It is always good to take an in depth look at articles in
the popular press about psychiatry – because of the clear antipsychiatry bias.
An article from the Economist was posted recently that seemed to get a positive
reception in some areas. In my
estimation that reception was not warranted. Interestingly the same principles of analyzing
rhetoric can be applied to this article as the last post on this blog about
“doing your own research.” I will use
the same concept by concept approach to examine this article that I used for
that video. At the time the article was
posted I read it for free online and I hope it is still available so that any
reader here can appreciate the full text.
The author was not listed.
1: “But her local
hospital, in Durham, England, was dismissive, suggesting she had anxiety, a
mental-health condition, and that she was probably spending too much time
watching videos on TikTok. Her mother describes the experience as “belittling”:
The author begins with a story about an autoimmune condition
with many neuropsychiatric manifestations Pediatric Autoimmune-Neuropsychiatric
Disorders Associated with Streptococcus (PANDAS). This is a condition that is known within psychiatry for at least 25 years and is covered in major psychiatric textbooks. The author proceeds to conflate the lack of a
definitive diagnosis with deficiencies in psychiatry as if it is totally unknown
in the field. It is not and the pathophysiology and neuropsychiatric
manifestations are known and taught within the field. Secondarily if I had to speculate on the
medical specialists who are most likely to see people who are told by a physician
or family member that “it’s all in your head” – they would be
psychiatrists. We tend to see more of
these people than anybody else.
2: And infections are one small piece of the puzzle. It
is increasingly clear that inflammatory disorders and metabolic conditions can
also have sizeable effects on mental health, though psychiatrists rarely look
for them. All this is symptomatic of large problems in psychiatry.
Psychiatrists have always been more interested in
inflammatory and infectious conditions affecting the brain than most other
specialists. Griesinger mentions
inflammation as a mechanism affecting brain function in his 1845 text on
psychiatry (2). It is highly likely
that in any community - psychiatrists are making more of these diagnoses than
primary care physicians because they know the manifestations and they need to
rule out physical causes of mental illnesses to make a psychiatric
diagnosis. All psychiatrists are trained
in making these diagnoses and not mistaking them for a mental illness occurring
in a healthy person or a person with chronic illnesses not affecting brain
function. The only large problem here is
the lack of knowledge about how psychiatrists are really trained.
Inflammatory disorders were used as treatments in the early
20th century. In the
pre-antibiotic era, 5-10% of asylum admissions were due to neurosyphilis and
the associated psychiatric manifestations. Some of the early treatments were
based on inducing fevers. Austrian
psychiatrist Julius Wagner-Jauregg was awarded the Nobel Prize in Medicine in
1927 for successful treatment of neurosyphilis by inoculating patients with
malaria (2). This work was replicated
and additional agents were used to induce fevers by other investigators with
similar results. In addition to the experimental results, this represented a
sea change in the general attitude of treating psychosis in asylums where a
previous biological treatment did not exist.
Subsequent innovations occurred when neuromodulation techniques were
introduced in 1932 (5) and psychopharmacology in 1952 (6).
The early focus on gross neuropathology and transition to microanatomy led to the discovery of Alzheimer's Disease in 1906 and Binswanger's Disease a form of vascular dementia in 1894. Both Alzheimer and Binswanger were considered psychiatrists - Alzheimer by his own designation and training and Binswanger was eventually appointed to head an asylum by age 30.
As far as "rarely looking for them" goes the top 4 medical conditions I diagnosed in newly seen patients were probably Type 2 diabetes mellitus, hypothyroidism, hypertension, and atrial fibrillation. Any psychiatrist practicing in the last 30 years is aware that psychiatric disorders and pharmacological treatment can be associated with metabolic syndrome and the need to monitor for and prevent that condition.
3: Chronic
conditions are poorly treated – apparently because they are not cured
(paraphrased):
This is always an interesting rhetorical sleight-of-hand. In
what other specialty is the expectation that chronic conditions will be cured?
It does not take a lot of research to show that nobody is curing most
diabetics, hypertensives, asthmatics, arthritics, or patients with a multitude
of other chronic conditions. In fact most of these patients remain symptomatic even when they are treated. These are all conditions with clear cut laboratory
tests and other disease markers. These
are all conditions where there is at least a speculative biological hypothesis
of pathophysiology. And yet – there is
no expectation of cure and in fact much more expected mortality in other specialties.
