Wednesday, February 24, 2010

The Impossible Profession

In a nice segue to the last post, and with a thanks to Retriever (since the current New Yorker hasn't quite arrived at the house yet), it was a pleasure to read Louis Menand's take on psychiatry's discontents. It is probably the best single overview of the profession's vexing ambiguities that I have seen; it's all there--the diagnostic quibbles, the ideological clashes, the greedy pharmaceutical companies.

Talk about fact and metaphor...on the way in this morning, I was thinking about how wisdom in psychiatry is a microcosm of wisdom in life, that is, learning to distinguish facts from metaphors, or things we can't change from things we can. Medicine is metaphorical to begin with, but psychiatry is meta-metaphorical; it engages metaphors to understand how our minds make metaphors.

It's good every now and then to revisit the obvious: nothing in medicine or psychiatry comes pre-stamped with a "DISEASE" label. The marvelously complex human body (including the brain), developed through natural selection, behaves in mulitfariously patterned ways with variable implications for life-span and subjective distress. All that science can do is to identify and trace these patterns in all their hideousness or glory; everything else--how to describe these patterns and what if anything to do about them--is the stuff of politics in the broadest sense of social wrangling and consensus (or the lack thereof).

Doctors are trained and appointed to diagnose and treat, most literally, but more widely, they act as society's representatives and arbiters when it comes to managing (juggling?) facts and metaphors as they pertain to the body (again, including the mind) and its existential frailty. Whether or not to compel treatment, or whether or not to recommend disability, or even to grant the "sick role" are not fundamentally scientific, but rather bespeak the negotiated attitudes of the culture at large. As Menand suggests, perhaps our error is to expect medicine and psychiatry to be primarily scientific in the first place. What happens in the lab or the clinical trial is (one hopes) science; what happens in the consulting room is quite different. The mistake is to assume a congruence between science and moral authority. In either direction, it is quite possible to have one without the other.

There is much more to be said, but this is a lunch hour post.


Anonymous said...

Is the ultimate measure of human health defined by the degree of cultural fit?

Will the crowning triumph of science be the manufacture of the convenient life unlived - the conceptual life, life as idea? Humans as objects to their non-selves? The big existential crunch...

Novalis said...

Psychiatry, like science, should be nothing but a means to an end, a ladder that may be kicked away once the summit (or the depths?) has been reached.

Anonymous 2 said...

Psychiatry is not a science, but a trade that depends on skill of its craftsmen. Maybe one day it might turn into science, but it isn't yet. Missing from the books reviewed in original article is functionality as the criterion for psychiatric diagnoses. There are other misconceptions about psychiatry as a field (many of the books mentioned in the piece were written by non psychiatrists. The article's author, btw, is Harvard English professor). Proposed DSM V is a disappointment, it solves none of the old issues and adds a few more. Bad classification shouldn't be used for repudiation of the field which apparently is moving in the right direction despite inertia, disagreements, and obstacles on its way.

Novalis said...

Points well taken. However, psychiatrists often seem so blinded by their own particular allegiances that they are incapable of providing anything like an objective appraisal of the field, of the kind that an outsider may provide.

Indeed, with the exception of Peter Kramer, I am at a loss to think of a psychiatrist per se within recent memory who has grappled with psychiatry's issues in a way that is accessible or interesting to a popular audience. It is striking that surgeons like Atul Gawande and Sherwin Nuland are medicine's version of the public intellectual in a way that psychiatrists, supposedly far more sensitive to language and meaning, are not.

Am I missing anyone? Kay Redfield Jameson, yes, but her focus on creativity, while fascinating, is relatively narrow.

Arguably psychiatry as a profession hasn't had an articulate and compelling public voice since the decline of psychoanalysis several decades ago. But who am I to complain?

Anonymous 2 said...

Fair, with a comment: Kay Redfield Jameson is not a psychiatrist, she has PhD in clinical psychology. This fact might look trivial for some, but non-prescribers and prescribers are as different as car salesmen and car mechanics.
A typical psychiatrist thinks like psychoanalyst while practicing biological psychiatry. One can do this but would have helluva time making sense out of it. The rest of us figure out our ways to thinking and practicing in modern times, only DSM and mindless clinical research (a separate topic) get in the way. Psychiatry can be and should be practiced as the rest of medicine, but until we develop objective ways to classify and diagnose, it will remain the mess it is today.
I agree, no one summarizes and articulates well the advances of the last decades, just a matter of time, I guess. The best popular modern “psychiatric” literature comes, surprisingly, from neurobiologists and neuropsychologists. Two recent titles: John Medina’s Brain Rules and Cordelia Fine’s A Mind of Its Own.
About a year ago I wrote a proposal for new classification model based on neurobiology but was discouraged to go any further with it. There is too much acrimony surrounding DSM-V. Not worth the fight, in my opinion. I’ll be happy to share it with you, if interested. Although not specifically articulated, the model is based on Paul McClean’s triune brain concept and looks at the brain as a system.

