Sunday, June 20, 2021

How Physicians Think




One of the more interesting aspects of my career has been contemplating how physicians make decisions on both the diagnostic and therapeutic side. Early in my career there was an explosion of activity in this area. Much of it had to do with internal medicine. There were computerized programs that were designed to assist physician decision-making. There were also entire courses taught at the CME level by experts in the field. At the time those experts included Jerome Kassirer, Stephen Pauker, Harold Sox, Richard Kopelman, Alvan Feinstein, and others.  The New England Journal of Medicine has a long-standing feature entitled Case Records of the Massachusetts General Hospital that showcases both diagnostic reasoning and the associated clinicopathological correlates. They added additional articles and a long standing feature on diagnostic decision making. After studying the subject area for about 10 years, I started to teach my own version to 3rd and 4th year medical students. It was focused on not mistaking a medical disorder for a psychiatric one.  It included a complete review of cognitive errors in that setting and how to prevent them. I taught that course for about 10 years.

There are a lot of ideas about psychiatrists and how they may or may not diagnose and treat medical disorders. Systematic biases affect the administrative and environmental systems where psychiatrists work.  Many psychiatrists are very comfortable at the interface of internal medicine or neurology and psychiatry. The most common bias about psychiatrists is that other medical conditions need to be “ruled out” before the patient is referred to a psychiatrist. From a psychiatric perspective the real day-to-day problems include inadequate assessment due to an inability to communicate with the patient and considerable medical comorbidity. Psychiatrists who work in those problem areas need to be competent in recognizing new medical diagnoses and making sure that their prescribed treatment does not adversely affect a person with pre-existing medical disorder.

Against that backdrop I decided to read 2 relatively new books. Both of them have the same title “How Doctors Think”. One book was written by Jerome Groopman, MD hematologist-oncologist by clinical specialty. The other book is written by Kathyrn Montgomery, PhD – a professor of Bioethics, Humanities, and Medicine. As might be expected from the writers’ qualifications Groopman is writing more from the standard perspective of a physician with an intense interest in medical decision making and Montgomery is describing the clinical process and analyzing it from the unique perspective of philosophy and the humanities. It follows that even though the titles are the same these are two very different books.

Groopman’s approach is to use a case-based style of looking at medical decision-making from the perspective of several clinicians-including his own work. The mistakes that occur are teaching moments and are explained from the perspective of heuristics or common cognitive biases. It is the approach I used in my course on preventing cognitive errors associated with psychiatric diagnoses. To cite one example, he describes an athletic forest ranger in his forties. The kind of a guy an internist might say: “I am not worried about his heart – he does his own stress test every day.”  He noticed increasing chest discomfort for a few days without any associated cardiopulmonary symptoms. He presented for an assessment on a day when the pain did not go away. He was seen and thoroughly examined.  There were no physical symptoms, exam findings, or laboratory finding to suggest a cardiac problem and he was released from the emergency department.  He returned a few days later with a myocardial infarction.  Discussions with the attending physician indicate that there were two issues associated with the missed diagnosis of cardiac chest pain – the generally healthy appearance of the patient and a lack of any positive tests indicating coronary artery disease.  Groopman discusses it from the perspective of representativeness bias (p 44) or being affected by a prototype – in this case the patient’s apparent level of fitness and attributing the chest pain to musculoskeletal pain rather than pain of cardiac origin. 

This case also allowed for a discussion of attribution errors especially if the patient fits a negative stereotype.  In the next case, a 70 yr old patient with alcohol use presents with and enlarged nodular liver on exam.  The presumptive diagnosis is alcoholic cirrhosis and the team’s plan was to discharge him back home as soon as possible. Closer examination confirmed that the patient was not drinking that much and searching for other causes of liver disease resulted in a diagnosis of Wilson’s disease.  For most of the book, Groopman uses this technique to illustrate substantial errors, the kind of cognitive bias that it reflects, and corrective action. The reality of “making mistakes on living people” comes though.

He recognized the importance of pattern matching and pattern recognition in clinical practice. There is an initial conversation with a physician that collapses pattern recognition to stereotypes and their associated shortcomings.  He elaborates on the concept and quotes a cognitive scientist to illustrate that pattern recognition may not require any conscious reasoning at all.  An expert can arrive at a diagnosis in about 20 seconds that may take a medical student or resident 30 minutes. Experts begin collecting information about the patient on contact and are immediately considering diagnostic possibilities. I have personally had this experience many times, typically for acute neurological syndromes (strokes, cerebral edema, encephalitis, meningitis) in patients who were referred for me to see in a hospital setting. Pattern matching clearly occurs in the diagnostic process, but it is more difficult to write about and discuss than verbal reasoning.

A major strength of the book is a fairly detailed look at uncertainty in medicine. The diagnoses are not etched in stone and no outcomes are guaranteed based on the accuracy of the diagnosis or not. He introduces a pediatric cardiologist who advances the argument that most of his cases are novel and that there are no set guidelines for what he treats. Even more complicated is that fact that what may appear to be sound science-based treatments like closing an atrial septal defect with a 2:1 shunt in kids it can be an illusion.  Many of those children do well without the surgery and many have had unnecessary surgery. The cardiologist also points out that study of this kind of problem is impossible because of the length of time it would take to do a randomized study.

Another major strength is advice to patients about how to keep the doctor they are seeing thinking about their case.  Numerous examples are given ranging from seeing large number of healthy patients where abnormalities are rare to seeing patients with real problems who have been stereotyped for one reason or another. Groopman is very specific in coaching prospective patients in how to overcome some of the associated biases.  This advice centers on the fact that biological systems are complex and don’t necessarily support logical deductions.  The astute doctor needs to be systematic, evaluate the data for themselves including the elicitation or more history, and question their first impressions. The patient aware of these limitations can ask the correct questions along the way to assist their physician in staying on track. He advises the patient to express their concern about the worst-case scenario to get that out there for discussion and to keep their doctor focused.  The patient is informed of how their history, review of systems and exam may need to be repeated along with some tests that have been previously done. The physician may have to ignore common aphorisms or maxims that are designed to focus on common problems and consider the complex – like more than one diagnosis being suggested. Business management of the medical encounter is seen to impair and obstruct this interactive process.

Groopman’s book is very good both as a guide to patients and a review for physicians who have been educated in diagnostic thinking. In the body of the book technical jargon is avoided and the case scenarios thoroughly explained. There is an excellent list of references and annotations for each chapter at the end of the book. 

How Doctors Think by Kathryn Montgomery takes the unexpected form of a philosophical argument against medicine as a science. She qualifies her criticism by being very clear that she is considering Newtonian or positivist science and not biological science. She recognizes several features of biological science that make it an integral part of medicine, but also not at all like the criteria for science that she sets as the premise for her argument. This is problematic at two levels. First, deterministic and reductionist physicists like Sabine Hossenfelder are very clear that everything is reducible to known subatomic particles and that particles in a brain are deterministic.

