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).

Conceptual competence in psychiatry

Awais Aftab and Scott Waterman have an interesting article on conceptual competence in psychiatry. As they say:-

The considerable challenges facing our discipline [psychiatry] will not be met without rethinking our approach to educating and training the next generation of psychiatrists, specifically attending to the implicit—and thus rarely confronted, examined, and questioned—conceptual foundations of the field.

The four elements of conceptual competence are: assumptions and questions; tools;  discourse; and humility. Training can improve conceptual competence.

I asked Awais Aftab in a tweet what the implications for practice are and he gave an interesting and important initial response (see conversation). I don’t think all practitioners need to be philosophers of psychiatry but they do need to understand there is a mind/body problem. I also think it may be worthwhile emphasising how cultural competence overlaps with conceptual competence.

The concept of mental illness

I want to follow up my previous post about the nature of mental illness. The article I've always thought that does the best conceptual analysis of 'mental illness’ is by BA Farrell (see article).

Farrell makes clear that ‘mental illness’ is a statement about psychological functioning. It’s not primarily a statement about statistical abnormality. It standardly implies social maladjustment, but social misfitting is not just due to mental illness. Nor does mental illness necessarily imply bodily dysfunction. As Farrell says, the regulative principles of physical medicine are extended in the concept of mental illness to the psychological reactivity of human organisms. In other words, the psychological functions of the person do not operate within their standard limits when someone is diagnosed as mentally ill. This concept of mental illness fits more clearly with psychotic than neurotic conditions in general, and may well be problematic for personality disorders. What counts as a psychologically morbid process can be open to debate. Applying the concept of mental illness is both descriptive and evaluative in the sense of implying an undesirable and unwelcome state. There are real problems with defining mental illness as behavioural disorder. As Farrell says “all concepts have their difficulties”. We need to work through what we mean by the term ‘mental illness’, rather than merely dismissing it as invalid.

This definition of mental illness is reinforced in an article by Aubrey Lewis. The concept of illness can be ambiguous. It designates a change from a pre-morbid state. As Lewis says, maladaptive behaviour is only pathological if it is accompanied by a disturbance of psychological functioning. Social criteria play no part as such in the diagnosis of illness.  To quote from Lewis: “The concept of disease ... has physiological and psychological components, but no essential social ones”. Doctors may well deal with more than illness. And psychoanalysis generally defines mental illness quite loosely. The recognition of illness may well not be very reliable or valid, and this is even more likely to be the case for mental than physical illness. But Lewis is clear that “it is not possible to set up essentially different criteria for physical health and mental health”.

Psychopathology is, therefore, a morbid process like physical illness. To be diagnosed as mentally ill, a person's psychological processes are dysfunctional. A tweet pulled me up for suggesting that psychosis is maladaptive, as using the word ‘adaptation’, perhaps particularly in the evolutionary sense, may actually explain why people do become psychotic. Psychosis may well increase survival eg. by preventing someone dying by suicide (see my twitter response). I agree that whether mental illness is maladaptive is not the essential relevant criterion to consider. From the individual perspective becoming psychotic may be a necessary reaction. However logical the private sense may seem to the person, it is the loss of common sense viewed by most people that is characteristic of madness. The correctness of our judgments and the soundness of our understanding are subjective but our understanding is also restrained by the understanding of others. As Jaspers said, there may be an 'un-understandability' about psychosis. This applies, however, to others' perspective, as from the individual's point of view a psychotic reaction may make sense (at the time at least).

As both Farrell and Lewis emphasise, our modern idea of illness as physical lesion only really starts from the nineteenth century. The concept of ‘illness’ itself is much more long-standing. Modern critics of the concept of mental illness need to have this longer historical perspective rather than juxtaposing it too much with physical illness and thereby invalidating the concept.

Facing up to the difficulty of treating depression

Following a Guardian article by Ed Bullmore, I tweeted today asking why psychiatry allows and encourages speculation about depression being an inflammatory disorder. As I've said before (eg. see previous post), it’s non-sensical to believe that depression is a form of inflammation. Yet, as in the article by Bullmore, such speculation is promoted as a “new frontier” which could lead to “breakthroughs” in the treatment of depression, with the “potential to transform our thinking about illness more broadly”. Exciting stuff apparently! But why the hype?

Of course part of the reason is to encourage participants to express an interest in the NIMA ATP trial. More fundamentally, the real problem is that depression is not always easy to treat (see previous post). We always need hope that there might be simpler and more effective treatments (see eg. previous post). I don't want to appear pessimistic about the treatment of depression. There can be spontaneous improvement over time. People have considerable personal resources and resilience to be able to overcome and adapt to their difficulties. 

Of course psychiatry is merely responding to our idealistic wish for a simple, quick, cheap, painless and complete cure for depression. It does this for psychological therapy as well as medication (eg. see previous post). But promoting myths that depression is due to inflammation does not justify deflecting from the hard work required to help people recover from their depression. 

Does psychiatry need a diagnostic system?

As I said in a previous post, when commenting on Lucy Johnstone’s article on whether mental illness exists, I was left with the issue about the nature of illness. I’m even more focused on this question, as I am reading Peter Kinderman’s book A manifesto for mental health. Like Lucy, Peter does not want to see emotional problems as illness. He, therefore, doesn’t want to see ‘psychological health issues’, as he calls them, as pathological. He wants to ‘drop the language of disorder’.

I think I do understand what Peter means when he says, “Madness and sanity are not qualitatively different states of mind”. There may not be an absolute distinction (see previous post). I agree with him that psychiatric diagnoses are not ‘things’. We need to focus more on “how and why we feel or act the way we do” rather than naming mental health problems. I even agree that psychiatry could still be practised without a psychiatric classification system (see previous post). Such a situation may well have benefits, as it would encourage psychiatry to focus on formulation, rather than biomedical diagnosis.

