Clarifying the message of critical psychiatry

Reaction to my BJPsych Bulletin editorial has made me realise I need to be clearer in my essential message about critical psychiaty (see previous post). It needs to be more relevant (see twitter conversation) and inclusive without becoming diluted. To this end, let me try to create a basis to build on in a couple of sentences.

Functional mental illness has a dynamic, systemic and purposive character and we need to move on from expecting to explain it in physico-chemical terms. It makes more sense to see it as a process rather than a static substance in the brain (see eg. previous post).

Has psychiatry really moved on from its radical reductionism?

I am grateful for Mohammed Rashed’s commentary on my BJPsych Bulletin editorial. At least we agree radical reductionism has had its day (or at least should have done). I also agree that the argument of critical psychiatry is partly empirical and partly philosophical, although Mohammed does not seem to appreciate that the philosophical implications, as well as empirical, are that there are no structural abnormalities in the brain in functional mental illness.

But Mohammed seems to have missed the point that critical psychiatry is not an argument just against radical reductionism. I would dispute that White et al (2012) do not take a reductionist position (see previous post). For example, they believe brain scans have shown structural brain abnormalities in various mental disorders. Mohammed does not seem to realise that critical psychiatry is against the eclecticism, which he seems to want to perpetuate, which was proposed by Anthony Clare, in particular, as the response to anti-psychiatry (see eg. previous post).

In my effort to show the continuity of critical psychiatry with mainstream psychiatry, I did not mean to give licence to the argument that “we are all now critical psychiatrists”. Psychiatry still needs to move on from a system based on a ‘disease’ model of mental illness (see eg. my Lancet Psychiatry letter). The editorial focused on conceptual aspects but feeds into all the ongoing critiques that Mohammed lists. I may not have succeeded in getting my message across but I am very clear that my version of critical psychiatry is not merely of historical interest. In fact, Mohammed shouldn’t marginalise its impact or indeed its conceptual argument.

Demonstrating brain abnormalities in major mental illness

Following up my last post about Lindsey Sinclair's BJPsych Bulletin commentary, I want to comment on how she insufficiently considers non-specific other explanations (including medication) for the so-called brain abnormalities which she thinks have been demonstrated in major mental illnesses. As she says, the modern resurgence of biomedical psychiatry goes back to a 1976 paper by Eve Johnstone, Tim Crow et al showing cerebral ventricular enlargement in chronic schizophrenia (see previous post). Brain tissue volumes decrease and CSF volumes increase over time may also be due to medication or non-specific factors (see another previous post). Sinclair admits that it has been difficult to prove definitively whether there are differences in volume even before the at-risk mental state (see another previous post).

I just think this evidence demands more cautious assessment. Why doesn't she mention that brain scanning studies are plagued by inconsistencies and confounders? (see yet another previous post). Certainly Sinclair cannot conclude that the null hypothesis has been rejected and that biological abnormalities have been demonstrated in major mental illnesses. In fact, it's more scientific to say they haven't been demonstrated. Sinclair does accept that "neuroscience is unlikely to hold all of the answers to why people develop mental disorders and when they occur in their lifetime". She needs to consider this issue further.

Familial origins of mental health problems

Lindsey Sinclair in her commentary on David Kingdon's article (mentioned in my last post) says that "[b]iological and genetic abnormalities have been demonstrated in major mental illnesses". Her claims need examining further and at least by being so definitive she can be held to them. For the moment, I just want to comment on how she contrasts what she says was the widely held belief 50 years ago that "parents could be responsible for their offspring developing schizophrenia" with what she perceives as the radical change in our biological and genetic understanding of mental health problems started in the past few decades.

As mentioned in a previous post, eminent psychiatrists, such as Anthony Clare and Robin Murray, have taken their position in psychiatry as a reaction to their understanding of R.D. Laing as blaming families for causing schizophrenia. As I said, for example in my book chapter, this is actually a misunderstanding of Laing's views. He wasn't talking about a direct one-to-one causal relationship but understanding schizophrenia in the familial context.

Frieda Fromm-Reichmann (1948) probably coined the term "schizophrenogenic mother". The book by Gail Hornstein (see previous post) To Redeem One Person Is to Redeem the World gives a positive view of her life and legacy. Biological and genetic accounts do not provide any understanding as such of mental health problems.

Neill (1990) asked the question 'Whatever became of the schizophrenogenic mother?'. As Neill said, probably the most important series of family studies was by Theodore Lidz (see extract from by book chapter). These kinds of studies were undertaken by both David Cooper (who probably coined the term 'anti-psychiatry') and R.D. Laing (see further extracts from another book chapter). The link between these family studies and so called 'anti-psychiatry' cannot be denied.

As Neill says, "By the mid-1970s, the concept of the schiophrenogenic mother seemed to have proven too elusive to be useful". Certainly any over-determined view of the familial origins of schizophrenia (which I don't think can be attributed to Laing) was abandoned. Understanding of the reasons for mental health problems is complex and there can never be a proof as such of their cause. Trouble is that too biological a view such as Sinclair's can also be overdetermined.

Disinvesting in neuroscience in psychiatry

David Kingdon (who I've mentioned in a previous post) asks in a BJPsych Bulletin Against the Stream article 'Why hasn’t neuroscience delivered for psychiatry?' As he says, "it is still not possible to cite a single neuroscience or genetic finding that has been of use to the practicing psychiatrist".

