Monday, June 08, 2020

Psychiatry in need of a paradigm

In his letter to the editor of Acta Psychiatrica Scandinavica, Gordon Parker argues for "multiple niched paradigms" in psychiatry. Parker's letter was written in response to a letter from Tilman Steinert arguing that psychiatry needs a new paradigm. Parker contends that psychiatry doesn't need a single over-arching paradigm, but instead should "determine which paradigm (of many current and candidate ones) best explains why this individual is suffering this condition at this particular risk period".

I agree with Parker than psychiatric assessment should be individualised, but I'm not sure this is to do with paradigms as such. Like Steinert, I too was trained in a hierarchical approach to psychiatric assessment and diagnosis, with organic factors trumping psychotic, then neurotic then personality factors. Karl Jaspers understood the history of modern psychiatry as a conflict between two factions of somatic and psychic approaches rather than a simple chronological development. Georges Lanteri-Laura divided modern psychiatry into three sequential paradigms (see previous post), although I tend to prefer the implication of what Jaspers was saying, that there's always been a conflict in the origins of medical psychology in its attempt to move on from Cartesianism (see my editorial).

I also agree with Steinhart that psychiatry has got quite muddled in how it understands mental disorder. As he says, there's a need for "an effort of rethinking, sorting, and grouping of available ļ¬ndings". That's partly been the motivation of this blog! For example, Pat Bracken has argued for the need to move from reductionism to hermeneutics in psychiatry (see previous post). A BJPsych 2012 special article talked about the need to move beyond the current paradigm in psychiatry (see another previous post). More recently, as another example, I've pointed out the value of enactive psychiatry (see eg. previous post).

George Engel proposed his biopsychosocial model as a middle way between biomedical reductionism and Thomas Szasz's 'myth of mental illness' position, which Engel called exclusionist. Since Engel's time, psychiatry has become quite muddled about what 'biopsychosocial' means (see eg. previous post). We do need to be clearer about the aetiology of mental disorder (eg. see previous post). I also think the mistaken abolition of the distinction between organic and functional mental disorders by DSM-IV has clouded perspectives (see eg. another previous post).

It seems to me that Gordon Parker has not really taken these issues seriously. I suspect this is because he wants to perpetuate the current eclecticism of psychiatry to avoid dealing with fundamental ideological issues. Psychiatry found it difficult coping with the onslaught from so-called "anti-psychiatry" and, to my mind, has still not really recovered a balanced perspective (eg. see my editorial).

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