But I do worry that the ‘drop the disorder’ mantra is open to misinterpretation. Peter does recognise that, “Giving a name to our distress serves a function”. But he wants to suggest that naming a mental health problem shouldn’t be identifying it as illness. He does nonetheless recognise that people may want the apparent benefits of identifying it as illness.

Talcott Parsons described the two rights afforded to people in the social role of being sick:-

1. The sick person is temporarily exempt from performing ‘normal’ social roles (such as going to work or housekeeping). The more severe the sickness, the greater the exemption. 

2. A genuine illness is seen as beyond the control of the sick person and not curable by simple willpower and motivation. Therefore, the sick person should not be blamed for their illness and they should be taken care of by others until they can resume their normal social role.

These rights are conditional on the patient following two obligations:-

1. The sick person is expected to see being sick as undesirable and so are under the obligation to try and get well as quickly as possible.

2. After a certain period of time, the sick person must seek technically competent help (usually a doctor) and cooperate with the advice of the doctor in order to get better.

Peter thinks simply listing people’s actual experiences and problems is sufficient rather than seeing them as ill. He doesn’t object to people taking time off work “if we’re depressed, or anxious or hearing voices”. And he acknowledges for some that “personal circumstances mean that we can no longer work on a permanent basis”. I agree with Peter that provision of services may only be connected loosely with psychiatric diagnosis. But I worry that by focusing so much on psychological aspects he has ignored the social implications of these experiences and problems. Health care may well be provided for people who are not ill as such, but that doesn’t necessarily invalidate the notion of illness.

People who are disabled also may not necessarily be ill. There is a need for judgement about whether people are ascribed the sick role. If people are in need, the reason for it may be illness. Not all need may be due to pathology, but some of it might be. I just worry that Peter’s insistence on avoiding pathologising is more technical than practical. His laudable aim to encourage understanding of the reasons for mental health problems may undermine the pragmatic sense in which mental illness can be like physical illness. Of course the concepts are not identical. Certainly functional mental illness should not imply physical lesions (see eg. previous post). But there is sufficient overlap for the concept of mental illness still to be useful and valid.

Resistance to critical psychiatry

Giovanni Fava (who I've mentioned previously eg. see post) quotes from Thomas Kuhn’s The Structure of Scientific Revolutions in an article about the importance of pluralism and the challenge to current paradigms in medicine: "Novelty emerges only with difficulty, manifested by resistance, against a background provided by expectation". Critical psychiatry seeks to help psychiatry move on from its current biomedical dominance (see previous post).

Fava describes obstacles to change, including: (1) barriers to publishing, such as the commercial nature of open-access journals, requiring contributors to pay for publishing, as truly innovative research is unlikely to be funded (2) special interest groups, including so-called key opinion leaders, using their power to suppress conflicting information and bias interpretation of the evidence (3) the pseudo-objectivity of evidenced-based medicine failing to recognise its limitations, and (4) the general lack of familiarity of researchers with clinical practice meaning that research lacks clinical relevance.

I've argued that social media can help maintain freedom in an academic system motivated by commercial interests (see post on my personal blog). I have used this blog and tweeting (@DBDouble) to promote critical psychiatry. But we do need academic journals, as Fava says, to "host dissent, debates, and heresy, as long as they are supported by methodological soundness" (see previous post). Academic psychiatry needs to be rebuilt by the recognition of the limits of biologic research (see previous post). Medicine in general needs to be rethought (see another post on personal blog).

Developing global mental health services

I've discussed before (eg. see previous post) how we tend to have an understanding of illness as implying physical abnormality. An article by Suman Fernando highlights how much this perspective is a 'Western' understanding. Even within Western cultures this interpretation of illness is only really since the nineteenth century (eg. see previous post). 

Suman highlights the plurality of mental health systems in place in the global south: "Western systems, traditional indigenous systems, new, innovative systems, and those that attempt to adapt Western systems to make them ‘culturally sensitive’ to local norms". I  don't think we should underestimate the plurality of health care systems in the global north with much uptake of 'alternative' and complementary health care besides standard health care.

This blog has been critical of biomedical approaches in psychiatry. I therefore agree with Suman than mental health development should not be colonised by biomedical psychiatry (eg. see previous post). Nor should we medicalise difficult social problems, like poverty and lack of social support, that require political and economic solutions (see previous post). As Suman concludes:- 

the aim of all agencies seeking to develop mental health services must be to enable local people to develop services that are ethical, that is for the benefit of the people concerned as subjects rather than objects of development, and sustainable without dependence on rich countries in the West. 

Integrating critical approaches into the training of psychiatrists

I've mentioned in a previous post that I had an application turned down for last year's International Congress of the Royal College of Psychiatrists (RCPsych) on 'Integrating critical approaches into the training of psychiatrists'. I'm not sure if RCPsych is really interested in an initiative of this sort.

I've said before (see previous post) that there is an orthodoxy in psychiatry. Trainees do need help to manage this indoctrination. Current training could be said to be biased towards neuroscience (see eg. another previous post). It is insufficiently global in its perspective (see previous post) and trainees need help to deal with psychiatry's institutional racism (see another previous post) and institutional corruption in general (see previous post). Trainees need to become more patient-centred (see another previous post) in their practice.

Psychiatry shouldn't see this agenda as a threat. As I've kept emphasising in this blog (eg. see previous post), critical psychiatry is a legitimate part of current psychiatry. It is not anti-psychiatry or a "warped political ideology" (see recent previous post).