Why is psychiatry different? It is not.
4: Some people in
the profession believe that biological psychiatry will lead to better
characterizations of psychiatric problems including pathophysiology, drug
treatment, and pharmacological targets/precision psychiatry (paraphrased):
It is obvious that biological psychiatrists have been at it
for decades and much longer. The journal
Biological Psychiatry was founded in
1969 but biology has been a focus of psychiatric research dating back to mid-19th
century when attempts were made to observe brain dissection correlates with
behavior. Griesinger (2) documents
efforts by both Pinel and Esquirol to document brain abnormalities in severe
mental illnesses. In his text he documents brain diseases leading to
psychiatric care and associated organ dysfunction at autopsy in patients
identified as having severe mental illness.
In the days of asylum care before biological psychiatry,
delirious mania had a mortality rate of 75% (7). That has essentially been reduced to zero
with advances in modern biological psychiatry including electroconvulsive
therapy and psychopharmacology. There is
probably no better example of advances due to biological psychiatry occurring
over decades.
Like all other medical specialties, biological psychiatry is
an active area of research with new journals like Molecular Psychiatry (1997)
and Translational Psychiatry (2011) that are focused on the latest
innovations in biological psychiatry and potential treatment applications.
5: The DSM or the Bible
of Psychiatry does not specify pathophysiology
Any time you see that the DSM is the “Bible of psychiatry”
that is a red flag that indicates the author either lacks knowledge about the
Bible or the DSM. Here is a brief
primer on the DSM to correct some misconceptions. That primer emphasizes that the person using
it (typically for diagnostic codes used for administrative purposes) is a
trained professional and understands its limitations. Chief among those
limitations includes ruling out medical causes of psychiatric symptomatology and
understanding that it is not a guide for everyman to use for diagnosis and
treatment. Kendler (8) and others have
taken it a step further to point out that it is an index of disorders
and therefore a starting point – rather than an actual diagnostic guide. In other words, meeting criteria for a
diagnosis is not that same as having the diagnosis. This is generally true of all codified systems
of medical diagnosis. An example would
be the American College of
Rheumatology classification criteria.
There is an extensive discussion of these classification criteria
compared with diagnostic criteria and why the ACR currently endorses only the former
(9). It is basically the same discussion
that Kendler uses in describing the indexing system – that there is sufficient
heterogeneity in clinical presentations over time and geographical areas that
every case needs to be individually considered. Here is the rationale from the
leading text on systemic lupus erythematosus (SLE) (10):
“The classification criteria do not contain a complete list
of all the possible manifestations of lupus.
The manifestations of SLE often develop over a period of time, sometimes
years, making the diagnosis more difficult at initial presentation. The
diagnosis of lupus is made on clinical grounds, supported by laboratory data
and depends highly on the physician’s knowledge and experience. (author’s
emphasis)”
Despite the title, the DSM is not a guide to diagnosis or
treatment. People who do not “meet criteria” are not automatically excluded from
treatment consideration. Separate knowledge about psychopathology and diagnostic
formulation is necessary. Speaking to the author’s concern about the lack of
specific etiologies – even the skeletal classification and indexing framework
of the DSM has chapters on clear medical, toxicological, and neurological causes
of mental disorders.
The Economist dates psychiatry’s “Bible” back to
1952. That would have been the DSM-I. I encourage anyone who is interested to read
the 6 page Forward to that document. It
started initially to standardize nomenclature. Each training program was using
their own version of nomenclature as well as the military. When trained psychiatrists went out to
practice in the community – there was no standard nomenclature being used to
described similar phenomenon and the requirements of military and civilian
nomenclature were different. The secondary goal was to use this nomenclature to
collect statistics that could be used to improve the necessary infrastructure
and resources to treat these disorders.
All of this can be done without any specific reference to
pathophysiology in both psychiatry and the rest of medicine.
And here is a news flash from the DSM-5, my estimate is that 69% of all of the diagnoses listed have a clear pathophysiology or medical test equivalent to any other branch of medicine. Given the classification problems with all medical diagnoses that overall figure probably compares well with any other branch of medicine.