“Biology can be reduced to chemistry, chemistry can be reduced to atomic physics, and atoms are made of elementary particles like electrons, quarks, and gluons.” (5)

So for at least some scientists – reductionism is not a problem and the boundaries are not very clear between physical science, biology, and medicine.  Second, it is now known that biological organisms have a wide array of stochastic mechanisms that by virtue of their own nature produce apparently random results. With that range of possibilities, it is not very clear if the standards of physical science are that much different than the biological science necessary for medicine.

Montgomery makes the argument about science and the damage that the idea of medicine as science does to both medicine and its practitioners at several levels.  First, she describes science in medical training. Medical students encounter the basic science curriculum in the first two years of medical school. It is not physical science but biological sciences relevant to understanding pathophysiology, pharmacology, and epidemiology/evidence-based medicine.  She suggests this exposure to science is less relevant as the student transitions to a clinician with adequate clinical judgment – almost to the point that the basic science is an afterthought. This aspect of training is also used to point out that medical students are not being trained as scientists and the remainder of their formal education is spent learning clinical judgement.  At places she describes the preclinical years as fairly bleak period of memorization peripherally related to clinical development.  Second, the uncertainty of biology and medicine is part of her argument.  She extends the argument from the patient side to the side of the doctor. Patients want and need certainty and therefore they want doctors who are schooled in the best possible science who can provide it. Patients want an answer and all they get is statistics. Third, she suggests that the moral and habitual practice of medicine although dependent on human biology and the associated technical advances is not really science.  Physicians are taught to practice medicine and the don’t question “the status of its knowledge” (p. 191). She describes medical practice as a set of rational procedures that are shared with many other professions in the humanities and social sciences.  Fourth, the notion of medicine as a science is “clinically useful” in that it reassures the patients that physicians are engaged in a rational process like they were taught in science classes rather than a contextual, interpretive, narrative process used by non-scientists.  She cites numerous examples of maxims and aphorisms used in medicine to guide this process like Peabody’s famous: “The secret of the care of the patient is in caring for the patient.” 

 Montgomery’s writing is as sophisticated as you might expect from a bioethics professor with a doctorate in English and extensive exposure to medical training. Her critique depends a lot on verbal reasoning and the application of that model to numerous disciplines. Philosophical critiques of medicine and psychiatry that I have responded to in the past are typically presented as arguments with the premises being set by the author. As I read through these arguments being repeated across chapters there were clear points of disagreement.  Here is a short list:

1:  The argument about medicine not being a physical science – that is a good starting point if you want to be able to attack the scientific aspects of medicine, but does anyone really accept that premise? No physical science is taught in the basic science years of medicine.  The basic sciences are focused on human anatomy and physiology. An associated argument is that biological sciences have no overriding laws like physics and that is given as further evidence that medicine is not a science. There is an entire range of science within the basic science of medicine that cannot be explained by physical science but it is necessary for clinical medicine and innovation in medicine.  Finally science is a process that is subject to ongoing verification. That is as true for biological science as it is for physical sciences. While there appear to not be as many absolutes for biology progress is undeniable even within the boundaries of medicine.

2:  Uncertainty in biological systems and medicine - the author makes it seem like defining medicine as a science gives the false impression of certainty. I don’t think that certainty is misrepresented or minimized in clinical medicine.  Every physician I know experiences the uncertainty during informed consent and prognosis discussions. It is built into surgical consent forms and in situations involving medical treatment or testing – the discussions are even more complex. In a typical day, I will advise patients on side effects that occur at rates varying from 4 out of 10 patients to 1 out of 50,000 and tell them what to look for and when to call me.  I have had patients tell me after those discussions that they would prefer not to take a medication or do the recommended testing. I will also discuss life threatening problems with patients, and let them know I cannot predict outcomes but can advise them on how to reduce risk. The only way medicine can practiced is by having appropriate informed consent discussions that fully acknowledge uncertainty and the associated biological heterogeneity.  From the patient side, everyone has a friend, acquaintance, or family member who was healthy until the day there were not. The uncertainty of physical health and medical outcomes at that point are widely known by the general public.

An additional and lesser known aspect of the effect of uncertainty on physician behavior is encouraging the correct answer or treatment as soon as possible. Montgomery attributes some of this to the moral dimension of the physician-patient relationship and doing the right thing for the patient.  But a critical part of uncertainty is that physicians eventually learn to project their decisions out into the future. Those projections are all taken into account in developing the current treatment plan. The outcome of an idealized plan can be viewed as the direct result of the uncertainties involved.  

3:  Physician detachment is a likely consequence of characterizing medicine as a science – At points Montgomery makes the point that physician can emotionally protect themselves by assuming the detached rationality of science. It follows that abandoning medicine as a science would result in a more realistic emotional connection with patients. She has a detailed discussion of the physician-patient relationship being more as a friend or a neighbor.  She concludes that neighborliness has a number of virtues to recommend it as the relationship for the 21st century. Two concepts from psychiatry are omitted from this discussion – empathy and boundaries. Empathy is a technical skill that is typically taught to physicians in their first interviewing courses in the first year of medical school.  It is a technical skill that allows for a more complete understanding of the patient’s emotional and cognitive predicament. In my experience what patients are looking for is a physician who understands them. That is generally not available from a friend or neighbor.  The basic boundary issue is that it is very difficult to provide care to a person who is emotionally involved with the physician. There are degrees of involvement, but any degree is important. A physician who is empathic, had a clear awareness of the relevant boundaries, and has a solid alliance with the patient is far from detached.  But I would not see them as neighborly or a friend.  The physicians job is the be in a position where they can provide the best possible medical advice. That can only happens from a neutral position where they can give a patient the same advice they would give anybody else.  That also does not mean that physicians are not emotionally affect when bad things happen to their patients or when their patients die.

4:  Do ancient Greek concepts still apply? – The author uses Aristotelian definitions of episteme and phronesis several times throughout the text. Episteme is scientific reasoning and phronesis is practical reasoning.  Aristotle’s view was that since there are no “fixed and invariable answers” to questions about health, every question must be considered an individual case.  In those cases, practical reasoning that considers context and additional factors or phronesis applies.  That allows the author to compare medicine to a number of social science disciplines that use the same kind of reasoning.  The question needs to be asked: “What would Aristotle conclude today?”  In ancient Greece there were basically no good medical treatments and medical theory was extremely primitive. Over the intervening centuries medicine has become a lot less imperfect. Uncertainty clearly exists, but the scientific advances are undeniable.  It is possible to say today that there are now fixed and invariable answers to large populations of people. Medicine has always been a collection of probability statements – but those probabilities in terms of successful outcomes have significantly improved.  One the corollaries of  Aristotle’s work is that there can be “no science of individuals” and yet the current goal is individualized or personalized medicine.

