Psychiatry Good and Bad
Psychiatry 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.
"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
More Biology and Brain Understanding
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.
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.
You may not care; perhaps you will ignore the larger
profession's delusions, and practice well in your little corner of the world.
Perhaps you'll do psychotherapy and enjoy helping people dealing with the basic
struggles and stages of life. That's good work, and important. And if it's your
calling, it's worth doing. But know that you'll be doing it in a larger context
that's inimical to your purposes.
Society punishes those who improve it.
Emerson observed this fact when he gave up a promising Christian ministry career
to instead minister to all of mankind. Don't expect awards and accolades from
the psychiatric profession for bettering it. The awards go to those who maintain
the status quo, not to those who change it. Freud never won a Nobel prize; they
gave it to the fellow who introduced frontal lobotomy.
Nassir Ghaemi . Choosing a Specialty: A Letter to a Medical Student.
Medscape, January 04,2017
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