The Irrational American Voter – Arrogance, Ignorance, or Both?

 

 “Critics are men who watch a battle from a high place then come down and shoot the survivors."  -  Ernest Hemingway

Let me preface this essay by saying that I am an expert in assessing cognition and cognitive disorders  based on my 35 years as a psychiatrist doing that specific job in acute care settings, outpatient clinics, nursing homes and other healthcare centers, guardianship and conservatorship proceedings, and contested hearings about decisional capacity.  For 15 years I ran a Geriatric Psychiatry and Memory Disorders Clinic.  I have made positive diagnoses of the various forms of dementia, detected and treated reversible forms of cognitive impairment, and corrected misdiagnoses of dementia. So, I was more than slightly taken back by all the armchair diagnosing of President Biden during the debate last Thursday. The press got (at least) – 3 days of sensational and speculative headlines. I just saw a poll today that showed an increase in the number of Americans who think “President Biden has a cognitive problem” from 35% prior to the debate to 70% after the debate.  As an expert – with no special knowledge of the President’s health status I can tell you why there is no sufficient information to make that determination.  I also have doubts about what “cognitive problem” means to the average American based on the hundreds of family conferences I have had to explain that concept.  

Just based on the debate, the President’s responses and overall presentation were suboptimal - but there are many untouched explanations.  I would describe the resulting press as excessive and discriminatory against Biden. Here are a few possible explanations:

My first thought was he was over preprepared and probably angry about having to confront a liar and a propagandist.  Let’s face it – this is the first time any Presidential debater has been forced to do this.  Trump is the first convicted felon and repetitive liar in any presidential debate.  He is good at it.  Recall how Trump made his fellow Republican primary candidates look in those debates.  Many of them were speechless and ineffective.  Trump’s propaganda style clearly makes it difficult for the media to criticize him.  He effectively neutralized the moderators who were unable to get him to answer questions.  Some in the press described him as a “ball of energy” rather than a “ball of lies”. They know that no matter what they say – Trump is repetitive and successful in wearing them down.  The best example is “The Big Lie” about how the election was stolen but there are more. He maintains lies in the face of solid evidence and even the press does not know how to handle it. They eventually acquiesce and start to treat the propaganda as fact.  During the debate he was able to not provide responses to questions while repeating his own brand of propaganda.  

Second, the cognitive task was much more demanding for Biden.  In the news leading up to the debate there was clear messaging from both camps on how they were being prepared. Trumps preparation was clearly casual and not information intensive. That was reflected exactly in his ease with repeating his overlearned propaganda, dodging solid answers to questions, and ad hominem attacks on Biden.  The Biden camp reported an intensive schedule of fact-based mock debates and attempting to answer moderators’ questions based on much more factual content.  Clearly the Trump strategy presented a markedly lower cognitive load and practically no information content to memorize.

Third, a single debate is not a marker of much – recall Barack Obama’s problematic debate from 2012 when CNN stated that Mitt Romney “trounced” Barack Obama in a debate. That is one reason Obama came out two days ago with the statement that “bad debates happen”.

Fourth, choking in a presentation even substantially should be a common experience. Public speaking is an almost universal fear. It happened to me in a memorable incident where I found myself suddenly blank and thinking about driving across Montana – as I was presenting in a pharmacology seminar in medical school.  I was about 26 years old at the time. My professor snapped me out of it by reminding me where I was and what we were doing. I was intensely prepared and sleep deprived at the time. Since then, I have found that the ability to focus and pay attention to what is happening in a presentation is inversely related to preparation intensity.  In other words – if I overprepare, I am likely to get bored with the content and will find my mind wandering in the presentation even to the point that I do not want to be there. Now, once I have the content mastered – I stop studying it and my plan is to just free associate to the bullet points.  President Biden had no bullet points.

