Monday, June 14, 2021

A new epistemology for psychiatry

Germán Berrios and Ivana Marková have a chapter in Kirmayer et al’s (2015) book Re-visioning psychiatry on ‘Towards a new epistemology of psychiatry’. As they point out, biological psychiatry tends to be seen as true, only hindered in its progress by its financial under-resourcing (see previous post). Instead they suggest psychiatry needs better conceptualisations and methodologies to treat and research impaired mental functioning.

They emphasise the hybrid nature of psychiatry, in that not all mental symptoms can be explained as natural kinds but rather are incongruous "admixtures of organic/biological and sociocultural components". The combination of biological and semantic elements in the hybrid object means that the functional specificities of the brain signal are lost. In other words, "a simple and direct (cause-effect) relationship between the brain signal and the symptom" is precluded. The meaningful nature of mental symptoms cannot be located in the brain (see previous post). 

Germán and Ivana distinguish between mental symptoms that have either primary or secondary brain inscriptions. In those with a primary inscription there is a relatively direct relationship between brain inscription and symptom; whereas in those with secondary inscription the meaningful nature of the symptom must be represented in the brain but no "alteration of brain activity is necessary or sufficient for this type of mental symptom formation because it can only occur in an intersubjective space". 

As I have pointed out before (see eg. previous post), DSM-IV wrongly abolished the distinction between organic and functional mental illness. In a way, dividing mental symptoms into those with primary/secondary brain inscriptions reintroduces this distinction, although German and Ivana seem to want to suggest that the differentiation they are making is not the same. For example, they complain that the organic/nonorganic distinction is too rigid. However, functional does not mean non-organic (see previous post). Similarly, they seem to imply that psychotic depression, for example, has primary brain inscriptions, whereas it's not clear to me that it is an organic rather than functional disorder.

I totally agree that psychiatry needs a new epistemology and think that relational psychiatry provides just that. For example, Thomas Fuchs’ ecology of the brain (eg. see previous post), Sanneke de Haan’s enactive psychiatry (eg. see another previous post) and Laurence Kirmayer’s ecosocial psychiatry (see yet another previous post) all have the same epistemology. The history of psychiatry shows that psychiatry has been caught in an opposition between psychogenesis and organogenesis (see eg. previous post). The distinction between mental symptoms with primary or secondary brain inscriptions is fundamental and may actually not be that much different from the distinction made by Étienne-Jean Georget in the origins of modern psychiatry in the early eighteenth century between symptomatic diseases with organic causes and idiopathic disorders resulting from purely functional disruptions (see previous post). The problem is that the success of the anatomoclinical method in medicine has led to belittling its different implications for psychiatry. We need to give up trying to establish biological causes of mental illness as such (see eg. last post). 

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