Reducing suicide in young people

Jacob Hess comments in an MIA blog post on a NYT Op-Ed essay entitled Why are young Americans killing themselves? In the UK, despite having a low number of deaths overall, rates among the under 25s have generally increased in recent years (Office for National Statistics, 2019). 

Despite some yearly increases (including 2018, the first increase since 2013), suicide rates for all persons have generally decreased since 1981. Over this time frame, it is particularly in the over 60s for men and the over 45s for women where this is apparent. Suicide reduction has primarily happened for older people. I'm not saying the recent increase for young people is not of concern but it does need to be set in context. Many factors contribute to trends in suicide rates which can be very difficult to disentangle.

I agree with Jacob Hess that the solution to suicide in young people is not as simple as the Op-Ed piece makes out. It asks, "How is it possible that so many of our young people are … killing themselves when we know perfectly well how to treat this illness?" It then goes on to state that "We know that various psychotherapies and medication are highly effective in treating depression."

Public mental health strategies should not be driven by exaggerated claims for the effectiveness of psychiatric treatment. For antidepressants, for example, there are substantial non-response and recurrence rates (see previous post) and the difference between active and placebo treatment in clinical trials is much smaller than most people realise (see eg. another previous post).

The readiness to use antidepressants in children has increased over recent years (see my BMJ letter) as the concept of childhood depression has been socially constructed (see previous post). Concerns about lack of efficacy and increased suicidality created a hiatus in 2004 in the relentless continuing increase in antidepressant prescribing for children. I suspect that children and young people object more than adults to the medicalising of their mental health problems. We do need to look wider than psychiatric treatment to helping suicidal young people.

Is critical psychiatry a "warped political ideology"?

Paul Morrison @PaulMor64695904 tweets praise for a blog post about antidepressants by George Dawson (who I have mentioned previously eg. see post). He suggests the blog counters the "warped political ideology of anti-psychiatry extremists". I'm not sure what is meant by his claim. I've said before (eg. see previous post) that psychiatrists often label views with which they do not agree as 'anti-psychiatry'.

Dawson regards what he calls the "war on antidepressants" as "really a war on psychiatry".  He doesn't seem to be able to appreciate the institutional corruption of modern psychiatry (see eg. previous post) and even seems to suggest that psychiatrists' conflicts of interest with pharmaceutical companies do not matter (see eg. another previous post). I'm not sure who he's blaming for the widespread belief in the chemical imbalance theory of depression (see previous post). He doesn't seem to be able to accept that the evidence for the effectiveness of antidepressants is still open to question (see previous post); nor that the placebo amplification hypothesis could be valid (see another previous post). In fact he seems to think that the placebo amplification hypothesis is that antidepressants work by side effects, which is a misunderstanding of the theory. He needs to gain more understanding of the position of critical psychiatry (see previous post).

I agree antidepressants are not "tools of the devil" but let's stick to the scientific arguments rather than  stigmatise so-called warped ideology.

Are mental illnesses really medical disorders?

Lucy Johnstone asks the question 'Does mental illness exist' in her IAI (Institute of Art and Ideas) article. Her answer leaves me with the question 'What is medical illness?'.

Lucy doesn't deny the reality of "suicidal despair, hearing hostile voices, crippling anxiety and mood swings". But she does not think these experiences should best be understood as mental illnesses/disorders. In fact she goes further and says that there's never been any evidence to support the idea that these "very real experiences" are best explained as medical disorders.

What she seems to mean by 'medical disorder' is a condition caused by physical pathology. Here, in a way, she follows Thomas Szasz, who thought mental illness is a myth. For Szasz, it was a misnomer to call mental illness an 'illness', because it's not an illness with physical lesions (see eg. previous post).

I agree with Lucy (and Szasz) that functional 'mental illnesses' are not "chemical imbalances, genetic flaws or other bodily malfunctions". Where I have difficulty with her (and Szasz's) view is that I think the best way to understand medicine is that it covers the treatment of both physical and mental illnesses (see eg. another previous post).

In fact, our modern idea of physical pathology only really developed from the mid-nineteenth century with the correlation of pathological, including histological, findings with clinical symptoms (see eg. previous post). The problem for psychiatry was that it did not completely fit with this development of anatomoclinical thinking, which was of such importance for the advancement of modern medicine in general (see eg. another previous post). Modern psychiatry's always hankered after this identification with the rest of medicine. Most psychiatric illness is functional and not organic, in the sense of not having an identifiable physical lesion in the brain (see eg. yet another post). Lucy's correct that much of modern psychiatry assumes that physical pathology will be found to underly what is called 'mental illness'. It's always tended to believe this, but, in my view, thereby avoids philosophical issues about the mind-body problem and the nature of life in general (see eg. previous post).

I also agree with Lucy that psychiatric assessment is about formulation. It's not commonly appreciated that the standardising of procedures for history taking and mental state examination in psychiatry at the beginning of the 20th century was about formulation (see eg. previous post). What should be important in psychiatric assessment is helping people understand their problems. Reducing people's problems to brain disease has the potential to be stigmatising by turning people into objects.

I, therefore, understand Lucy's concern about psychiatric classification. I agree with her critique, if the aim of psychiatric classification is to create a functional diagnostic system based on biological markers. This was the original intention of DSM-5 and it failed (see eg. previous post). But Lucy seems to think that psychiatry needs to have a reliable and valid classificatory system to be a science. Following Peter Breggin, she argues that psychiatry is undermined by not being able to treat mental illness as physical illness.