Fifth, the reaction of the pundits has bordered on mass hysteria. Their conclusions that Biden is acutely impaired and too “feeble” has very little basis in fact. Several people including some pundits have described talking to Biden and noticing that in his face-to-face conversations there is no doubt that he is capable and mentally competent.  The fact that he seemed like his old self immediately after the debate in a Waffle House and the next day in a rally also defies the common explanation of what happened in the debate – that he is somehow irreparably impaired. I also had some interesting reactions to this when I was contacted and asked about “what they gave Biden after the debate that brought him back to normal.”  To my knowledge there is nothing.  Memantine was suggested to me, but as a physician who has prescribed this medication for cognitive problems the results are far from impressive. The real question is whether he took anything for cold symptoms before the debate.  Typical medications used have clear cognitive side effects. 

Sixth, time of day – the debate started at 9 PM and went to 10:30 PM Eastern time.  Circadian rhythms are important.  Drawing on my own experience I would never schedule a presentation or a lecture in the morning.  I am not a morning person and that is probably the main reason I did not elect to go into a surgical specialty.  I could not imagine trying to concentrate intensely in the early morning hours. The later in the day the better. I don’t know Biden’s typical schedule but speculate it is loaded in the mornings rather than evenings.

Seventh, Biden’s longstanding articulation disorder.  He has never tried to cover it up. It is a life long problem with no cure, but he has discovered some management strategies. It is probably worsened by stress and changes in voice quality from a recent cold.

Eighth, the pervasive ageism bias has never been more real.  The next day Biden observed that he doesn’t walk, talk, or debate like he did when he was a young man but he is still competent to do the job. His record of accomplishments in the face of an obstructionist party and their Supreme Court - backs him up.

If anything, the debate has taken the focus off Trump’s severe deficiencies.  There were several attempts to fact check the candidates and it was clear Trump had 3 to 4 times as many inaccurate statements.  Some were obvious like the stolen election and infanticide propaganda.  Like all propagandists – repetition seems to work on an unknowing or willfully ignorant public. Apparently, Mussolini was such a skillful propagandist that some of what he said is still believed as accurate today.  In this case the focus on Biden has basically given Trump and the MAGA GOP a free pass and they have been emboldened to the point of suggesting the 25^th Amendment be invoked against Biden based on a 90-minute television broadcast.

Rather than provide another point-by-point contrast between the candidates like I have done in the past there is a simple thought experiment that involves common sense thinking that can be applied. It is not based on wishful thinking or speculation.  It involves looking at the Presidency like a job application. Anyone who has ever applied for a job knows that you need to get recommendations from previous employers, supervisors, and in some cases co-workers.  The Presidency is interesting from this perspective because – all the coworkers are hand selected by the President himself.   Of the 15 cabinet level positions in the Trump administration only 6 people endorse him for re-election.  Eleven do not.  That number does not add up to 15 because of the turnover in the Trump administration and there are probably more people that I missed.  In addition, the most recent same party President George W. Bush and 2 of his 3 Chiefs of Staff, and a National Security Advisor do not endorse Trump in some cases criticizing him with the harshest possible language.  I am not aware of a single Biden staffer who has not endorsed him and President Obama came out with a statement of his support after the debate.

Although a direct comparison of Trump versus Biden is not possible on Cabinet level endorsements because of the lack of a survey of the Biden cabinet – the Trump results are striking based on the level of vehement criticism and what they say about the former President’s intelligence, inquisitiveness, and character.  A direct comparison across multiple dimensions is possible in the survey that President Biden described during the debate.  Presidential scholars rank Presidents across a number of dimensions and in that process, Biden ranks number 14 and Trump is dead last at number 45. Refer to the link for the specifics and outside validation.  The survey has received no coverage post debate relative to President Biden’s performance – even though it is an acknowledgement of his administrations’ accomplishments and a stark contrast to Trump’s rhetoric about how Biden has “destroyed” the country (he used the word destroy 22 times) and he is the “worst” President – (he used the word worst 22 times).  That contrast alone reveals Trump’s strategy.