5:  Is science relevant to clinicians on a day-to-day basis? -  I think that it is.  I have certainly spent hours and even entire weekends researching patient related problems to find the best solution to a problem and to be absolutely sure that my recommended course of treatment would not harm the patient. All of that reading was basic or clinical science.  On the same day that I received Montgomery’s book, I got my weekly copy of the New England Journal of Medicine.  I have been a subscriber since my first year of medical school based on the recommendation of my biochemistry professor. Our biochemistry class was designed around research seminars where we read and critiqued basic science research. There was also the assumption that you were reading the text cover to cover and attending all of the lectures.  He encouraged all of us to keep up on the science of medicine by continuing to read the NEJM and in retrospect it was a great idea.  In that edition I turned to the Case records of the MGH (6): An 81-Year-Old Man with Cough, Fever, and Shortness of Breath. It was a detailed discussion by an Internist about the presentation and differential diagnosis of the problem. And there on page 2336 was a diagram of the ventilation perfusion mismatch that occurs with a pulmonary embolism and acute respiratory distress syndrome. I have seen this science at the bedside in many clinical settings.  

The clinical competency of pattern matching, pattern recognition, and pattern completion is left out of Montgomery’s description of how doctors think and it is an important omission.  It is a good example of non-verbal and unconscious reasoning that can be a critical part of the process. The answer to the question: “Is this patient critically ill?” and the triage that follows depends on it.  Pattern matching is also experience dependent with experts in their respective fields being able to more rapidly diagnose and classify problems that physicians who are not experts. Biases affecting verbal reasoning can negatively impact the diagnostic process, but so can the lack of experience in seeing patterns of illness and an inadequate number of cases in a particular specialty.

I consider both of these books to be good reads, especially if you are a physician and have had no exposure to thinking about the diagnostic process.  Both authors have their own ideas about what occurs and there is a lot of overlap. Both authors have the goal of stimulating discussion and analysis of how physicians think and educating the general public about it. Physicians will probably find Groopman a faster and more relatable text. Physicians may find the references and vocabulary used in Montgomery to be less recognizable. I would encourage any physician who is responding to initiatives to change the medical curriculum or critique it to read Montgomery’s book and work through her criticisms.  Both books have excellent references and annotations listed by the chapter for further reading. Non-physicians especially patients who are working with physicians on difficult problems may benefit from Groopman’s tips on how to keep those conversations focused and relevant.  As a psychiatrist who is sensitive to attacks (even philosophical ones) from many places – you may find my criticism of Montgomery’s work to be too rigorous. I tried to keep that criticism down to a level that could be contained in a blog post.  I encourage a reading of her book and formulating your own opinions. It is an excellent scholarly work.

Finally, the area of expertise in medicine and the associated clinical judgment of experts is still a current research topic.  The research has gone from basic experiments about who can properly diagnose a rash or diabetic retinopathy to a clear look at brain systems responding during that process. Those changes have occurred over the past 30 years. At the descriptive level it remains important to be aware of the possible cognitive biases and what can be done to overcome them.

 

George Dawson, MD, DFAPA

 

References:

1:  Groopman J.  How Doctors Think. Houghton Mifflin Company, New York, 2008.

2:  Montgomery K.  How Doctors Think. Oxford University Press, New York, 2006.

3:  Kassirer JP, Kopelman RI.  Learning Clinical Reasoning. Williams and Wilkens, Baltimore, 1991.

4:  Sox HC, Blat MA, Higgins MC, Marton KI.  Medical Decision Making. Butterworths, Boston, 1988.

5:  Hossenfelder S.  The End of Reductionism Could Be Nigh. Or Not.  Nautilus June 18,2021 (accessed on June 18, 2021) https://nautil.us/blog/the-end-of-reductionism-could-be-nigh-or-not

6:  Hibbert KA, Goiffon RJ, Fogerty AE. Case 18-2021: An 81-Year-Old Man with Cough, Fever, and Shortness of Breath. N Engl J Med. 2021 Jun 17;384(24):2332-2340. doi: 10.1056/NEJMcpc2100283. PMID: 34133863.

 

Monday, May 31, 2021

The Current Moral Crisis In The United States

 


It is fashionable these days to talk about moral crises that really aren’t moral crises. The level of rhetoric is at the point where disagreements can be spun as moral crises, while people are dying in the streets. The best examples I can think of are the long-standing epidemics of gun violence and racism. New examples are cropping up every day. There are current trends in violence against Asian Americans and Jews against the backdrop of long-standing trends. Discrimination and violence against black Americans is finally acknowledged as being widespread and is the basis of an activist civil movement and hopefully systematic reforms.

All of the statistics to back up my statements in the first paragraph are easily available and I am not going to post all those references here. Since I started writing this blog one of my concerns has been gun violence and how to stop it given the level of interference with common sense gun law reforms by one of the major parties and major lobbying concerns. I saw the attempt to counter that political interference as being futile and focused more on public health interventions and possible psychiatric intervention. The latest good review of that approach is available in a review by Knoll and Pies (3).  For many years I have advocated that homicidal ideation should be seen as a public health intervention point and that it should be part of the strong public health message. To this day nothing has happened. Public health organizations do have research-based suggestions such as locking up firearms and common-sense gun laws like banning large capacity magazines, banning assault rifles, and universal background checks, but the general lack of progress in that area is not reassuring. There has been some movement in allowing more research on gun violence, an area that was previously blocked by gun lobbyists.

What is the connection between gun violence, racism, and violence toward our fellow Americans?  I think there are all based on the same interpersonal dynamic. That dynamic is seeing another person as being significantly different from you, attributing negative characteristics to them, and using both of those premises for treating them different from you up to and including perpetrating violence toward them.  In psychiatric jargon, we use the term projection to capture this process or in the extreme projective identification. These are not psychiatric diagnoses, but defense mechanisms that are distributed across the population even though they may be more likely in people with specific psychiatric diagnoses.

In my readings over the years I have been looking for a likely origin or at least first sign of this kind of thought pattern. In other words, have people been thinking like this since the beginning of recorded time, or is this a new phenomenon?  In the course of that reading, I came across a book written by the anthropologist Lawrence Keeley called War Before Civilization. In this book, Keeley explores the idea of the noble savage from prehistoric times.  In other words, were pre-historic people inherently peaceful as some had suggested or were there early signs of violence and aggression. A review of the evidence suggests that the majority of human prehistoric civilizations engaged in frequent warfare and total warfare – in other words attacks not limited to combatants and decimating the opposition’s infrastructure and ability to make war.  Keeley reviews the motivations and consequences of primitive warfare in great detail including tactics (surprise attacks, slaughter of noncombatants, and general massacres) and specific practices like mutilating dead bodies. There is clear evidence the latter functioned in part to dehumanize and humiliate the enemy and send a message to the survivors. These dynamics were not limited to prehistoric man and have continued through modern times and modern warfare.

A recent report referencing Keeley’s book appeared on Scientific Reports (2) this week.  It was a reanalysis of a Nile Valley burial site of 61 people from about 13,400 years ago. It is thought to be some of the earliest evidence of Homo sapiens interpersonal violence.  In that analysis over 100 lesions were identified in the skeletal remains from what appeared to be projectile weapons.  Examining the mortality curve of the individuals in the cemetery showed that it was consistent with multiple burials rather than a single event.   The stone artifacts examined were consistent with spear or arrow heads. Some we designed to kill by lacerating and causing blood loss. Some were discovered embedded in bones, but others were discovered within the area where the body was discovered and that was viewed as being consistent with the ability to penetrate the body.  The authors conclude that the majority of people in the cemetery died of blunt or sharp force trauma and that there were multiple episodes of interpersonal violence.  Some of the combatants had been wounded multiple times prior to death.  They also concluded that these episodes were most likely the result of “skirmishes, raids or ambushes” likely related to territorial disputes that may have been affected by the weather. (p. 9).