Here, again, I have difficulty with her view. Any psychiatric classificatory system is merely descriptive, not aetiological, certainly not biologically-based in the sense of brain abnormalities (see eg. previous post). It needs to be understood for what it is, and there may well be nothing to be gained, or even harm caused, by using psychiatric labels. But sometimes it can be helpful to use words to describe mental states. This was in fact how modern psychiatry first started from the end of the eighteenth century by attempting to reason about madness (see eg. previous post). There will be inevitable uncertainty about using these descriptions of the ways in which people react to the situation in which they find themselves (see eg. another previous post). Of course brain abnormalities can cause psychotic symptoms as part of delirium or dementia (see eg. previous post). However, for the vast majority of psychiatric presentations, which are functional, we have to rely on our ability to identify patterns of responses if we are going to create any validity for a psychiatric diagnostic system (see eg. previous post). We are profoundly limited in what we can achieve and too much should not be made of these limitations.

I just worry that Lucy is making too much of this situation. Mental health practice is interdisciplinary but that doesn't mean it's not medical. I just think it's potentially misleading to suggest that what's identified as 'mental illness' may not be a medical problem. Medicine includes both physical and mental aspects.

Reality of mental health problems

I’ve mentioned before several times (eg. see previous post) about the hope that neuroscience will explain mental illness. Psychiatry commonly assumes that there is an underlying hypothetical brain lesion, even if not yet discovered, causing mental health problems. But these are often mere conjectures (eg. see another previous post).

The problem with continually promising ourselves physical lesions is that we can tend to ignore psychosocial facts that are already available. As Adolf Meyer (1906) said, “it has become my conviction that the developments in some mental diseases are rather the results of peculiar mental tangles than the result of any coarsely appreciable and demonstrable brain lesion” (see previous posts about Meyer eg. Pathologist of the mind). This doesn’t mean ignoring organic factors when they exist. But, again following Meyer, “we had better use the facts at hand [psychosocial factors] for what they are worth” rather than “have to invent them [somatic factors] first in order to get anything to work with”.

Pragmatic treatment is about helping the person adapt and adjust. This may well not be easy, but it’s not a reason for avoiding trying to do so or deflecting the problem onto the brain.

The scope of psychotropic medication discontinuation problems

The stakeholder comments submission (see table) from the College of Mental Health Pharmacy about the Scope for the NICE guideline on Safe prescribing and withdrawal management of prescribed drugs associated with dependence and withdrawal is revealing about why antidepressant discontinuation problems are minimised (see eg. previous post). The College questions why antidepressants have been included within the Scope. What it's worried about is that patients might discontinue or not seek antidepressant treatment when they need it, if they know about antidepressant discontinuation problems.

Similarly, prescribers may use the chemical imbalance theory as a way of persuading patients to take antidepressants (see previous post). This is despite the fact that believing the theory may make patients more pessimistic about the prognosis of their depression and lower their perceived ability to regulate their mood (see previous post). More seriously as far as antidepressant discontinuation problems are concerned, believing the chemical imbalance theory may at least contribute to, if not cause, discontinuation problems (see previous post). Eveleigh et al (2019) found evidence from patients that the chemical imbalance theory was a prominent factor in creating fear of discontinuation.

Several stakeholders in the NICE consultation suggested including in the Scope other drugs, such as antipsychotics, which also cause discontinuation problems. NICE refused, saying that such guidance is included within the NICE guideline for psychosis and schizophrenia in adults, although I can't see any mention of discontinuation problems there. NICE only seems to have included antidepressants within the Scope because it was asked to by the Department of Health.

The Royal College of Psychiatrists usefully raises the issue of the psychological component of dependence but I'm not sure that NICE really takes this on board in its response. People who have antidepressant discontinuation problems often experience them very physically. It's good that NICE will presumably expand (although maybe by not very much) on its Depression guideline to produce more detailed advice for safe prescribing, monitoring and safe withdrawal of antidepressants. But people are being made dependent on psychotropic medication in general. The psychological element, at least, of antidepressant discontinuation problems cannot be denied (see previous post). It's understandable NICE may wish to sidestep this complex issue but these wider factors do need to be addressed.

Misdiagnosing dementia

When I first started this blog several years ago now, I indicated I would return to the issue of the National Dementia Strategy (see previous post). Times have moved on and the incentivisation of GPs in the NHS to diagnose dementia, which began in 2011, has been controversial. This is because of the increased number of referrals of people with cognitive complaints not due to dementia (Bell et al, 2015). Mistakes can be made about the diagnosis of dementia and doubts have been expressed about the security of diagnosis for at least some so-called dementia advocates (Howard, 2017) (see previous post).

A systematic review of functional cognitive disorders has just been published in Lancet Psychiatry. Current views of functional neurological disorders tend to emphasise excessive attention towards physical symptoms rather than psychological stress as such in the generation of symptoms. People with functional disorders are more likely to attend alone and be worried about their memory, providing a detailed account of personal history and memory failures more than patients with neurodegenerative disease. Those with functional cognitive disorder phenotypes are at risk of iatrogenic harm because of misdiagnosis or inaccurate prediction of future decline.

Are there no problems with psychiatry?

George Dawson (who I have mentioned previously - see post) has responded in a blog post to a NEJM article by Caleb Gardner and Arthur Kleinman entitled 'Medicine and the Mind — The Consequences of Psychiatry’s Identity Crisis'. As far as Dawson is concerned there is no identity crisis in psychiatry. The only problem he recognises is that:-

most psychiatrists are working in toxic practice environments that were designed by business administrators and politicians. As a result, psychiatrists are expected to see large numbers of patients for limited periods of time and spend additional hours performing tasks that are basically designed by business administrators and politicians and have no clinical value.

Dawson is a believer in psychopharmacology, ECT and transcranial magnetic stimulation and thinks the benefits of psychosocial treatments are significantly limited. He also believes neuroscience research is translating into benefits for clinical practice, but these seem to be more about possibilities for the future rather than now.