That is my analysis of the debate from the perspective of a physician who has done thousands of cognitive and decisional capacity examinations.  To be clear, I have no way of knowing whether my suggestions are accurate.  I have not examined either candidate or their medical records. But I know that it takes a lot more to determine a person’s cognitive capacity than what we saw in that debate. The most straightforward solution would be to have each candidate take a standard assessment of their cognitive status and release the results to the public – but politics rarely takes a rational approach.  In the meantime, it is best to avoid the assessments of partisan politicians and party members, comedians, and gossip show pundits.  

This is not a laughing or pitiable matter.

 

George Dawson, MD, DFAPA

 

References:

1:  Nicholas P, Liebowitz M.  Dozens served in Trump’s Cabinet. Four say he should be re-elected.  NBC News July 30, 2023 https://www.nbcnews.com/politics/donald-trump/trump-cabinet-endorsements-rcna96648

2:  Joint Statement from Elections Infrastructure Government Coordinating Council & the Election Infrastructure Sector Coordinating Executive Committees.  November 12, 2020.  Accessed July 1, 2024  https://www.cisa.gov/news-events/news/joint-statement-elections-infrastructure-government-coordinating-council-election

This was known within days of the 2020 election. It is still not accepted by former President Trump and MAGA Republicans:

“The November 3rd election was the most secure in American history. Right now, across the country, election officials are reviewing and double checking the entire election process prior to finalizing the result.

“When states have close elections, many will recount ballots. All of the states with close results in the 2020 presidential race have paper records of each vote, allowing the ability to go back and count each ballot if necessary. This is an added benefit for security and resilience. This process allows for the identification and correction of any mistakes or errors. There is no evidence that any voting system deleted or lost votes, changed votes, or was in any way compromised."

3:  Presidential Greatness Project - see rankings at this site.  Biden #14  Trump #45   

No mention of this comment by Biden or the survey by any of the press.

Graphics Credit:  

Wikimedia Commons - click on photo for full credits and Creative Commons License

Disclaimer: 

As previously noted I am not now and have never been a member of any political party in the United States.  At the same time, it is clear to me that the Republican party, their Presidential candidate Donald Trump, and their partisan Supreme Court are an unprecedented danger to the United States that I have known all of my life and that they should be defeated. It is also clear that they have a level of organization that resulted in political advantages over the opposition and that their rhetorical strategy is to blame the opposition for what they in fact are doing.   

Classification in Biology, Medicine, and Psychiatry

 

Classification in Biology, Medicine, and Psychiatry

I was a double major in college – biology and chemistry. Anyone with similar experience who has done fieldwork in zoology, botany, or associated systems disciplines like ecology is aware of various forms of biological classification. I spent months doing population surveys of plants, aquatic invertebrates, and plankton in undergrad courses and working on water quality surveys for the southern tributaries of Lake Superior.  In the winter, a friend and I would go out on the ice in various locations, chop a hole in the ice, and pump about 80 gallons water through a plankton net – and then carefully take that concentrated sample back to the lab and count plankton species under a microscope. It was painstaking work – but the payoff was a much greater knowledge of the life forms around you.  The lakes, streams, and rivers, and even the ground you were standing on is teeming with life.  Hundreds of species that were unknown until you took those courses and learned how to collect and classify them.

All of that classification was done using a Linnean binary classification system – genus followed by species. As an example, Loblolly pine is Pinus taeda.  Douglas fir is Pseudotsuga menziesii. The Douglas fir example is given because it is not a true fir tree (genus Abies) despite the common name.  The difference is based on morphological characteristics although the entire genome was characterized in 2017. Both the common and scientific names illustrate how species are named.  The common name was after David Douglas a Scottish botanist who described it and the species name after Archibald Menzies – a Scottish physician and naturalist.

