) you will actually end up emptying your plate.

This is an illustration of an interesting philosophical paradox where more is less, and addition eventually works out as subtraction.

Similarly to mastering reading, mastering the philosophy of neuroscience is NOT an addition of some additional passive knowledge to an already full storage.  Rather, it is mastering of a new set of skills, a new tool, a new way of thinking about things, which will then organize everything else.

© Copyright Adrian Preda, M.D.