Flawed pioneer of biological psychiatry

I have been reading Richard Noll's book American Madness, which is well worth a read. He includes information about Bayard Taylor Holmes (1852-1924), a Chicago physician and surgeon, whose son was diagnosed with dementia praecox aged 17. Holmes was devastated by his son's illness and vowed to use his scientific expertise to find a cause and cure for dementia praecox (the precursor name for schizophrenia).

He came to believe that caecal stasis led to the production of ergot-like toxic amines that poisoned many organs in the body, including the brain leading to dementia praecox. The solution was appendicostomy or caecostomy and daily irrigations of the caecum. This theory was congruent with popular theories of autointoxication at the time. For example, Emil Kraepelin, the originator of the concept of dementia praecox, speculated that the sex glands were the source of toxins that poisoned the brain in dementia praecox. In fact, Kraepelin was unusual in blaming the sex glands rather than the intestines for autointoxication.

The first patient Holmes operated on was his son, but unfortunately he died 4 days later. This didn't stop him and colleagues operating on a further 21 patients. Only one other patient died from complications of his surgery. This story needs to be set in the context of Andrew Scull's book, Madhouse (see my review), about Henry Cotton, who operated on 645 patients by removing what he considered to be hidden infections in various parts of the body, particularly teeth and tonsils. 25-30% of Cotton's patients died, particularly from colectomy.

As I said in my book review, I think we can learn from our sense of outrage about these misguided attempts to produce biological cures for mental illness. Psychiatric practice needs to have a strong ethical foundation.

Functional psychosis without brain disease

Allen Frances in a blog on Huffpost suggested that psychosis is at least partially caused by neurological (brain) malfunction. Of course brain dysfunction in medical disease can cause an organic psychosis (see previous post). But Frances means more than this. He talks about "misfiring nerve cells" playing a central role in schizophrenia and delusional disorder. I don't know what he means by this unless it's pure speculation.

Like Frances, I have expressed some concerns about the BPS report on psychosis (eg. see previous post). But its psychosocial emphasis is its strength. It was Allen Francis, who as Chair of the DSM-IV Task Force, abolished the distinction between functional and organic psychosis (see eg. previous post). It needs to be reinstated.

Psychiatrists are still needed

Frank Blankenship comments on Mad in America about my previous post on "Psychiatry as a cultural system". He suggests there's a simpler explanation for why psychiatrists are resistant to giving up the biomedical model than because it's like a religion - they'd be out of a job!

I do understand his view. I too was schooled in the biomedical perspective that mental illness is brain disease. It's such an ingrained perception in society that people don't think to challenge it. Medical training reinforces this indoctrination (eg. see previous post and my Lancet Psychiatry letter).

I also agree that psychiatrists are worried that non-medical professionals are taking over their job (eg. see previous post). This fear encourages them to adopt a biomedical model by focusing on "what doctors do best".

However, where I disagree is that it is important to remember that medicine is psychosocial as well as biological, if only to ensure that practice is patient-centred. It's not purely a bodily exercise. Even more so, patients go to doctors with physical symptoms which have a psychological origin. Medicine has to adopt a sociopsychobiological approach to provide an integrated perspective in practice (see previous post).

I've also mentioned before my disagreement with Peter Kinderman, who has argued that mental health care should actually be non-medical, as it is not treating 'illness' as we understand it (see previous post). From his point of view, doctors should concentrate on the biological aspects of mental health care and this should be seen as a minority activity within the field as most psychiatric presentations are psychosocial, not biomedical, in origin. By contrast, Peter Sedgwick, in the same way as I have been saying, would have regarded Peter's position as ‘psycho-medical dualism’, because psychosocial approaches should not be separated too much from medicine. Sedgwick adopted a unitary concept of illness, beneath which is subsumed both physical and mental aspects (Cresswell & Spandler, 2009).

Conceptual conflict exists about the nature of mental illness and this is as much of an issue for psychiatrists as it is for specialists from other mental health disciplines. Merely putting psychiatrists out of a job won't solve this dilemma. And, medicine needs the specialty of psychiatry.

Too much neuroscience

NIMH has a new director, Dr Joshua Gordon. An article in The New York Times criticises the previous director, Thomas Insel, for shifting the focus of the NIMH research budget too much away from clinical research to neuroscience. Although the article could have been more sceptical of the possibilities of neuroscientific research, there is an important question about whether biomedical research funding is good value for money. Powerful vested interests don't necessarily produce the most neutral scientific progress.