As he explains,

The neuroscience tools we have available and indeed, those that are likely to become available in the foreseeable future, are far too insensitive to achieve an understanding of the complexities of human pathological emotional reactions. Can we really expect neuroscience to illuminate the aetiology, to take a common example, of a severe depressive illness in a recently widowed woman who has hated her husband for the last 20 years of his life? Will not a clinical interview always shed more light and lead to more effective interventions in such a scenario than an assessment based on neuroscience?

He goes on:

Might it not be that the difference with other areas of medicine is that there are demonstrable and incontrovertible biological abnormalities in neurological disorders, dementia and so on? No such clear causative changes exist in severe mental illnesses such as depression, anxiety, bipolar disorder and schizophrenia. 

Like me (see eg. previous post), he thinks we may well be setting up unachievable expectations for new entrants to psychiatry by focusing on neuroscience in recruitment. He concludes that "the time has come to challenge the justification for such relatively high levels of investment of time, expertise and resource in neuroscience for mental disorders". I couldn't agree more.

Labelling of personality disorder

Keir Harding has an excellent The Mental Elf blog post summarising the new position statement on personality disorder by the Royal College of Psychiatrists. He expresses disappointment about the way in which the position statement has approached the issue of the diagnosis of personality disorder.

Considering the way I have been critical of those that want to completely abandon the term 'mental illness' in recent posts (see example), it may seem surprising that I agree with Keir. I think a distinction needs to be made between personality disorder and mental illness. In a way, the diagnosis of 'personality disorder' can be taken to imply that the person does not have a mental illness as such. This is why it can become a diagnosis of exclusion, if services are seen as only dealing with people with mental illness. In my practice, I was often reluctant to use the term personality disorder, instead using a description such as 'personal problems or difficulties'. In fact, if the term 'personality disorder' has any meaning, what it does mean is personal problems or difficulties. This isn't to underestimate the potential severity of such problems which can be very incapacitating (and for which such severe conditions a diagnosis of ‘illness’ may actually make sense).

As The Consensus Statement for People with Complex Mental Health Difficulties who are diagnosed with a Personality Disorder makes clear (albeit with slightly clumsy wording), there is a lack of "consensus on what words we should use to talk about the problems and difficulties people with this diagnostic label experience". The implication that there is something wrong with the person's personality can be very misleading and it may well be better if the term is abandoned or replaced. Personality disorder also shouldn't imply that there is no room for improvement.

It is reasonable to expect that the College would properly deal with this issue in its position statement, although the title of its statement 'Services for people diagnosable with personality disorder' implies that the diagnosis, as such, may not necessarily be needed or used. As Adrian James, newly elected President of the College, acknowledges in the foreword, "there is the potential for a diagnosis [of personality disorder] to cause harm, particularly if this is done in a way that lacks appropriate dialogue". However, he goes on, "on balance, we believe that the diagnosis has brought benefits of better describing the impact of such difficulties on people’s health and social outcomes".

It worries me that the position statement countenances the use of the term personality disorder in adolescents, rather than conduct, or even emotional disorders (although these may predispose to a diagnosis of personality disorder as an adult). I'm not sure if the diagnosis of personality disorder as such always "interferes with the sufferer’s sense of wellbeing and ability to function in full in ordinary social settings". Some people diagnosed as being personality disordered (eg. antisocial personality disorder) may well not have any subjective sense of being unwell. Although the College accepts that the issue is controversial, I don't agree that "a range of evidence exists to support a neurobiological role". It is of concern that the College believes that "changing terminology will simply cause confusion and divert attention (and funding support) from the need to develop accessible, effective and safe services". However, a scientific statement about personality disorder shouldn't be determined by such expectations. I'm not sure if the College is making a pitch for psychiatrists to be the only ones that are sufficiently qualified to make a diagnosis of personality disorder.

Like Keir, I am disappointed by this position statement. To me there seems to be more work that the College needs to do. Maybe the wish to come to some agreement amongst The British and Irish Group for the Study of Personality Disorder executive avoided the hard work needed to deal with these issues, although as Keir points out, "The document doesn't actually describe how it came together". In fact, I don't think it does 'come together'.

Psychosomatic medicine and the biopsychosocial model

Nassir Ghaemi has added to the debate in Psychiatric Times on the biopsychosocial (BPS) model (see his article). From his point of view, "the BPS model for the past half century has served as a postmodernist excuse for eclecticism".

I have been critical of Ghaemi's book The rise and fall of the biopsychosocial model (see previous post and my book review with response and reply). However, I do essentially agree with his statement that the "BPS of the past half century is not the same BPS of George Engel in 1977" (see previous post). I can't really accept Ghaemi's simplistic definition of postmodernism as eclecticism (or nihilism), but I think he is right that modern psychiatry is eclectic and that "[m]ental health clinicians ... claim support [for eclecticism] ... in the BPS approach".

As Ghaemi indicates, Engel's BPS model comes from psychosomatic medicine. Ghaemi seems to define psychosomatic medicine as "the idea that unconscious psychology affect[s] ... the body to cause disease". Certainly this idea is present in the history of psychosomatic medicine from Franz Alexander. However, psychosomatic medicine is a wider concept and it now tends to emphasise excessive attention towards physical symptoms rather than stress as such or even unconscious motivation. Ghaemi is essentially anti-psychoanalysis (see previous post), which is why he calls the BPS model a "disproven psychosomatic medicine" model.

But the point of Engel's BPS model is that it promotes an integrated mind-brain understanding. It provides an explanatory anti-reductionist position for psychiatry (see eg. previous post).