What can be inferred from this long history of human violence and aggression? First, groups of humans have been perpetrating violence against one another since prehistoric times. Second, during these episodes total warfare was very common and the human cost of war is always high. The estimated percentages of deaths in ancient society were generally higher than in modern society for a number of reasons. That was not a deterrent to ancient humans.  Third, the psychological states during these episodes of violence show a potentially broad range of thinking leading to aggression.  Very limited incidents such as the theft of livestock or a rumor of a sexual affair between members of different tribes or villages may be all that was required to start a series of retaliations leading to all out war.  Once a violent conflict ensued – there were thought patterns and rituals in place to justify the killing, prevent bad outcomes for the killers, humiliate the dead, and embarrass their families.

The current moral crisis in America seems to have a direct link with prehistoric behaviors. It is enacted by aggressive behavior that is described as racism, antisemitism, and gun violence, but the dynamic is the same one described in ancient man.  In other words, once a person can be seen and characterized as an enemy (for whatever reason),  it is very easy to vilify them, attribute the worst possible motivations to them, and use that as a basis for rationalizing aggressive behavior. In the past weeks, I saw two elderly Asian American women attacked at a bus stop by a man wielding a knife. The attack as so violent that the large blade of the weapon broke off inside the body of one of these women. In a more recent event, a heavily armed long time employee shot 9 of his coworkers and then killed himself when he was surrounded by police.  In both cases, the “motivation” for the violent behavior is unknown.  There is a suggestion of mental illness, but the majority of people with diagnosed mental illnesses and even the same diagnoses are not violent or aggressive. The sheer volume of mass shootings in the United States suggests it is more of a cultural phenomenon here than anywhere else but that is confounded by the easy availability of firearms.  The main difference between modern and ancient times is that we have a societal structure that is designed to contain violence and aggression and prevent larger outbreaks.  It is clearly ineffective at this point in preventing violence.

I am suggesting a common thought process here that does not require any psychiatric diagnosis and one that can be intervened upon and self-monitored.  In order to perpetrate discrimination, hate crimes, and even homicidal violence toward others 3 conditions have to exist.  First, the potential victims of violence need to be seen as sufficiently different from the perpetrator so that he can attribute unrealistic negative attributes to them and rationalize his aggressive action.  Second, the attacker can see himself as sufficiently different from the potential victims that he feels threatened by them and can rationalize attacking them for that reason alone.  A common example is that the attacker feels victimized by his coworkers and feels the need to strike out at them.  And finally, the attacker must have a plan to either seriously injure or kill the victim(s). All of these thought patterns can be considered derivative of thoughts present in ancient man leading to the wide ranging aggression and warfare described in the references.

I think there is much to be said for intervention based on the observations in this post.  For the time I have written this blog, I have advocated for intervention based on homicidal or aggressive behavior. When I worked as an acute care psychiatrist – treating violence and aggression was easily half of my job.  If we can suggest that persons with suicidal ideation or self-injurious behavior contact a crisis intervention service or hotline – why don’t we have a similar suggestion for people with homicidal thinking?  And further what about general education about the primitive origins of these thought patterns.  Just the other day I posted the following:

“Ridiculing people who died of C-19 and were antivaxxers and anti-maskers is bad form - plain and simple.

Bring civility back and restart civilization.

It starts with recognizing the value of a single human life.”

There was much agreement with the post, but also several people who suggested that I was naïve for not being able to recognize enemies or that I was a “better person” for being able to overlook the behaviors of a group of people who were potentially dangerous to others.  My post was not about moral superiority or not recognizing enemies – it is all about the fact that disagreement should not lead to enmity and beyond that we are all members of the same tribe.  We all came from Africa. And seeing differences between us that do not exist is probably ancient thinking that obscures the fact that we are all a lot more similar than we are different.  As I explained to some of the critics of my post, they seemed to be focused on the exceptions rather than the rule.  They also seemed to be making arbitrary exceptions based on seeing more differences than similarities. 

We are currently at a crossroads in this country.  People are making money and generating political capital by emphasizing differences and exploiting the primitive thinking that I have outlined in this post.  Much of the aggression plays out at a symbolic level in social media, but the Insurrection at the Capitol building and the increasing levels of physical violence illustrates that it is far from always symbolic. Americans have traditionally left ethics and morality up to religious institutions where it may be presented at an abstract level.   

It is time to get back to the basic premise of why every person is unique and needs to be treated with respect by virtue of being a member of the human race. It seems like an obvious but untested approach to reducing interpersonal violence at all levels in a society that is not currently equipped to prevent it.

 

George Dawson, MD, DFAPA

 

References:

1:  Lawrence H. Keeley. War Before Civilization. Oxford University Press, 1997.

2:  Crevecoeur I, Dias-Meirinho MH, Zazzo A, Antoine D, Bon F. New insights on interpersonal violence in the Late Pleistocene based on the Nile valley cemetery of Jebel Sahaba. Sci Rep. 2021 May 27;11(1):9991. doi: 10.1038/s41598-021-89386-y. PMID: 34045477 (Open Access).

3:  Knoll JD, Pies RW.  Moving Beyond "Motives" in Mass Shootings.  Psychiatric Times 36(1) Jan 13, 2019. Link


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Saturday, May 29, 2021

News From Africa

 



 











Some readers of this blog may recall posts in the past about human origins from Africa. I first became aware of the migratory pathways of early humans and the archaeological and genetic evidence from participating in a National Geographic test. That test looked at haplotypes and how modern humans migrated from East Africa to essentially around the world. The test also estimated the percentage of Neanderthal heritage. Since that original sample I have been tested at 2 other laboratories. One of them confirmed the National Geographic analysis and the third test is pending. My original intent was to highlight the fact that all Homo sapiens are from East Africa, and that the distinctions we like to consider “race” mean a lot less than most people think. Genetically human beings from different races are much more similar than different.  If we all share common ancestors, similarities would seem to be intuitive, but the events that have occurred since my original post suggest otherwise.  Racial and tribal biases have been with her since prehistoric times and continue in modern societies.

Despite those biases, evidence continues to flow from Africa. In the may 6 Nature there was a research paper on the discovery of a 78,000-year-old gravesite in Panga Ya Saidi, Kenya that contained the body of a 3-year-old child. The body and gravesite had evidence of burial practices including intentional placement in an excavated grave, specific positioning of the body, and wrapping of the body in a perishable material.  The authors exhaustively review the evidence for those conclusions. They and the author doing the commentary on this article (2) also review the meaning of these rituals.