I would like to see more investment in social psychiatry (see previous post) and critical neuroscience (see another previous post).


(With thanks to Facebook post by Christian Perring)

Is psychiatry currently undergoing a crisis?

Richard Bentall (mentioned in eg. previous post) and Simon Wessely (again, mentioned in eg. previous post) go head-to-head in a conference next year, as to whether psychiatry is currently undergoing a crisis. I suppose I can see both sides. Psychiatry ought to be in crisis but it isn't.

As Richard says, the biomedical model is "on the edge". Its wishful thinking about finding a biological basis for mental illness has failed to come to fruition (eg. see previous post) but that doesn't seem to matter. As Simon says, "psychiatry is in good health". It can plough ahead with its ecelectic view that it is not narrowly biomedical even though it does not really take a psychosocial perspective. I'm not sure how this impasse can be broken.

Nonetheless, I think we do need to move forward. We need to accept that psychiatrists find it difficult to give up the biomedical model (see previous post). But more of them need to abandon the faith that mental illness is due to brain disease.

Is critical psychiatry merely anti-psychiatry?

I have been looking at a presentation I gave on whether critical psychiatry is the same as "anti-psychiatry" (see powerpoint slides). I have always tended to emphasise critical psychiatry's links with mainstream psychiatry.

For example, I have mentioned Adolf Meyer several times in previous posts (see example). He was the foremost US psychiatrist in the first half of the twentieth century. His approach, which was called Psychobiology, has the same integrated understanding of mind and brain as critical psychiatry. The problem with Meyer was that he did not follow through on his challenge to biomedicine. He had a tendency to compromise. The full impact of his objection to the biomedical model in psychiatry tended to get lost. In a personal note in his papers a few years before he died, he himself admitted that he should have made clear his "outspoken opposition, instead of a mild semblance of harmony" [his emphasis].

Similarly, George Engel promoted the biopsychosocial model, which forms the basis for patient-centred medicine and psychiatry, as does critical psychiatry. As I pointed out in another talk, Engel was specifically responding to a paper by Arnold Ludwig when he published his 1997 paper in Science arguing for a new medical model. He was explicit that he was challenging biomedical dogmaticism. However, what has happened over recent years is that the biopsychosocial model has been interpreted in an eclectic way evading its full ideological impact. Nassir Ghaemi agrees with me on this point (see my review of his book The rise and fall of the biopsychosocial model). Where we disagree is that I don't think he has fully appreciated the validity of Engel's biopsychosocial model in its original form. I have even suggested using the term "sociopsychobiological" to make clear that I am not using biopsychosocial in an eclectic way (see previous post).

The point I'm making is that critical psychiatry does have roots in mainstream psychiatry. It is not "anti-psychiatry" in that sense.

Psychiatry as a cultural system

Gary Sidley expresses his frustration in a blog recently reposted on Mad in America that it "seems unrealistic – even naïve – to expect that radical change away from bio-medical approaches to human suffering can be achieved organically". Nonetheless, he remains "optimistic that, in the next decade or so, we will witness a radical change in the way we as a society respond to human suffering" (see recent post on Tales from the Madhouse).

I do understand his frustration and I think we may need to understand better why there is such reluctance for psychiatry to change. To do this, it may be helpful to look at the work of Clifford Geertz, who I have mentioned before (see previous post). Geertz saw religion as a cultural system (see his paper). In the same way, psychiatry can also be understood as a cultural system. 

The biomedical model that mental illness is brain disease is both a model of "reality" and for "reality", to use Geertz's terms. Note the use or the word "reality" in inverted commas. A model does not necessarily describe the real world, which is what critical psychiatry would say about the biomedical model, that it does not. The biomedical model is a model for "reality" because it justifies treatments such as physical interventions, including medication.

The biomedical model gives a sense of direction to psychiatry. It induces certain dispositions in psychiatrists to treat people in a particular way. It provides a worldview, which if psychiatrists did not believe it would make their practice uncertain, too uncertain for most. To quote from Geertz, "Man depends upon symbols and symbol systems with a dependence so great as to be decisive for his creatural viability and, as a result, his sensitivity to even the remotest indication that they may prove unable to cope with one or another aspect of experience raises within him the gravest sort of anxiety". The biomedical assumption is clothed with an aura of factuality by people having faith in it. It is sustained by professional institutions. 

Viewed in this way, it's not surprising that people don't want to give up the biomedical model. To do so is like giving up one's religion.