Gardner and Kleinman (2019) recommend reducing the amount of spending on biologic research in psychiatry to support only the highest quality such research. They suggest that academic psychiatry needs to be rebuilt by more recognition of the limits of biologic research. Dawson wonders why NEJM has accepted this article, and I agree it is surprising considering how biomedical the perspective of the journal has been about psychiatry. I wonder, though, whether, like Wellcome apparently (see previous post), NEJM has become more sceptical about whether psychiatry is really being advanced by neuroscience.

I'm not saying managed care doesn't create problems for psychiatry, but there are wider conceptual issues that do need to be addressed. I agree with Dawson this issue shouldn't just be decided by rhetoric.

How medical psychology became psychotherapy

A post on the British Psychological Society (BPS) History of Psychology Centre blog marks 100 years since the first BPS Member Networks were formed. The Medical Section was one of the first of the three sections formed in 1919 (the others being Educational and Industrial) and I've posted previously on 'The roots of medical psychology’. The Medical Section is now the Psychotherapy Section - name changed in 1988, having previously changed to Section of Medical Psychology and Psychotherapy in 1976 (see BPS history timeline). I'm not sure if the Psychotherapy Section is aware of this history.

Incorporation of the Society in October 1941 reflected the safeguarding of the professional interests of trained psychologists and instituted different classes of membership (Edgell, 1947). Membership had been opened in 1919 to anyone ‘interested in psychology’, not just recognised scholars or teachers. This deprofesionalisation led to an increase in membership from 98 at the end of 1918 to 427 at the close of 1919. A large proportion of these new members were in the Medical Section. Charles Myers used his First World War medical contacts (some treating shell shock; Myers probably being the first to recognise the essentially psychological nature of shell shock) to persuade them to join the Society (Jackson, 2019).

I'm sure there is a need to protect professional psychological expertise, but there are also advantages in extending general interest in psychology. Professional separation of medicine and psychology is not always helpful.

Creating a ketamine epidemic?

Ketamine has been claimed to be the first truly new pharmacological approach for treating depression in the past 50 years and promoted as the first of a new generation of rapid acting antidepressants (eg. see BMJ news report). US clinics increasingly offer IV infusions of ketamine off label. In March, esketamine, a nasal ketamine-based drug, was approved by the US Food and Drug Administration (FDA) for treatment-resistant depression. This is despite it performing better than placebo only in one out of three studies (see my tweet).

Concern about potential approval of esketamine by the Medicines and Healthcare products Regulatory Agency (MHRA) in the UK has led to discussion through responses to a BMJ article. The latest response by Mark Horowitz and Joanna Moncrieff expresses concern that "history is repeating: a known drug of abuse, associated with significant harm, with scant evidence of efficacy, is being submitted for licensing, without adequate long-term safety studies".

It's important not to forget the epidemic of amphetamine use that peaked round the end of the 1960s (see article). Ketamine has the ability to induce an acutely altered state of consciousness, reminiscent of indigenous medicines such as ayahuasca, peyote, and ibogaine, which have been used for centuries across many cultures (see another article). Amphetamines in general were prescribed readily and light-heartedly in the past (see yet another article). Amphetamine was said to adjust hormonal balance in the central nervous system by creating or amplifying adrenergic stimulation so as to promote activity and extraversion. It was even said that true addiction to amphetamine probably did not occur.

However, evidence emerged after 1960 that amphetamine is truly addictive, instead of merely habituating. The introduction of monoamine oxidase inhibitor and tricyclic antidepressants from the end of the 1950s did not immediately lead to a significant decline in prescribing of amphetamines, but eventually the claim that the newer durgs were superior to amphetamines held sway. Amphetamines and barbituates had nonetheless seemed better to doctors than the bromides and nerve tonics that had been prescribed up to the 1950s. Psychiatrists used to complain that GPs, when they did use the newer antidepressants, did not use them in sufficiently high enough therapeutic doses. This complaint was heard less when the SSRIs were introduced in the 1980s, perhaps partly because fluoxetine, maybe the most successful SSRI, was initially introduced at a single dose.

50 years may seem a long time not to have had any new pharmacological treatment for depression but it's important history isn't repeated. It actually wasn't that long ago that the epidemic of amphetamines was created by doctors. Do they really want to do the same with ketamine?

Neuroscience in psychiatric education

The Royal College of Psychiatrists (RCPsych) has published its first issue of PSynapse, the newsletter for its programme (that I've mentioned previously eg. see post), which has support from Gatsby and Wellcome, to transform UK psychiatric training by integrating modern neuroscience. The newsletter mentions that TrOn (the RCPsych online learning resource to support trainees preparing for its membership examinations) is looking for an additional specific neuroscience trainee editor in addition to its other trainee editors. It also mentions the third RCPsych neuroscience spring conference that marked the launch of the College neuroscience champions scheme, which creates a network of psychiatric trainees across the UK to ensure that neuroscience is properly integrated into their respective deaneries.

I’m not against trainees having a proper understanding of neuroscience. But I don’t think the College programme has incorporated critical neuroscience (see previous post). Wellcome has said it wants a radical new approach to mental health research (see previous post). Yet it’s also supporting the Psychiatry Consortium (mentioned in the PSynapse newsletter) of 6 drug companies, Alzheimer’s Research UK and MQ (mentioned in previous post), to accelerate innovative drug discovery in psychiatric diseases. The newsletter also has a report from the British Neuroscience Association festival of neuroscience in April 2019 which highlights ketamine as a potential antidepressant. The rest of the newsletter reports conversations with two of the leaders in the field of ketamine use for depression in the UK. But there’s no discussion of the potential risks of approving ketamine for antidepressant use (eg. see BMJ response by Mark Horowitz and Joanna Moncrieff).