The editorial first and the commentary by Louise Humphrey (2) from the Center for Human Evolution Research. Dr. Humphrey sets the stage in the Middle capstone Age (320,002 30,000 years ago). The research question is the first evidence of modern human behavior during that era. Various human innovations were discovered during this timeframe in Africa. The earliest human fossils were also discovered in Africa during this timeframe. One of the key indicators of complex behavior is how the dead were prepared and handled. Anthropologists considered this to be a marker of increased symbolic capacity and thought. Dr. Humphrey reviews existing fossil records of mortuary treatments done by humans and provides a map in her paper (2) where the archaeological sites are mapped ranging from 50 to 780 thousand years ago. Given the time range the hominid species identified included Homo sapiens, Homo neanderthalis, and other species of the genus Homo.  The critical work of the scientist involved is to “reconstruct a series of human actions associated with the deposition of the body”. What does the planning suggest? What meaning can be inferred from the site? Time and effort involved in the ritual suggest that the treatment is more meaningful. In the literature reviewed that included a dedicated site, wrapping the body, and positioning the body. Her conclusion was that the paper suggested the burial in the main paper was “symbolically significant”.

The research article (1) is a detailed description of the excavation and analysis of gravesite of a 2.5 to 3.0-year-old child. The researchers named the child Mtoto – a Kiswahili word for small child.  Estimated age of the gravesite was about 78,000 years ago. There is a detailed drawing of the preserved skeleton that includes a large portion of the cranium, spine, ribs, right clavicle, left scapula, left humerus, and proximal femurs.  There were 5 teeth present and they were felt to be consistent with H. sapiens, although some other features were present suggesting that there may have been regionally distinct populations. The evidence for placement of the body in a specific location was reviewed. The skeletal remnants were minimally displaced. The body was in a flexed position. The body present position was consistent with wrapping. This was interpreted as “more elaborated involvement of the community in the funerary rite…”. The evidence for intentional burial included an excavated trench and settlement patterns consistent with burial.

The authors review the scant evidence for mortuary practices during this era. They conclude that H. sapiens was probably preserving corpses of the young members of their groups between 69 and 78 thousand years ago.  That is contrasted with burial practices in Eurasia by Neanderthals and other modern humans dating back 120,000 years.  Infant and child burials in the sites were described as “ubiquitous”. The authors see the lack of mortuary practices during the middle Stone Age in Africa in general as being inconsistent with “modern-like conceptions of the afterlife and/or treatment of the dead”. They do point out that the absence of the behavior is not the same as the lack of capacity.

This paper was important from a number of perspectives. Overall, it is apparent that archaeological/paleobiological evidence of burial practices during the Stone Age is limited. East Africa is commonly viewed as the cradle of civilization. In 2 of the DNA analyses I have had done on myself, all my ancestors retraced back to East Africa. The data about Neanderthals mortuary practices is interesting because in the past decade, archaeological evidence supports the idea that they were conceptually more sophisticated than they had previously been given credit for.  One of the questions I came away with from this paper is why so few burial sites or other evidence of mortuary practices exist in Africa.

The inferences about human cognition based on mortuary practices are interesting to consider even in modern times. Over the course of my lifetime, funerals have changed significantly. Embalming and displaying the body, was fairly typical in the families I have been affiliated with until the turn-of-the-century. That mortuary practice was primarily grief focused. There was a religious service that was often a divine explanation of what had occurred and what was to be expected. Over the years I grew to become very interested in what the clergy from different faiths would say during the funeral. Other people would frequently speak with varying degrees of effectiveness. A common meal or reception would frequently follow the religious service there is often a separate burial with the graveside religious service the next day.

In about the year 2000, things seem to change significantly. I remember attending a funeral and being shocked that the body had been replaced by a small box of ashes. Cremation suddenly became the rule rather than the exception. The funeral service was focused on being a celebration of the deceased’s life rather than strictly grief focused. There were often photographs and video displays relevant to the deceased person’s life. The eulogies were also more lighthearted. Jokes or humorous vignettes about the deceased were more common. I don’t know what lead to these changes and have not been able to find a good analysis of why it occurred. The archeological elements of ritual, respect for the dead, the existential balance of the meaningfulness of their life in contrast to death, and the promise of a spiritual afterlife is all there. With cremation there is an added element of remembering the deceased as they were in real life and that theme is more consistent with a celebration of their life.  All of these elements are fairly implicit and embedded in ritual. An obituary is written and proofed several times. In the Internet era, it is posted on several sites and is eventually routed to sites when ancestry analysis occurs.  I have seen direct evidence that Internet obituaries exist in cyberspace much longer than they could be viewed in a newspaper. There is no doubt that multiple people have carefully planned the event.

The most important aspect of the death of an individual is their impact on the conscious states of others.  That is often simplified as a “memory” but it is more complex than that. For decades the grief process was considered to be a closed process. The person grieving goes through a number of cognitive-emotional stages and at some point they reach a stage where there baseline emotions return and they are left with memories of the individual. In the common vernacular that was described as closure.  In reality, the process is typically more open ended and the relationship with the deceased lives on. Any one of us who has lived long enough can recall at will or by association what those relationships and that person was like, why they are missed, and how they are still affecting us.  The increasing lifespan of modern humans leaves us all with a lot more time for those thoughts.

An additional consideration is the pattern of mortality and how it differs from the Stone Age to modern times. The average age of a person in the Stone age is estimated to be in the 25-35 range but that is skewed by considerable (45%) infant mortality. Did that have an impact on mortuary practices and the grief process?  Some experts suggest that more care was taken in attending to deceased infants and children implying that our ancestors had a selective thought process about those deaths. Given the time and scant evidence we may never know what our ancestors were thinking with a high degree of certainty. We do know that in the Middle Stone Age – our ancestors engaged in rituals that reflected their thoughts on death in general and that specific person.

 

George Dawson, MD, DFAPA

 

 

References:

1:  Martinón-Torres M, d'Errico F, Santos E, Álvaro Gallo A, Amano N, Archer W, Armitage SJ, Arsuaga JL, Bermúdez de Castro JM, Blinkhorn J, Crowther A, Douka K, Dubernet S, Faulkner P, Fernández-Colón P, Kourampas N, González García J, Larreina D, Le Bourdonnec FX, MacLeod G, Martín-Francés L, Massilani D, Mercader J, Miller JM, Ndiema E, Notario B, Pitarch Martí A, Prendergast ME, Queffelec A, Rigaud S, Roberts P, Shoaee MJ, Shipton C, Simpson I, Boivin N, Petraglia MD. Earliest known human burial in Africa. Nature. 2021 May;593(7857):95-100. doi: 10.1038/s41586-021-03457-8. Epub 2021 May 5. PMID: 33953416.

2:  Humphrey L.  Burial of a child during the Middle Stone Age in Africa.  Nature. 2021 May; 593(7857): 39-40.

3:  Ponce de León MS, Bienvenu T, Marom A, Engel S, Tafforeau P, Alatorre Warren JL, Lordkipanidze D, Kurniawan I, Murti DB, Suriyanto RA, Koesbardiati T, Zollikofer CPE. The primitive brain of early Homo. Science. 2021 Apr 9;372(6538):165-171. doi: 10.1126/science.aaz0032. PMID: 33833119.

4:  Beaudet A. The enigmatic origins of the human brain. Science. 2021 Apr 9;372(6538):124-125. doi: 10.1126/science.abi4661. PMID: 33833107.