Other physicians have been involved in the taxonomy of both human diseases and biological species most notably Carl Linnaeus (1707-1778) – a Swedish physician who is credited with founding the binomial nomenclature used in all modern taxonomy.  He also recognized the necessity of organizing illnesses so that physicians could know they were discussing similar problems. By 1746 he had organized them into nine classes – critici, phlogistici, doloritici, mentales, privatii, spastici, deformans, evacuatorii, and chrirurgia.  Linnaeus was trained as a physician and got his doctorate degree in 1735, but worked as a physician intermittently and for a short period of time until 1741 when he became a professor of botany and theoretical medicine.  

Linnaeus also focused on a species diagnosis rather than a description, meaning features that could clearly distinguish one taxon from another. He went as far as saying the diagnosis should not exceed 12 words and should include previous references and diagrams (6). According to the same reference, the concept of species diagnosis is included in modern nomenclature for species as: “a statement of that which in the opinion of its author distinguishes the taxon from others.” (p. 1090).

Linnaeus taught medical students a course in the diagnosis of disease and in 1759 published a book - Genera Morborum (Varieties of Disease).  He described 11 classes of disorders, 37 orders and 327 genera.  Mental disorders (Mentales) were divided into 3 orders and 25 genera (7). Inspecting the list from that reference suggests that delirium, mania, melancholia, hypochondriasis, anxiety, sleep, and appetitive disorders were all included.  Vertigo was also included and today is considered a neurological or otolaryngological diagnosis.  The overall tenor of reference 7 is that the various systems devised by 17^th and 18^th century physicians would never attain the level of certainty as the biological taxonomy used in natural history that we now know is also controversial.

That brings me back to the problem of biological classification – specifically speciation. That has been a predominate area of study in biology since Darwin and it is not without controversy despite the broad use of these methods in all of biology and science. What is equally interesting is that as far as I know there have been no direct comparisons to medicine and psychiatry.

Let me start by touching on the controversies of speciation from a biological standpoint.  I qualify these remarks by saying my training was at the undergraduate level and all of what I say here is based on recent readings.  I am very interested in hearing from professional biologists on this topic and so far have not been able to get any email responses. My overriding hypotheses are that the same mechanisms leading to speciation controversy in biology may be responsible for classification controversy in medicine and psychiatry.

Coyne and Orr (1) break down speciation into three phases.  The first phase began with Darwin and they point out that he had more to say about changes within species than the origin of new species.  Natural selection was seen as the most important force. The second phase began in about 1935 and was also known as the Modern Synthesis.   It was also marked by a critique of the species concept by Dobzhansky a noted evolutionary biologist.  Reproductive isolating mechanisms were stressed as a necessary cause of speciation. Ernst Mayr another noted evolutionary biologist came up with the biological species concept (BSC).  He defined species as interbreeding populations that are reproductively and geographically isolated from one another.  The third phase started in the 1980s. Coyne and Orr suggest that “more work on speciation has been performed in the past two decades than the entire period from 1859 to1980.”   They speculate that this explosion of work was due to several factors including the new tools of molecular genetics, more extensive use of mathematical models, a new emphasis on ecology, and a use of comparative studies.  The old hypotheses about speciation were re-examined and many new concepts were introduced (in addition to the BSC).  They list nine possibilities grouped as based on interbreeding, genetic or phenotype cohesion, evolutionary cohesion, and evolutionary history (p. 27).

Coyne and Orr described how the species concept was validated over the years.  First, arguments from common sense.  That is that anyone can see clusters of species and recognize they are real. This same phenomenon occurs with physical and psychiatric illnesses.  A second stronger argument is that there is concordance between folk and scientific species.  In this case researchers will look at the species in a given area and see if it is separated out and recognized by local people as being a unique cluster of traits.  That has also been referred to as folk taxonomy.  The concordance is typically high, and I suggest that the same type of concordance experiment is not only possible in medicine – it may have been done using the disease concept (2,3). And finally statistical identification of clusters. This has been done with both medical and psychiatric diagnoses to examine diagnostic features and also to determine if they separate different clusters adequately enough from one another.