There is a need for interdisciplinarity in mental health research (see previous post). I hope the College isn’t encouraging a neuro-turn in academic psychiatry (see another previous post). I’d like to see it also incorporating critical psychiatry into psychiatric training (see yet another previous post).


(With thanks to Frederico Magalhaes)

Psychiatry's reductionist tendencies

Rebecca Roache (who I’ve mentioned previously) has a useful PPP article which discusses the different forms of reductionism in relation to psychiatry. I’ve tried to make my view clear that critical psychiatry’s anti-reductionism is primarily explanatory (see eg. previous post).

Roache says that psychiatrists writing about the biopsychosocial model often contrast it with reductionism. Indeed I did so in my article (as did George Engel originally). I wish, though, that Roache had been clearer that Engel’s biopsychosocial model and Meyer’s Psychobiology are not eclectic (see eg. previous post).

Roache also seems to go along with Nassir Ghaemi that Roy Grinker originated the term 'biopsychosocial'. There is no use of the term in the reference she gives (viz. Grinker 1994), which she says was a 1954 lecture by Grinker. In fact, it's a paper that was first presented in October 1952. I'm grateful to an unpublished review of Ghaemi's The rise and fall of the biopsychosocial model by Neil Vickers that points out that Grinker used the near synonym ‘psycho-somatic-social’, not 'biopsychosocial' in this presentation. He first used the term ‘the biopsychosocial model’ in 1962, some eight years after Nathan Ackerman (1954). It was also used in two papers by F. A. Weiss in 1958. As Neil says, "In short, the case for Grinker’s priority is not credible." John Romano and George Engel had been talking about an integration of biological, psychological and social factors in psychosomatic medicine at least since 1945. True, Engel may well have had Grinker in mind when he linked the biopsychosocial model to systems theory, but I don't think his biopsychosocial model is dependent on systems theory as such.

I agree with Roache's critique of the confusion in the psychiatric academic literature about reductionism. There is widespread hope in psychiatry that neuroscience will explain mental illness. As I keep saying, critical psychiatry's challenge to this 'disease' model of mental illness is legitimate (see eg. previous post). I'd be interested to know if Rebecca Roache agrees with me.

Foundations of the biopsychosocial model

Derek Bolton is giving a series of colloquia on Engel's biopsychosocial model, based on his book with Grant Gillett (ebook freely available, and references below taken from it). Gillett and he recognise the need for the biopsychosocial model in the light of "historical prejudices against psychosocial causation deriving from physical reductionism and dualism" (loc 132). Nonetheless, they seem to accept criticism of the model by authors, such as Nassir Ghaemi in The rise and fall of the biopsychosocial model, that its eclecticism makes it "vague, useless and even incoherent" (loc 132).

I have myself reviewed Ghaemi's book (see review and response from Ghaemi and my reply). It critiques psychiatric eclecticism and in my view wrongly blames this on Engel's biopsychosocial model. Ghaemi is correct to note the contribution of Roy Grinker, who appreciated the relevance of general systems theory to psychiatry (see my article). Engel suggested that systems theory provided a suitable conceptual basis for his biopsychosocial model. Bolton & Gillett think this is "fundamentally the right way to go" (loc 563). But they seem unaware that Engel's biopsychosocial model is not responsible for the eclecticism in psychiatry.

As I've said before (see eg. previous post), the real origin of the eclectic view in psychiatry is Anthony Clare's response to anti-psychiatry. As Bolton & Gillett say:

The way Ghaemi tells the story ... [is that] the biopsychosocial model arose in the context of competing general views about illness, favouring one or other of the social, the psychological/psychoanalytic and the biological. ... Ghaemi interprets the biopsychosocial model as an elegant ... solution to these ideological conflicts ... [as] if all participants won, [as] if they were not really in opposition at all, but were in fact all true general accounts of illness and healthcare in all aspects. (loc 237)

This was what Clare argued, not Engel. Clare wanted to avoid the ideological conflict created by anti-psychiatry and proposed eclecticism as a way forward.

Bolton & Gillett do realise that "this line of thought [ie. eclecticism] is not apparent in Engel's main papers" (loc 237). In some of Engel's other papers, he does make the general comment that biological, psychological and social must all be taken into account. Misuse of this statement by Ghaemi to mean that all three are more or less equally relevant in all cases and at all times, seems to convince Bolton & Gillett that Ghaemi has a valid point.

As I’ve said (see eg. my editorial and previous post), Engel’s original paper was in fact written to counter Ludwig (1975), who recommended a retreat to a rigid biomedical model in the face of the onslaught of anti-psychiatry. In the same year as Engel, Manschrek & Kleinman (1977) similarly argued for a critical rationality to replace the hubris (dogmatic biomedical) and semi-critical (eclectic) positions in psychiatry (see previous post).

I'm not convinced that Bolton & Gillett have fully appreciated this context. Engel was aware of the success of biomedicine in explaining physical diseases. As a psychosomatic physician, he was also mindful that many presentations to doctors do not necessarily have an underlying physical disease. He wasn't retreating to vagueness, but accepting of the uncertainties of medicine and psychiatry. I, too, have reviewed the book on Biopsychosocial medicine edited by Peter White (see my review), which Bolton & Gillett reference by quoting from The Lancet review of that book by McManus (2005). As McManus notes, "the broader view [of biopsychosocial medicine] is seen by biomedicine as irredeemably soft, with no clear methodology, measurement, or experimental manipulation". This isn't a reason for dismissing the psychosocial nature of some patient complaints; nor for having a negative assessment of Engel's biopsychosocial model.