5:  Olden K, White SL. Health-related disparities: influence of environmental factors. Med Clin North Am. 2005 Jul;89(4):721-38. doi: 10.1016/j.mcna.2005.02.001. PMID: 15925646.

6:  Brotherton P, Haak W, Templeton J, Brandt G, Soubrier J, Jane Adler C, Richards SM, Der Sarkissian C, Ganslmeier R, Friederich S, Dresely V, van Oven M, Kenyon R, Van der Hoek MB, Korlach J, Luong K, Ho SYW, Quintana-Murci L, Behar DM, Meller H, Alt KW, Cooper A; Genographic Consortium. Neolithic mitochondrial haplogroup H genomes and the genetic origins of Europeans. Nat Commun. 2013;4:1764. doi: 10.1038/ncomms2656. PMID: 23612305; PMCID: PMC3978205.

7:  Fu Q, Rudan P, Pääbo S, Krause J. Complete mitochondrial genomes reveal neolithic expansion into Europe. PLoS One. 2012;7(3):e32473. doi: 10.1371/journal.pone.0032473. Epub 2012 Mar 13. PMID: 22427842; PMCID: PMC3302788.

 

Supplementary:

Additional references above are for a more expansive essay on paleobiology, genetics and the importance recognizing a common ancestry.

Thursday, April 29, 2021

Hypertension - Clinical and Historical Significance for Psychiatry

 

 

I have written about hypertension in the past on this blog. During the treatment and ongoing care of the many patients I have seen over the years it is always present. The prevalence of hypertension increases with age and other comorbidities. The case of the patients I have seen alcohol and other substance use, obesity, smoking, stress, and prescribed medications are all risk factors. As a psychiatrist following blood pressures, I have to be more compulsive than the average physician. I have rarely been in an outpatient clinic where blood pressures were routinely checked. On the inpatient units where I have worked, blood pressure monitoring could also be a problem. I am reminded of teaching in services on blood pressure monitoring. In inpatient settings is also fairly common to see patients admitted who have discontinued antihypertensive therapy and developed dangerously high blood pressures. In many of those cases they continued to refuse the medication. I was put in the uneasy position of having to follow extremely high blood pressures until a probate court judge could convince the patient it was in their best interest to take those medications.

I have also seen the long-term consequences of uncontrolled hypertension in the form of acute hemorrhagic strokes, subarachnoid hemorrhages, aortic aneurysms, hypertensive cardiomyopathy, and the variations of hypertension related dementia. Many of these findings were in the context of an acute emergency. Several were more of an unexpected finding such as the likely long-term consequences of eclampsia and a brain imaging study done 30 years later.

In the day-to-day care of patients, knowing whether or not they may have hypertension is a critical aspect of care. That is true whether you are considering a medication that can elevate or decrease blood pressure, advising the patient on lifestyle changes to improve their health, or discussing their current exercise program. Most people are unaware of the acute effects of exercise on blood pressure and why strenuous exercise may be contraindicated until they have adequate control of blood pressure.

For all of these reasons, I am always interested in when new guidelines come out or blood pressure screening. Over the years that I have been practicing the suggested cutoffs demarcating hypertension and ranged anywhere from 120/80 to [Age + 100]/90. The [Age + 100]/90 cutoff was a guideline we used when I was an intern in the 1980s. That meant that if you are treating a 70-year-old their acceptable blood pressure was a maximum of 170/90. Over the years extensive research has examined blood pressure dependent outcomes and determined that systolic blood pressures that high are problematic. The question is always-where is the cutoff? Specifically at what point are we maximizing the gains and reducing the risks from overtreatment and using excessive diagnostics. 

The question is one that the US Preventive Services Task Force (USPSTF) seeks to answer. They published their comprehensive look at the issue recently (1).  Hypertension prevalence of 45% of all adults in the US is noted as well as the morbidity and mortality associated with untreated hypertension.  The quoted range of cutoffs is from 130/80 to 140/90. The technical considerations of blood pressure determinations are discussed. Suggested sensitivity of 0.8 and specificity 0.55 for office blood pressure measurement (OBPM) and 0.84 and 0.6 for home blood pressure measurement (HBPM).  Review of 13 study showed that the harms of blood pressure screening are minimal. 

The standard online medical text in the US is UpToDate and it defines hypertension as <120 mmHg systolic and <80 mmHg diastolic with Stage 1 hypertension being 130-139 mmHg systolic and 80-89 mmHg diastolic.  Stage 2 hypertension is defined as systolic of 140 mmHg and diastolic of 90 mmHg. UpToDate also defines a category of treated hypertension for any patient taking antihypertensive medication irrespective of their blood pressure reading. 

The USPSTF paper had an interesting section called How Does Evidence Fit with Biological Understanding? This did not involve a discussion of pathophysiology, but the description of subtypes and what the implications might be.  Sustained hypertension was defined as elevated blood pressure determine both in the office and outside of office settings. Whitecoat hypertension was defined as elevated blood pressure in the office but not in ambulatory settings. Masked hypertension was defined as elevated blood pressure outside of the office but not in office settings. For the purposes of the document, sustained hypertension is considered the entity that the recommendations are based on and the overall risk of cardiovascular disease is sustained hypertension > masked hypertension > whitecoat hypertension.  The diagnosis of white coat hypertension is made by comparing OBPM with HBPM or ABPM (ambulatory blood pressure measurement).  No specific biological mechanisms are discussed. The document points out that even though masked hypertension and whitecoat hypertension are associated with adverse cardiovascular outcomes there is no current evidence that treatment improves as outcomes and they consider that to be a knowledge gap.

UpToDate take a more detailed look at primary and secondary hypertension but does not elaborate much more on the pathogenesis and biology of hypertension. For example, it outlines the autonomic nervous system, the renin aldosterone system, and total plasma volume as being the main systems involved in hypertension. Secondary causes and screening for these causes is suggested but there are no confirmatory tests for essential hypertension.  Interestingly atypical antipsychotics and antidepressants are on a list of medications thought to contribute to hypertension but in personal correspondence with a hypertension specialist – he considered even the most likely medications in that category (bupropion and venlafaxine) to be rare causes.  Empirical treatment and how to treat more resistant forms of hypertension are reviewed. The medications typically address a purported mechanism of hypertension but there is no suggestion to determine the underlying physiology and match it with a medication effect.

Monitoring is another role that psychiatrists can fill. I see the same patient ranging from 6 to 24 visits per year and ideally those would all be heart rate and blood pressure data points. With many of those patients I also discuss home monitoring since approved devices are now very affordable and many of them are being treated often intermittently for hypertension. It is also critical that some patients are able to do HBPM if they are treated with medications that can clearly affect blood pressure such as beta-blockers, prazosin, and clonidine. For subgroup of people who have sustained tachycardia who need close monitoring I also recommend HBPM.