The authors carefully explain the exceptions to the various species concept and settle on their own version of the BSC as the more viable one. But even the modern-day species concept is a problem because it does not clearly define all cases.  Several authors refer to it as the “species problem” and there is ongoing controversy in the literature. At the extreme there have been suggestions that the idea of species stems from a limitation of human cognition (we must lump things into categories) or there is a biological continuum that we are marking up arbitrarily.  Any reader of this blog realizes that these are frequent arguments made against psychiatric diagnoses and by extension other complex polygenic medical conditions.  Keep in mind that as far as I know all biology majors working on taxonomy in the past 50 years use the same binary system of classification that I used in college.

To their credit the authors propose how the species concept is useful and they come up with the following observation most biologists want an operational classifier that allows for systematic classification, describes what is seen in nature, helps develop an understanding about how things occur in nature, is consistent with evolutionary history, and applies to most organisms. In other words, it is not very different from what physicians expect diagnostic classifiers to do.  They realize that these are imperfect complex, multidimensional classifiers that are nonetheless useful for daily work and can be fine-tuned for improvements in the individual case.

That is what I am working on so far. I think I have demonstrated how biological classification even using all available methods and directly observable data is difficult if not impossible in many cases. The same can be said about medical diagnoses. That is because both the medical diagnoses and binary species designations are complex, multidimensional variables rather than basic physical structures. It does not mean that groupings in biology do not exist.  The key questions for my additional focus will be on the underlying mechanisms.  I have already described stochastics as a basic biological mechanism introducing some degree of uncertainty into biological systems – but I am sure there are many more.  In this era of proposed alternate diagnostic systems for mental disorders (Research Domain Criteria (RDoC), The Hierarchical Taxonomy Of Psychopathology (HiTOP), etc) – my reading so far suggests that there has been very little input from biological sciences. In most cases it seems like just a reshuffling of existing theory and measurement. My hypothesis going forward is that biological theory has a lot more to offer.

 

George Dawson, MD, DFAPA

 

References:

 

1:  Coyne JA, Orr HA.  Speciation.  Sunderland, MA Sinauer and Associates, 2004: 1-82.

2:   Tikkinen KA, Leinonen JS, Guyatt GH, Ebrahim S, Järvinen TL. What is a disease? Perspectives of the public, health professionals and legislators. BMJ open. 2012 Jan 1;2(6):e001632.

3:  Tikkinen KAO, Rutanen J, Frances A, Perry BL, Dennis BB, Agarwal A, Maqbool A, Ebrahim S, Leinonen JS, Järvinen TLN, Guyatt GH. Public, health professional and legislator perspectives on the concept of psychiatric disease: a population-based survey. BMJ Open. 2019 Jun 4;9(6):e024265. doi: 10.1136/bmjopen-2018-024265. PMID: 31167856; PMCID: PMC6561450.

4:  Hey J.  Genes, categories, and species. NY, NY. Oxford University Press, 2001.

5:  Broberg G.  The man who organized nature.  Princeton, NJ. Princeton University Press, 2023; p. 221.

6:  Renner SS. A Return to Linnaeus's Focus on Diagnosis, Not Description: The Use of DNA Characters in the Formal Naming of Species. Syst Biol. 2016 Nov;65(6):1085-1095. doi: 10.1093/sysbio/syw032. Epub 2016 May 4. PMID: 27146045.

7: Munsche H, Whitaker HA. Eighteenth century classification of mental illness: Linnaeus, de Sauvages, Vogel, and Cullen. Cogn Behav Neurol. 2012 Dec;25(4):224-39. doi: 10.1097/WNN.0b013e31827de594. PMID: 23277141.

 

Graphics Credit:

Stonefly drawing by Carpenter, George H. (George Herbert), 1865-1939.  Public domain per Wikimedia Commons.  Genus is Plecoptera and it was one of the many species I studied in freshwater streams of Wisconsin and Michigan as an undergrad.  Click on the graphic for details. 

