Monday, May 16, 2011

Whistling in the wind

Edward Shorter, in his response to an article by Thomas Szasz, says there are solid biological findings in psychiatry. Shorter, who I've mentioned in a previous post, is the Hannah Professor of the History of Medicine at the University of Toronto. In 1996 he was cross-appointed to a professorship in psychiatry. As a non-clinician, has this professional association gone to his head?

The examples he gives of "obvious evidence" are the role of panicogens in triggering panic disorder; the response of catatonia to barbiturates and benzodiazepines; and what he calls the reliable accompanying of melancholic depression by hypothalamic-pituitary-adrenal dysregulation, as reflected in high levels of serum cortisol, a positive dexametasone suppression test (DST) and a shortened rapid eye movement sleep latency.

The reference Shorter gives for the importance of panicogens is from the proceedings of the 32nd annual meeting of the American Society of Clinical Investigation held in Atlantic City on 6 May 1940. In this study, patients with anxiety neurosis were found to increase sighing respiration more than controls when exposed to carbon dioxide and rebreathing. The feelings that they had during this rebreathing tended to resemble or be identical to their panic attacks. Shorter suggests that studies such as this were marginalised because of the influence of psychoanalysis. He doesn't make any mention of the controversy in the literature about the mechanism of action of lactate, which has been seen as the common pathway for the mechanism of action of carbon dioxide and several other panicogens.

The reference he gives for the evidence of the organicity of catatonia was a study of 4 cases, which were actually thought to be neuroleptic-induced, which responded to intravenous lorazepam. Shorter also mentions the response of catatonia to barbiturates. William Bleckwenn's use of intravenous amobarbital to produce lucid intervals in catatonic patients quickly led to the development of the so-called "truth serum".  How's this proved the organic basis of catatonia?

The reference Shorter gives for the biological basis of melancholic depression is his own recent book, written with Max Fink, entitled Endocrine Psychiatry. Fink has been an advocate of ECT over the years. I need to read the book. The DST was rejected as a biological marker because it was insufficiently sensitive and specific. I know that Fink thinks it shouldn't have been rejected, but this does seem to be a very idiosyncratic view. I'll come back to this when I've read the book.

Shorter seems to be using his historical expertise to suggest that modern psychiatry has overlooked evidence of its biological basis. As I have repeatedly said, please do not misunderstand me. Of course mental illness has a biological basis, as does our "normal" behaviour. But to be suggesting that biological markers have been established, or even overlooked in history, is whistling in the wind. This is what Shorter accuses Szasz of doing by claiming the opposite. As Szasz makes clear in his article, what he is stating is what he calls an "analytic truth", not dependent on scientific research.

Furthermore, Shorter suggests views such as those of Szsaz (he actually says the makers of the movie One flew over the cuckoo's nest) have led to many people committing suicide because they've avoided treatment. Not surprisingly, he doesn't give any reference for this opinion. As I've commented in a previous post, it's a pity debates such as this get so polarised.

And I'm not saying this because I totally agree with Szasz (eg. see my book review). But on the point on which Shorter has attacked him, he's correct. Shorter may be right that mainstream psychiatry now acknowledges a neurological basis for much psychiatric illness, whereas when Szasz was first writing psychoanalysis was more influential (see my article). But it's just as wrong to take a biomedical view now as it was then.


Anonymous said...

Shorter is short of neurons that underlie common sense.

IBRAHIMI said...

Psychiatrists are complacent about their blood- stained history-their involvement in eugenics and the holocaust. In the 1960's, men such as Foucault and Szasz spoke out against the authoritarian character of psychiatry.

Anonymous said...

The simple fact is that if psychiatry wants to be respected the same as any other medical profession they need to practice the same as any other medical profession, and that involves getting fully informed consent BEORE treating them. Since psychiatry is a type of police force then this is simply not possible.

It is also time they actually started to explain what the psychosocial aspects of the biopsychosocail model are, because the last I knew forcibly injecting someone was not psychological treatment or social treatment.

Psychiatry is based on a bio bio bio model, that has NO evidence base.

You only have to look at any criminal trail in which you have someone claiming they were mentally incapacitated, you have equally prominanent psychiatrists on each side and niether of them can agree on anything. Can you imagine a case in which two determatologists said that the person had no skin condition, two nuerologists who said there was no nuerological conditions, etc, etc. Sure doctors can differ on what they believe should be done, but the fact is psychaitrists never agree with each other, and they are still actively involved in their own form of Eugenics, even if they do not publically admit to it.

Psychaitry will not and cannot change until they are willing to tell the truth which would be something along these lines: we have no idea of what causes a person to become psychotic and even less idea of how to treat it. We have some medications, that seem to provide some level of relief for a very small number of people, but they come with the most toxic and lethal of side effects, that are intolerable for 99% of people who take them. There has been some talk in the literature of some talk therapies, but no one is trained in them, no one can be bothered doing any research on them, and they take time and no one can be bothered even practicising them. We have no idea of who the people who may gain from medication are.

Now that is the truth, yet I can't imagine a psychiatrist saying that anytime soon!!!! Instead they bring in laws to force people to take the drugs they are paid to prescribe, as they have no other way of convincing people to take them.