Tuesday, March 14, 2017

The contested nature of psychiatry

Charles E. Rosenberg has an interesting paper on how psychiatry expanded in the last third of the 19th century to "include an ever-broader variety of emotional pain, idiosyncrasy, and culturally unsettling behaviors". Our modern somatic understanding of illness had to accommodate older "[h]umoral explanations of temperamental peculiarity", such as hypochondriasis, hysteria and melancholy. It began to do this at the beginning of the 19th century, by, for example, Benjamin Rush seeing hypochondria as having a corporeal cause. These "reductionist, mechanism-oriented, and antivitalist" ways of viewing illness created hypothetical disease entities, such as neurasthenia, regarded by George Beard in 1869 as a somatic condition which would eventually be confirmed by postmortem pathology.

As Rosenberg says:-
The dominance of reductionist styles ... has an extraordinarily salient place today. We have never been more infatuated with visions of molecular and neurochemical — ultimately genetic — truth.
As he also says, "yet at the same time we are reflexive [and] critical ... in our approach", even if this is a minority perspective. As discussed in my previous post, psychiatry is polarised about the nature of mental illness. Psychotropic medication has helped legitimate the specific disease entity model of mental illness. This is a "phenomenon that is always in process, always contested, and never completed". With the expansion of the "range of human dilemmas that we ask medicine to address", to quote from Rosenberg:-
[I]t is ... inevitable that the powerful concept of disease specificity has been — and will continue to be — employed as a tool for the ideological management of problematic emotions and behaviors.

(With thanks to a tweet from Richard Hassall)

Monday, March 13, 2017

Polarisation in the debate about mental illness

I have mentioned Mike Owen in a previous post. In a recent blog, he argues for less polarisation in the debate about the nature of mental illness. I couldn't agree more.

However, Mike does need to represent his opponents correctly if there is going to be a rapprochement. He says, "They assume, implausibly, that mind and brain are separate entities rather than different aspects of the same thing". This isn't true. The argument being made is not Cartesian. As Steven Rose says, "That brains enable minds is uncontroversial. That they 'are' the mind is a reductionism too far" (see Lancet article).

Similarly, Mike also says "They also fly in the face of a large body of evidence indicating the importance of genes and altered brain states in contributing to disorders of mental health". Again, not true. The critiques are evidenced-based. Genes, of course, set the boundaries of the possible but environments define the actual. More caution is needed in interpreting so-called altered brain states.

It is important that Mike understands what people are saying who are critical of his view. As Steven Rose says, people like Mike should not "dismiss without a backward glance not only millennia of philosophical debate but also a huge current literature on mind/brain relationships". There is a "conceptual innocence" about his position, although he is, of course, trying to dismiss any criticism. Despite what he may think, modern psychiatry has not solved the mind-brain problem.