Irrational American Gun Landscape Gets Worse….

The Supreme Court voted 6-3 to lift the ban on bump stocks yesterday (on June 14, 2024). The bump stock is a device that allows a shooter to depress the trigger of a semiautomatic rifle once.  After the initial firing the recoil energy of the firearm is used to bring the trigger back against the trigger finger for repeated firing without a subsequent trigger pull.  The result is a very high rate of fire with various quotes of 800 rounds per minute.  The limiting factor is rounds in the magazine and a standard magazine is 30 rounds with some states having lower limits or no limits.  

The majority decision was done by the Republican appointed justices (Roberts, Alito, Gorsuch, Kavanaugh, and Barrett), who used a series of rationalizations to show that in their opinion the bump stock does not convert a semiautomatic weapon to a machine gun as defined by the National Firearms Act of 1934.  Note that the majority opinion uses graphics (Figures 1-6) from the Firearms Policy Foundation - an organization that fights gun control laws (see reference 2 and their web site).  The dissenting opinion by Justice Sotomayor in the final few pages points out the inconsistencies in the majority opinion.  

Both court opinions include the precipitant for the bump stock ban – a 2017 Las Vegas shooting where the perpetrator was able to fire over 1,058 rounds from a hotel room into a crowd at a music festival killing 60 people and wounding 413.  An additional 454 people were injured in the ensuing panic. The gunfire occurred from 10:05 to 10:15 PM.  It is the deadliest mass shooting in the country that holds the record for mass shootings.  From the perspective of bump stocks, the Las Vegas shooter used 14 AR-15 (.223 cal) semiautomatic rifles and 8 AR-10 (.308 cal) semiautomatic rifles.  All of the AR-15s were fitted with bump stocks and 100 round magazines.  None of the AR-10s were fitted with bump stocks and 5 of 8 had 25 round magazines.  The remaining three AR-10s had no magazines. The AR-15s had a potential capacity of  1400 rounds that could have been discharged with a bump stock. The relevant factors from this list is that magazine capacity rather than firing rate is the major limiting factor in the total number of rounds that can be discharged and the shooter overcame that limitation by using more firearms with bump stocks. Only 15 states ban or restrict large capacity magazines.

There are various opinions in the media about how a bump stock ban originated in the Trump administration. The politics is interesting because the precipitating event was so egregious that the National Rifle Association supported restrictions on bump stocks.  I can find no action by the Trump administration other than encouraging the Bureau of Alcohol, Tobacco, and Firearms (ATF) to consider rule changes and in fact this report suggests there was a memo circulated with the usual “guns don’t kill people” message.  The Supreme Court refers to the ATF rule changes but also makes one reference to Trump.  Unless I missed something it seems clear that he did very little on the issue.

At the end of the day – we have a typical party line vote supporting gun extremism.  I don’t care who you are – the only reason you need a bump stock is to kill large numbers of people.  A bump stock is not useful for hunting or target shooting.  It converts a weapon that is already a military weapon (semi-automatic rifle) to what is essentially a fully automatic rifle. Justice Sotomayor’s opinion also includes the original reason for the machine gun ban and that was to keep these weapons out of the hands of gangsters.  Two of the typical gun extremist arguments against even minimal forms of gun control are:  “We already have enough gun laws on the books and they are not enforced” and “If we have more gun control laws only the criminals will have guns.”  They make these arguments while continuing to deregulate guns, make gun regulations harder to enforce, and make guns even more widely accessible either by Republican legislators or judges.

A second development on firearms was a recently released report by the CDC on the accessibility of firearms by children.  This is a timely study because of the April 2024 Michigan court case against a couple whose son shot and killed 4 students at his high school.  In that case the couple was found guilty of involuntary manslaughter and sentenced to 10 years in prison because their son used an unsecure handgun and they did not attend to behavior suggesting he could become violent. At the time of the shooting Michigan did not have a statute about securing firearms at home and that law was passed during the first prosecution of the parents. It was widely hailed as a warning to parents about securing firearms at home.

