Psychiatry Good and BadPsychiatry is considered a medical specialty, and for better or worse represents some physicians’ view of the human mind. The best that can be said is that psychiatry remains an eclectic discipline that developed outside of neurology and neuroscience. At the core of psychiatry, there is a collection of assumptions, superstitions, examined and unexamined beliefs about how the human mind works that date back several centuries. The main feature of psychiatry text is a collection of descriptions and categories that appear to sort human peculiarities into more or less intelligible categories and organize “mental illness” into manageable lists of disorders. The taxonomic tradition in biology has been adopted by psychiatrists. A proper taxonomy begins with detailed descriptions of individuals who are then assigned membership in one of several categories. When I was a medical student, you could fit most humans into six groups: normal, neurotic, psychotic, affective disorder, psychopathic, and miscellaneously disturbed. You could classify any human by asking is he neurotic? Is he psychotic? Is he psychopathic? Is he moody and unstable? “Neurotic” was a favorite diagnosis of Freud and Jung who referred to such a broad spectrum of human misadventure and dysfunction that the term was eventually dropped from the psychiatric taxonomy. Since almost everyone was neurotic, it was not necessary to make the diagnosis.
Psychosis referred to disabling and disruptive mental illness. Crazy people were psychotic and psychotic people were crazy. Affective disorders broadly applied to people who were depressed, emotional, speedy, unstable and unreliable, or otherwise difficult to live with. Psychopaths (sociopaths) were sane, cunning, amoral and anti-social; they lacked empathy, and enjoyed cheating or hurting others. The best place to meet psychotic people is a mental hospital. The best place to meet psychopaths is a prison.
When medical students and physician suffer psychiatry become conspicuously inadequate. The same inadequacy plagues patients of all kinds.
Psychiatry in recent years has attempted to incorporate more biology by focusing on the biochemistry of neurotransmitters, as revealed by drug action in experimental animals. Chemical theories of depression, for example, are often over-simplifications, based on observations of altered neurotransmitter synthesis and function in the brains of mice and rats. It has not been possible to study the living chemistry of the human brain; hence, we do not really know how relevant animal data is.
The study of antidepressant drugs remains an abstract contribution to our general understanding that different brain systems utilize different chemical transmitters in highly organized, complex circuits to produce our mental states and behavior. The increasing use of antidepressant and other psychotropic drugs, is not, however, a favorable trend.
The root intellectual problem with psychiatry is that there is no coherent infrastructure of knowledge about what humans do, how they do it and why they do it. There is too little real biology in psychiatry. The use of drugs to modify brain function passes as biology but is not linked to any coherent understanding of brain function. Since the notions of drug interaction with the brain are all abstractions, arriving from research on animal brains, these ideas are disconnected from the biological reality lived by patients day after day. Psychiatrists, for example, will add chemicals to patients daily input of chemicals but show little or no interest in other chemicals that that the patient is inhaling and ingesting.
I am convinced, for example, that the food intake of a person has a determining effect on the way their brain functions, but some psychiatrists are hostile to this insight. A reasonable approach, in my view, is to examine and modify a patients diet, improve nutrition and remove toxic chemicals in the air before prescribing drugs, but psychiatrists rarely take this approach. The use of psychotropic drug use would appear to be somewhat rational and regulated, but is largely an improvisatory and amateurish exercise rather than a coherent application of biological knowledge. You could argue that the use of drugs to modify brain function has some benefits for some patients, but prescription drug use can cause dysphoria, mental and neurological disorders. You could easily argue that the negative effects of psychotropic drugs exceed benefits.