Bolton & Gillett try to meet the challenges to the biopsychosocial model by suggesting that it needs to be made "specific to particular health conditions" (loc 456). From their point of view, Engel's biopsychosocial model is not really a general model, and this explains its vagueness. I'm not against looking at examples and specifics, but I don't think this is an adequate reason for undermining the generality of Engel's model. Bolton & Gillett do recognise the connection between patient-centred medicine (see previous post) and the biopsychosocial model and the centrality of this element for Engel (loc 2707). An integrated understanding of the whole person is required for all medical conditions.

Bolton & Gillett suggest that the foundational theoretical constructs of the biopsychosocial model need rethinking and reconceptualising. Again, I'm not convinced this is necessary as such, although I recognise there is a need to develop the biopsychosocial model as a philosophical and scientific theory of health, disease and healthcare. This is the strength of Bolton & Gillett's book. For example, they argue that information processing theory has moved biology on from understanding causes as merely physico-chemical. There is some truth to this view and Bolton & Gillett are correct that psychiatry should not be dualist or vitalist (see previous post). However, the mechanistic perspective remains pervasive in biology. Biology still needs to move onto a processual, organismic philosophy (see previous post), in the same way as indicated by Engel.

Bolton & Gillett argue against physicalism. Persons do need to be understood as biological processes. An integrated biopsychosocial model studies people within the framework of biology. A mechanistic conception of nature fails to provide a complete characterisation of living systems (see previous post). We need a new organismic biological perspective to enrich the integrated mind-brain understanding promoted by Engel for medical and psychiatric practice.

Scientists think antidepressants work but is the evidence biased?

Gemma Lewis and Glyn Lewis popularise their PANDA study (published in The Lancet Psychiatry) in The Conversation. The headline of their piece is 'Antidepressants work, but just not how scientists thought they worked'.

Even though the PANDA study did not find a significant difference in depression scores at 6 weeks between sertraline and placebo groups, the authors still claim antidepressants work. This is because they found evidence of a significant difference for anxiety symptoms and suggest the benefit of antidepressants is more for anxiety than depression. I'm not sure if they're saying that antidepressants should be renamed anxiolytics.

As I've pointed out previously (eg. see post), despite antidepressant trials on average showing a statistically significant difference for active drug over placebo, the difference is small and there is a question about how clinically significant this difference is. Furthermore, methodological difficulties, such as unblinding, can bias the results, so it is possible that any statistically significant result is an artefact (see my Bias in controlled trials webpage). This is called the placebo amplification hypothesis of the apparent statistical advantage of antidepressants over placebo in clinical trials. It is difficult to prove and the debate about antidepressant efficacy is still open in the literature (see previous post), despite the Lewises apparently not being prepared to admit that their PANDA study may actually provide evidence that antidepressants are not effective.

Data is given on unblinding in the PANDA study, although the authors do not make very much of it. The authors knew of three incidents when participants opened the capsule to see if there was a tablet included, and these patients were withdrawn from the trial. The majority of participants did not think they were on active treatment, even though half of them were. More people on sertraline (46%) thought they were on active treatment than those on placebo (19%). People seem to have generally thought they were not on active treatment, and placebo patients were quite good at recognising this. Participants were able, therefore, for whatever reason, to distinguish sertraline from placebo, so it's misleading to say the PANDA trial was double-blind.

Despite what the authors seem to think, antidepressant trials are not adequately blinded (Even et al, 2000). The findings of the PANDA study may therefore merely reflect the authors bias (transmitted to the participants) that antidepressants are effective (although for some reason not detected at 6 weeks with depressions scores). Antidepressants may merely be placebo panaceas for emotional problems.

The validity of the distinction between functional and organic mental illness

A tweet by Mohammed Rashed has intrigued me. He says the distinction between functional and organic mental illness is not valid, and suggests it's a false distinction based on a misunderstanding of the concept of illness. The brevity of communication on twitter leaves me not understanding what he means.

I have argued that critical psychiatry seeks to restore the functional/organic distinction (eg. see previous post). It was abolished by DSM-IV (see eg. previous post) but this was a mistake.

Mental and brain activity need to be understood as a single biological response. The problem is that we tend to have a mechanical view of biology, which can make it difficult for psychiatry to integrate mind and brain (see eg. previous post). Mental dysfunction ie. functional mental illness, as much as brain disease ie. organic illness, is a medical condition resulting from pathological process.

We have always needed myths to understand illness, including madness (see eg. previous post). Relating symptoms to their underlying physical pathology was a major advance for medicine in the first half of the nineteenth century and still underlies our modern understanding of disease (see eg. previous post). Applying this anatomoclinical method in psychiatry was not as successful because it was not always very easy to relate mental conditions to underlying brain pathology. In fact, it led to an overenthusiastic search for anatomical localisation of mental illness in the second half of the nineteenth creating a brain mythology that was unrelated to empirical findings. Acceptance of the organic/functional distinction helped psychiatry to move on from such fanciful notions.

Of course acute brain disease can cause delirium and chronic brain disease can cause dementia. The symptom patterns of brain disease are different from functional illness, with a prominent disturbance of cognitive function, such as orientation. Clinicians are trained to assess and detect whether a psychiatric presentation may have an underlying organic basis by testing cognitive function in particular. To suggest that the distinction between functional and organic mental illness is invalid does not seem to make sense to me clinically, let alone conceptually.

Nor am I sure what understanding of illness Mohammed thinks we should have that will make it apparent that the functional/organic distinction is invalid. Technically a distinction has been made in the scientific literature between illness, which is the personal experience of symptoms and suffering, whereas disease is the underlying biological pathology (see eg. previous post). Disease is something an organ has; illness is something a person has. It's commonly assumed that the organic basis of mental illness will be found (see eg. previous post). Could this be what Mohammed means? If so, my claim is that the functional/organic distinction is more fundamental and critical psychiatry is a legitimate challenge to the disease model of mental illness (see eg. previous post).