Anonymous 2 said...

add on:

There was another enlightening article in WSJ on the same topic by E. Shorter

Novalis said...

I have read Shorter before--he is a well-informed critic of psychiatry, and the article you link to is a good one, even if it makes a psychiatrist wince.

I especially agree with his point that DSM diagnoses parade pseudo-specificity, when the only real specificity available is in the existential detail of the patient in question. I don't know how many times I have refused to list GAD, Panic Disorder, PTSD, and Social Phobia even if a patient meets criteria for all; the point is just that s/he is a "bundle of nerves." One diagnosis does the work of four!

I'm open to any additional insights and have updated my email in the profile section.

the alienist said...

I have only recently started blogging about psychiatry and reading the psychiatry-related blogs that others write, but it amazes me how critical and pessimistic most blogs (and the articles they reference) are. (By the way, this blog seems moderate in this regard.)

Why should people get so frustrated and angry at efforts to classify mental illnesses? Sure, the classification systems can be misused, but be angry at those that misuse the system, not at the system itself. Criticize the system intellectually and philosophically, but only as a way to improve it, not as a way to tear it down.

There is a great deal of suffering in this world. Plenty of suffering to keep us all busy. Let's use our energy to address the suffering, not to attack those who are sincerely trying to relieve it.

I'm not suggesting that psychiatry, psychology, social work, and religion are beyond criticism. I am suggesting that we do each other a favor when we criticize one another in ways designed to build each other up instead of tear each other down.

(Pardon me for the rant, it was directed not at this blog or its participants but at the critical arguments referenced in the blog).

Novalis said...

It seems to me that psychiatry is contentious for the same reasons that politics and religion are contentious: all pertain to existential and far-reaching matters of life, all reside in ambiguity, and all offer the temptation to hold forth with more supposed authority than is legitimately available.

It's a good question, though, and worthy of a post of its own sometime.

Dr X said...

The points made in this thread have considerable merit, but let me be the contrarian for a moment. Where do we draw the semantic line between science and non-science? If we generate falsifiable hypotheses and test them, is that not rudimentary science?

Not being a prescriber, my notions of psychiatry as practiced might be a bit too idealistic, but I would see the work of a psychiatrist as something akin to the single-case study:

Observation: the presentation and complaints of the patient

Generate falsifiable hypothesis: complaint x will respond as predicted to medication y.

Test the hypothesis: patient takes prescribed medication

Results: check on patient progress.

That certainly isn’t religion.

If I were to compare psychiatry to other branches of medicine, I would suggest an analog in the management of chronic diseases: there are no cures, response to treatment varies greatly from patient-to-patient and the underlying processes are not fully understood (although advances in molecular medicine are bringing us much closer).

I think the process is cleaner when psychiatry treats complaints rather than DSM diagnoses. As my psychopharmacology professor insisted: "we should not treat the DSM, we should target pharmacologically responsive states and complaints." Does anxiety abate when the patient takes this drug or undergoes that course of treatment? Does mood stabilize when the patient takes this drug? Does the patient fall asleep more quickly on this medication? The lack of complete understanding of underlying processes doesn’t mean that it isn’t science.

The deeper problem of psychiatry—the problem of existential matters that reside in ambiguity—is similar in my mind to the problem of reconciling quantum mechanics and general relativity. The fundamental nature of reality boggles the mind. Physicists propose mathematical explanations, but it isn’t clear that we will ever be able to test explanations that rest upon multidimensional models of reality.

Novalis said...

As is often the case, the DSM seems the fly in the ointment. After all, the FDA grants indications for drugs to treat specific disorders, and patients tend to want a name for their suffering, so their inference is that the drug is in fact treating the disorder. And yet it is not--it is palliating symptoms of the disorder.

A frequent patient complaint, or just observation, is that they feel "like a guinea pig." This isn't even metaphorically true, of course, but it does reflect a regrettable lack of specificity and predictability.

Your points about science are well taken, but in this case I would take "science" to reflect at least a basic understanding of the critical mechanisms of pathology. For instance, while supplementation of insulin for diabetics doesn't always alleviate all the stigmata of their disease, it does indicate a recognition of what is going on in the body. We're not there yet in psychiatry.

As Churchill said of democracy I think, psychiatry is the worst possible option--except for all the others.