Every psychiatrist should be aware of both the USPSTF screening guideline and either the UpToDate chapter or a similar comprehensive book chapter or review.  Making sure that the patients in question get adequate screening, evaluation, and treatment is as critical as the treatment for their psychiatric disorder.  Comorbidities that are the direct result of end organ damage from hypertension also need to be addressed. I have been able to advise patients on dietary changes, exercise programs, and accepting treatment for obstructive sleep apnea when it was ignored from other sources.

Apart from the medical and clinical considerations of hypertension – are there any other lessons for psychiatry?  It turns out there are and they were first noted in 1960 and since forgotten.  Until that year there was a predominance of the view that diseases are caused by discrete pathological lesions. That view was advanced by Virchow and Koch and was the predominant view of the day. A corollary is that there are always qualitative differences between health and disease.  If a person has the required lesion, they have the disease and if not, they are healthy. That theory was disrupted by a paper by Oldham, et al (3) on the nature of essential hypertension. At that time, the dominant theory of hypertension was that it was an autosomal dominant determined disease that “separately sharply” from the normotensive population. The authors looked at collected data on families and showed that the percentage of families in previous generations with hypertension was too low for Mendelian inheritance.  The authors looked at data on the blood pressure ranges of first-degree relatives of their index hypertensives. The graphical data was interpreted as bimodal distribution of blood pressures consistent with a clear demarcation between elevated blood pressure and normotension.  However, re-examination of the data and a further trial showed that the frequency distribution of blood pressures was not consistent with a bimodal distribution or as the author’s state:

 “seems to illustrate once again that it is not hypertension that is inherited but the degree of hypertension.”

The authors use this data to reject a dominant gene and qualitative differences between disease and non-disease state.  They go on to describe the biological implausibility:

The alternative hypothesis-that arterial pressure is inherited polygenically over the whole range, and that the inheritance is of the same kind and degree in the so-called normal range as in that characteristic of essential hypertension-is in general conformity with biological theory and with the facts of observation. Just as stature, the classical human example of polygenic inheritance, is the sum of a number of separate bones and tissues, so is the arterial pressure the resultant of a number of discrete components of the cardiovascular system. One need only mention the radii of different parts of the vascular system, the lengths of the vessels constituting the resistance, their elasticity, the chemical composition.”  p. 1092.

As I read that passage, I was reminded of current work looking at the tens to hundreds of network genes activated across the genotypes of millions of unique individuals as a basis for the polygene events that occur in polygenic disorders including psychiatric disorders.

Once the polygene quantitative model was accepted over the single dominant gene qualitative model, it led to a broader application including the obvious one to psychiatric disorders.  Psychiatric disorders have been demonstrated to have familial patterns and some have a very high degree of heritability, but they also do not follow single dominant gene inheritance.  To recap, Oldham, et al basically blew the single gene, qualitative difference between disease state and normality, single pathological mechanism out of the water for complex disorders and they did it in 1960! No philosophy or rhetoric – just good old science. At one point the authors point out that “no student of genetics” had explained the dips in the hypertension frequency graphs.

The psychiatric significance of these authors’ work occurs when Kendell (4) highlighted it 15 years later to illustrate why the single pathological mechanism as “proof” of psychiatric disease is a failure.  Hypertension is a complex polygenic disorder that all psychiatrists must concern themselves with if they are actively treating patients.  It is also a useful comparison model for the psychiatric disorders that we treat,

 the body fluids, the action of the heart, and the

 George Dawson, MD, DFAPA

 

References:

1:  US Preventive Services Task Force, Krist AH, Davidson KW, Mangione CM, Cabana M, Caughey AB, Davis EM, Donahue KE, Doubeni CA, Kubik M, Li L, Ogedegbe G, Pbert L, Silverstein M, Stevermer J, Tseng CW, Wong JB. Screening for Hypertension in Adults: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. 2021 Apr 27;325(16):1650-1656. doi: 10.1001/jama.2021.4987. PMID: 33904861.

2:  Basile JM, Bloch MJ. (2021) Overview of Hypertension in Adults. In GL Bakris, WG White, GP Forman, L Kunins, UpToDate (Accessed 4/28/2021) from:  https://www.uptodate.com/contents/overview-of-hypertension-in-adults

3:  Oldham PD, Pickering G, Fraser Roberts JA, Sowry GS. The nature of essential hypertension. Lancet. 1960 May 21;1(7134):1085-93. doi: 10.1016/s0140-6736(60)90982-x. PMID: 14428616.

4:  Kendell RE. The concept of disease and its implications for psychiatry. Br J Psychiatry. 1975 Oct;127:305-15. doi: 10.1192/bjp.127.4.305. PMID: 1182384.

5:  Breu AC, Axon RN. Acute Treatment of Hypertensive Urgency. J Hosp Med. 2018 Dec 1;13(12):860-862. doi: 10.12788/jhm.3086. Epub 2018 Oct 31. PMID: 30379139.

6:  Rossi GP, Rossitto G, Maifredini C, Barchitta A, Bettella A, Latella R, Ruzza L, Sabini B, Seccia TM. Management of hypertensive emergencies: a practical approach. Blood Press. 2021 May 8:1-12. doi: 10.1080/08037051.2021.1917983. Epub ahead of print. PMID: 33966560.

 

Graphics Credit:

The image at the top of this blog is for Shutterstock per their standard licensing agreement. I picked it based on the fact that it reminded me of a patient I saw in the emergency department when I was an intern.  He had a large left basal ganglia cerebral hemorrhage that was most likely due to sustained hypertension.


Apologies:

Editing this post was tough. For some reason my Word processer switched to Polish language and stopped automatically checking my grammar and spelling. That was compounded by the fact that I was dictating in Dragon and sound alike words that were spelled correctly were substituted.  I ended up proofing everything on my phone and just finished tonight (4/29).   

Monday, April 26, 2021

The First 25 Pages….

 

I was minding my own business on Twitter last week and noticed a slide posted with the image of the DSM-5.  It did not take too long the realize that it was not posted by anyone who had read the DSM – at least not the first 25 pages.  These pages are technically the introduction to the diagnostic section of the manual.  Important words because they summarize the process, orient the reader to the manual, and describe several important qualifiers.  That is how I was able to tell that the slide on Twitter had nothing to do with the DSM.  The statements made about it were essentially false.

The first problem is the characterization that diagnoses are “operational criteria” and that therefore it is a “fallible tool”. These are common mistakes by anyone who has not been trained in medicine and the understanding of disease states.  For simplicity, consider the definition from my physical diagnosis text from medical school:

"For several thousand years physicians have recorded observations and studies about their patients.  In the accumulating facts they have recognized patterns of disordered bodily functions and structures as well as forms of mental aberrationWhen such categories were sufficiently distinctive, they were termed diseases and given specific names. “ 

 

DeGowan and DeGowan, Bedside Diagnostic Examination. 1976, p 1

 

The introduction notes that the precursor to the American Psychiatric Association (APA) published the precursor to the DSM back in 1844.  Even before that, the description of psychiatric disorders stretches back for thousands of years. The above definition notes the importance of patterns that are consistent over time.  A detailed description of these patterns and those evolved descriptions is how all of medicine has advanced.  The other important aspect of these descriptions is that they are sufficiently descriptive.  In the most basic analysis, the DSM is the standard way that physicians have indexed diseases and medical problems from the beginning.  The idea that it is merely operational criteria” as in arbitrary routine measurement is far from accurate. The introduction is very clear that a diagnosis is not a checklist of symptoms and that a formulation is required.