Too many patients receive prescriptions for multiple psychotropic drugs, a scrambled eggs kind of psychopharmacology. A simple rule of thumb for patients is that one well-chosen psychotropic drug has a chance of being beneficial long-term; more than one drug at a time will usually cause brain function to deteriorate. Several drugs at once confuse the mind, may be dangerous and may cause death by accident or suicide.e."Nearly 90,000 adults go to emergency rooms each year for side effects of psychiatric medications, and a few specific drugs may be to blame for 57% of those visits. The study estimated that sedatives and anxiolytics were most often to blame, causing nearly 31,000 annual emergency department visits. Following those, antidepressants account for more than 25,000 visits, antipsychotics for nearly 22,000, lithium salts for 3620 and stimulants for 2779. The ten drugs that were implicated in most of the emergencies are the following, according to the research team: zolpidem tartrate (Ambien), a sedative; quetiapine fumarate (Seroquel), an atypical antipsychotic; alprazolam (Xanax), an anxiolytic; lorazepam (Ativan), a sedative and anxiolytic; haloperidol, an antipsychotic; clonazepam, a sedative and anxiolytic; trazodone, an antidepressant, anxiolytic and sedative; citalopram hydrobromide (Celexa), an antidepressant; lithium salts, a mood stabilizer; and risperidone, an antipsychotic." Hampton et al of the US Centers for Disease Control and Prevention in Atlanta, Georgia. Ten Drugs Cause Majority of ER Visits in Adults for Adverse Psych Med Effects. JAMA Psychiatry 2014
Biologists, on the other hand, think in terms of populations, food supply, seasons, weather, and social-behaviors, and do field studies which reveal patterns of adaptation to specific environments. The biologist sees every living creature connected to and interacting with his/her environment. Anyone who has worked with animals or fish in closed environments knows how critical environmental conditions and diet are in determining both the behavior and the physical status of the residents. When a fish in an aquarium displays psychotic behavior, you do not call a fish psychiatrist; you check the oxygen concentration, temperature, and pH of the water. You have to clean the tank and change the fish diet. .
We all live in and interact with home and work environments which determine our biological fate. In industrialized countries, the micro-environment of each individual is controlled by human constructions and is generally polluted by toxic substances. Food and ingested liquids are selected by socioeconomic and cultural factors more than biological factors Food selection is part of more complex behavioral patterns which become enduring attributes of individuals. Common abnormal eating behaviors include food cravings, compulsive-eating, compulsive drinking, binge-eating, addictions, aversions, and anorexia.
Dr. Ghaemia, a respected psychiatrist wrote a letter to a medical student inquiring about psychiatry as a specialty. His description of his profession is remarkably candid and insightful. For example:” Psychiatry is the least medical of medical branches. Some celebrate this fact, others rue it; some deny it; many refuse to come to terms with it. It's acceptable in a way, if by "medicine" we mean biological aspects of physical diagnosis and treatment, because psychiatry deals sometimes with the mostly physical and sometimes with the mostly psychological. The problem with that medical aspect of psychiatry is that the field is ambivalent about it. The diagnoses found in the Diagnostic and Statistical Manual of Mental Disorders (DSM) are created as social constructions, as preferences of the profession—not solely, or even primarily, as scientifically based definitions. For two decades, our profession has bound itself to these social constructions and pretended that they were scientific facts. This has been proven a lie, but we are unwilling to admit our self-deception. This is nothing new. Before DSM's hegemony began in 1980, psychiatry had self-deceived itself with psychoanalytic orthodoxy for about half a century.
"Do you want to enter a field that engages in such deep self-deception, and
doesn't mind? Not just my career, but those of at least four prior generations,
have passed this way. This process could easily continue for another generation
or two at least. Are you willing to let your entire career pass under its sway?
You can fight it. You can make it your passion to try to raise psychiatry up and
move it forward when all the influence of the status quo holds it back. Are you
willing to spend your entire career fighting the powers that be? You may become
a hero for future generations, if you succeed in the process of change in the
long run, but that posthumous adulation will do nothing for your personal
happiness in this life.
Nassir Ghaemi . Choosing a Specialty: A Letter to a Medical Student. www.medscape.com. January 04, 2017