I'm hoping this blog may help to clarify what Mohammed meant by his tweet. Once I've understood, maybe this issue does need to be taken forward in debate in a scientific article. There does need to be further discussion about the validity of the functional/organic distinction of mental illness.

Reclaiming the term ‘biopsychosocial’

Joanna Moncrieff comments in a tweet on Niall McLaren’s Mad in America blog, saying that the biopsychosocial model is “just a phrase used to dress up biomedical reductionism”. I’ve commented before several times on the biopsychosocial model (eg. see previous post). I do understand what Jo means when she implies that psychiatrists who say they adopt a biopsychosocial model are really using a weaker version of biomedical reductionism (see eg. extract from my book chapter). And, as Niall indicates in his blog, despite Ronald Pies claim that psychiatry is biopsychosocial, Pies himself is quite biological in his approach to psychiatry (see previous post).

The definition of biopsychosocial has become quite confused and I have advocated using the term ‘sociopsychobiological’ (see previous post). But George Engel’s original biopsychosocial model was a deliberate challenge to biomedical reductionism and I think that critical psychiatry does take a biopsychosocial position (eg. see my article). What happened was that Anthony Clare (see previous post) deliberately avoided any ideological implications for psychiatry, encouraging an eclecticism as a way of dealing with the challenge of anti-psychiatry (see eg. my eletter [original layout has been lost on website upgrading]). We need to move on from this eclecticism (see eg. previous post). The original meaning of ‘biopsychosocial’ needs to be reclaimed by critical psychiatry.

The implications for psychiatry of a processual philosophy of biology

René Descartes was the first to apply the natural scientific mechanistic approach to life (although excluding the soul) (see previous post). This perspective has remained the most pervasive view within biology. Nonetheless there have been challenges that recognise that living beings have a purposiveness that cannot be derived from mere physical-chemical processes. For example, Georg Ernst Stahl differentiated organic life from the inorganic, integrating the soul and the body in the organism. This led to his erroneous claim that living things possess a vital entity. 

With the origin of enlightenment thinking in the second half of the eighteenth century, Immanuel Kant’s critical philosophy was clear that it is absurd and futile to expect to be able to understand and explain life in terms of merely mechanical principles of nature (see previous post). A mechanistic conception of nature fails to provide a complete characterisation of living systems. Organisms, unlike machines, are self-organising and self-reproducing systems. Different modes of explanation are therefore required for teleological and mechanical points of views. Although we can never have theoretical knowledge that anything in nature is teleological, such judgment is nonetheless necessary and beneficial for us and we commonly embark on a ‘daring adventure of reason’ to understand life in mechanical terms. 

American pragmatic philosophers, such as William James and John Dewey, in the context of Darwin’s theory of evolution, attempted to dissolve such metaphysical disputes by focusing on nature and experience and the centrality of the organism-environment interaction. Following the development of quantum mechanics in physics, a group of organicist biologists promoted life’s dynamic, systemic and purposive character as a way of moving on from physico-chemical reductionism (see previous post). For example, John Scott Haldane recognised the distinctiveness and irreducibility of living beings because of the continuous dynamic preservation of the internal environment. One of the most important principles of biology for Ludwig von Bertalanffy was the stream of life conception, that living forms are the expression of a perpetual stream of matter and energy.

More recently, Dupré and Nicholson (2018) have proposed a manifesto for a processual philosophy of biology to move on from explanation in terms of static unchanging entities. Their project promotes the metaphysical thesis that the living world is made up of processes not substances. Alfred North Whitehead articulated a comprehensive metaphysical system for process thinking, but Dupré and Nicolson distance themselves from its details. There needs to be more discussion about the underlying philosophical worldview and limitations of the mechanistic approach to biology and such processual thinking provides a valuable framework to take this debate forward. 

This process perspective has implications for medicine in general, in particular in relation to the concepts of illness and disease. Illness disturbs a person’s functional equilibrium and disease, particularly since the development of anatomoclinical methods in the 19^thcentury (see previous post), tends to be understood as structural biological pathology. Emphasising the disruption of dynamic processes as a way of understanding disease moves on from this simple contrast between organism as thing and its independent pathological process. 

This paper focuses on the implication for psychiatry of processual thinking. The mind-body problem can be seen as a more specific form of the mechanistic-processual dilemma (see eg. previous post). Persons need to be understood as biological processes. There is a history in psychiatry of attempts to integrate somatic and psychosocial aspects, and this can be related to developments in processual thinking in biology (see previous post).

For example, George Engel proposed a new medical model, suggesting that the general systems theory of von Bertalanffy provided a suitable conceptual basis for his biopsychosocial model (see previous post). Perhaps in a similar way to Dupré and Nicolson, whose project does not specifically build on Whitehead’s overarching theory, an integrated biopsychosocial approach is not dependent on general systems theory as such. For example, Adolf Meyer’s Psychobiology was more related to American pragmatism. Meyer was clear that Psychobiology studies man as a person within the framework of biology (see previous post). 

Such integrated mind-brain understandings were also present in the origins of modern psychiatry. For example, Ernst von Feuchtersleben published his textbook influenced by Kantian critical philosophy in the same year, 1845, that saw the publication in German of the book in which Wilhelm Griesinger set the trend for understanding the pathology and therapy of mental diseases as a mechanical natural science. The argument of this paper is that processual thinking in biology counters this dominant positivist tendency within current psychiatry (see previous post).

(Abstract submitted to Peter Sowerby interdisciplinary workshop: Conceptual issues in biological psychiatry)