The fact that they DSM inconveniently contains a Neurocognitive Disorders chapter and qualifiers about ruling out all other medical illnesses as causes of the presenting disorder is typically not mentioned by the discrete pathological lesion crowd.  If it is, the standard rhetoric that is applied goes something like this: "Well it is a disease it's just no longer a psychiatric disease. When real diseases are discovered they are no longer in the purview of psychiatry."  Even though psychiatrists have been diagnosing and studying these diseases for over a hundred years.

 One of the frequent mischaracterizations of medicine and psychiatry is that it operates from a biomedical model. This is confusing to a lot of people because physicians are certainly trained and interested in the molecular biology of both normal human function and all of the associated pathophysiological functions. Psychiatrists are interested in brain function in particular but also other systems that directly affect psychiatric care. Every psychiatrist has performed physical and neurological examinations at some point in their career.  Every psychiatrist has done a detailed neurological examination. Every psychiatrist has seen and read ECGs and brain imaging studies. That does not mean that psychiatrists don’t know the limitations of standard medicine when it comes to analyzing problems generated by both the brain and its associated conscious state.  If fact, psychiatrists have some of the best analyses and criticisms of these approaches. The standard biomedical model criticism is used to suggest an absurd degree of reductionism.  That is a model that no psychiatrist adheres to and the evidence is the statement in the DSM about multiple underlying causes of mental disorders.  Interestingly many of these same critiques often advocate for specific psychosocial causes of mental disorders on a global scale – a form of psychosocial reductionism.

 

There are often philosophical digressions on the nature of mental illness and whether mental illness is a disease or not.  I have written fairly extensively about that in other areas of this blog.  For the purpose of addressing the slides I will say that the lesion basis for both mental illnesses and physical illnesses was addressed from within the field in response to the pathological theories by Virchow and Koch. Interestingly, the answer to that theory was a study of hypertension:

“It was in fact the example of hypertension which finally discredited the nineteenth-century assumption that there was always a qualitative distinction between sickness and health. The demonstration by Pickering and his colleagues twenty years ago (5) that such a major cause of death and disability as this was a graded characteristic, dependent, like height and intelligence, on polygenic inheritance and shading insensibly into normality, was greeted with shock and disbelief by most of their contemporaries, and the prolonged resistance to their findings showed how deeply rooted the assumptions of Koch and Virchow had become.” (2)

Sixty years later, some academics apparently still have a hard time realizing that mental illnesses are polygenic illnesses of varying severity and a source of significant death and disability and yet there is no clear qualitative difference between illness and disease demarcated by a lesion.  We are well past the time that they should be ignored.




 Conflict of interest is also a favorite tactic of those who seek to discredit psychiatry.  The suggestion in the original slide was that both committee approaches and pharmaceutical influence were sources of corruption.  The first 25 pages describes why this is not true.  The financial limitations of committee members were significant. In the intervening 6 years since the DSM-5 was released there has been no evidence of pharmaceutical influence.  Why would there be?  Pharmaceutical companies can come up with any indication they need for medication indications. They don’t need a manual to develop a symptom list and initiate a clinical trial for that purpose.  Anyone who has actually read the manual notices that the highlights under each category stress a pluralistic approach to mental illness and no actual treatment approaches are described.  The vast majority of new pharmaceuticals are prescribed by non-psychiatrists like primary care physicians and physician extenders. In my experience, many of these prescriptions are for transient conditions that a psychiatrist would not prescribe a medication for.

 

The current reality is this.  The DSM consider mental disorders to be disorders. They don’t address the issue of what is a disease and what is not. The manual is very clear about their process and the fact that it is a work in progress. That is nothing unique to psychiatry. Diagnoses are always in a state of flux across all of medicine and that even includes diagnoses that are defined by particular lesions.  As the science of medicine advances, expect more diagnoses and large diagnostic categories like asthma, diabetes mellitus Type II, and depression to be broken up into smaller and smaller categories that will probably correlate with physiological findings.  The authors of DSM-5 are very clear that the manual is designed to be a cooperative document with both NIMH Research Domain Criteria (RDoC) for research purposes and International Classification of Diseases 11th revision (ICD-11) for administrative an epidemiological purposes.  The good news is that if you are not a psychiatrist or mental health clinician the details contained in the manual are probably not useful for you to know.  On my blog, I pointed out that even primary care physicians don’t read it, so why would anyone else?




 Psychiatrists have obvious theoretical and historical interest in the manual, but on a day to day basis it is safe to say that nobody is closely reading it except for researchers. It is very apparent that the so-called critics of psychiatry rarely do or they would not be adhering to premises that are clearly wrong at the outset. Equally disappointing is the endless stream of philosophical arguments that make similar errors. I read a paper by Jefferson (6) less than a month ago where she posits three different ways that mental disorders can be considered brain diseases. And of course the first one is Szasz’s – specifically:

 

If Szasz is right, the very idea that mental illness is an illness depends on the idea that there is independent brain pathology causing mental distress.”

 

She goes on to say that Szasz ”drew a skeptical conclusion” from his own definition of brain disease and concluded that most mental disorders were not brain diseases. I seem to be the only one that recognizes that Szasz has been wrong about a lot of things for a long time, most notably the restricted pathologically based view of any or all diseases. 

 

That doesn’t seem to prevent it from being dragged out time and time again. The realm of philosophers and antipsychiatrists is apparently the only place Szasz is never wrong. And people can say whatever they want about the DSM-5 – even if they clearly have not read the first 25 pages.

 

 

 

 

George Dawson, MD, DFAPA

 

 

 

References:

 

1:  Leonard A. The theories of Thomas Sydenham (1624-1689). J R Coll Physicians Lond. 1990 Apr;24(2):141-3. PMID: 2191117; PMCID: PMC5387565.

 

2:  Kendell RE. The concept of disease and its implications for psychiatry. Br J Psychiatry. 1975 Oct;127:305-15. doi: 10.1192/bjp.127.4.305. PMID: 1182384.

 

3:  Smith R. In search of "non-disease". BMJ. 2002 Apr 13;324(7342):883-5. doi: 10.1136/bmj.324.7342.883. PMID: 11950739; PMCID: PMC1122831.

4:  Meador CK. The art and science of nondisease. N Engl J Med. 1965 Jan 14;272:92-5. doi: 10.1056/NEJM196501142720208. PMID: 14223129.

5:  Oldham PD, Pickering G, Fraser Roberts JA, Sowry GS. The nature of essential hypertension. Lancet. 1960 May 21;1(7134):1085-93. doi: 10.1016/s0140-6736(60)90982-x. PMID: 14428616.

6:  Jefferson, A. (2021). On Mental Illness and Broken Brains. Think, 20(58), 103-112. doi:10.1017/S1477175621000099


Graphics Credit:

Slides are all made by me with appropriate referencing.  Click on any slide to enlarge.