Whatever your take away from this post, The Economist knows very little about psychiatry and medicine. But that should not be too surprising. The tone and factual content clearly resemble much of what you see on the Internet and in the press about psychiatry. That does not make it any less wrong. If you are really interested in what is going on in the field – I would recommend reading the general literature in the field or summaries about it. The popular press – newspapers and magazines – is clearly not up to the task.
6: Attempts to
find causal mechanisms for mental illnesses have failed (paraphrased):
News flash – that is true of every other complex disease as
well as the medication used to treat them.
This post
illustrates that fact with medication used to treat multiple sclerosis. The table lists 18 FDA approved drugs – many of
which modify the course of the illness but in every case the specific mechanism
of action of the drug is unknown.
7: Genetics has
been a clinical “flop” (paraphrased):
It would probably be a good idea to get the opinion of an
expert in psychiatric genetics. The article
seems to focus on the issue of polygenic risk analysis (PRA) and those studies
generally have low effect sizes due to the number of genes studied. Any commercial assessment of a genome will
result in hundreds of these profiles – most of them for non-psychiatric
illnesses. The example given above illustrates polygenic risk scores (PRS) when
the small risk factors (both protective and potentially causative) are summed and
compared to a standard sample so that 100% is highest percentile risk in the
sample and 0% is the lowest. This is only one approach and there are major
psychiatric initiatives in this space doing ongoing research. PRA/PRS is accepted
science at this point but the widespread clinical utility is not known for
practically all polygenic disorders.
Recent examples given by Kendler (11) in his commentary on
whether psychiatric disorders are brain diseases points to the importance of
genetics in psychiatry. To this day
there are endless debates, typically by people who are not trained to be
psychiatrists that psychiatric disorders are somehow independent of brain substrate.
In other words, even though it is widely acknowledged that a brain is required
for mental life – there is no evidence at the molecular level that an
alteration in brain function causes mental illness. Contrary to The
Economist, Kendler states: “I use the most robust empirical findings in
all of psychiatry—that genetic risk factors impact causally and substantially
on liability to all major psychiatric disorders.” He quotes the recent literature illustrating
that risk variants for schizophrenia are located only in brain tissue. Similar evidence is accumulating for bipolar
disorder and major depression. This correlation of strongest known risk factors
and brain substrate location is good evidence of specific genetic effects in
the brain. Similar work is being done to identify signaling systems, proteins,
and physiological processes underlying the DSM classifiers. Once again, this is similar to the approaches being taken with all complex non-psychiatric diseases.
8: Biology is
coming, whether psychiatry is ready or not:
When I saw this caption – it seemed like a joke. Over the 40 years of my career there has been
a constant battle based on the false dichotomy of biological psychiatrists and
psychotherapy focused psychiatrists. That left out important additional
identities including medical psychiatrists, neuropsychiatrists, and community
psychiatrists. Practically all the criticism in the press has been that
psychiatrists are too biological. I could probably write a book about
this – but in this case suffice it to say that The Economist has not
done much homework. The smattering of research projects listed in the last several
paragraphs about immunology and metabolism ignores that this type of research
has been going on for decades and gradually making progress.
Every psychiatrist is trained in the biology of medicine and psychiatry - just like me. We are willing to incorporate the latest research innovations and look forward to them. Biology comes as no surprise.
George Dawson, MD, DFAPA
References:
1: “Many
mental-health conditions have bodily triggers: Psychiatrists are at long last
starting to connect the dots.: April 24,
2024. In the print edition this story is
under the general heading "Psychiatry’s blind spots". No author was listed for the online
version that I read.
2: Griesinger W: Die
Pathologie und Therapie der Psychischen Krankheiten: für Aerzte und Studirende.
(The pathology and therapy of mental illnesses, for doctors and students). Stuttgart,
Germany, Verlagvon Adolph Krabbe, 1845 https://www.deutschestextarchiv.de/book/view/griesinger_psychische_1845?p=47
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Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi:
10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PMID: 27138588.
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Ringold S, Khanna D, Neogi T, Johnson SR, Miller A, Brunner HI, Ogawa R, Felson
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10: Rudinskaya A,
Reyes-Thomas J, Lahita R. The clinical
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11: Kendler KS. Are
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PMID: 38416478.