The CDC report was based on a Behavioral Risk Factor Surveillance System module administered in 8 states (AK, CA, MN NV, NM, NC, OH, and OK)  in 2021–2022.  The survey was administered by land line telephone calls. The nonresponse rate ranged from 3.5% to 12.8% by state.  The prevalence of firearms kept “in or around the home” was 18.4% (CA) to 50.6% (AK).  The general figure from Gallup is in the high 40%.  In 19.5% (MN) to 43.8% (NC) the firearm was stored loaded. Half of those reporting storing a loaded firearm said it was unlocked.  25.2% (OH) to 41.4% (AK) of those reporting storing an unlocked loaded firearm also reported children less than the age of 17 in the home.  For adults 65 years of age or older 58.5% (NM) to 72.5% (OK) of those with firearms had them stored unlocked.  The authors list the usual limitations of telephone self-report surveys but do not comment on cultural or political factors like the belief of some gun owners that the government is coming for their guns.  

The authors conclude that unlocked firearms may place children and other vulnerable populations at risk.  There is a higher suicide risk in the elderly.  It also illustrates how common the scenario is that led to the conviction of the parents for their son being a mass shooter. A secondary consideration of those convictions was a warning to parents that firearms at home need to be secured to prevent them from similar risks. As I commented at the time, that is a very inefficient approach to a problem that could be addressed at the population wide level. It is in effect, one political party putting parents at risk to continue saturating the population with firearms. And now we know it may be  about four in ten parents who store unlocked, loaded firearms, with children in the home.

To me, mass shootings are a function of:

- mass availability of high-capacity and rapid-fire firearms - both rifles and handguns

- gun extremism translated into effects at every level

- cultural effects - the disgruntled employee/student/etc as mass shooter has been an American meme for 50 years...

The Republican Party and their judicial appointees essentially control two of those three variables.  They are a party with no good ideas but they know how to get votes by stimulating excessive emotion around issues like firearms and abortion.  Their current approach to firearms is to place large part of the population at chronic risk with an arbitrary interpretation of the Second Amendment that they think that they can use to get votes. The basis for their gun extremist view, including the current Supreme Court decision is based on false premises rather than rational thought or legal precedent.  Americans generally don’t expect much from political parties and now they can expect the same from a highly partisan Supreme Court.    

George Dawson, MD, DFAPA

 

Supplementary:

I frequently talk about gun extremism on this blog and decided to attach a checklist of what I consider gun extremism to be.  Basically it is a marked divergence with common sense gun laws from the 1970s and earlier (see Tombstone ordinance from 1881). From a political standpoint it is clearly a political maneuver to excite and agitate people and get them to vote for a particular political party.  Like all of the so-called hot button issues it is an exercise in rhetoric and conspiracy theories that has unfortunately led to historic levels of gun violence in the US when compared with high income and low and medium income countries around the world.    

 

Gun extremism checklist:

☐  Advance “stand your ground” and “castle doctrine” laws.

☐  Eliminate bans on handguns

☐  Eliminate bans on assault weapons

☐  Minimize the characterization of “assault weapons” or military style weapons because they are not fully automatic weapons

☐  Eliminate bans on large capacity magazines

☐  Eliminate waiting periods

☐  Eliminate bans on public carry of guns

☐  Eliminate the need for permits to purchase handguns and/or carry them openly or as concealed weapons

☐  Eliminate gun-free locations (ie. places of worship, public transportation, healthcare facilities, public buildings)

☐  Eliminate bans on self-manufacturing of firearms

☐  Eliminate laws on age limits to firearm purchase and possession

☐  Eliminate laws on age limits for handgun and ammunition purchase

☐  Eliminate bans on gun accessories like bump stocks and pistol grip extensions

☐  Eliminate laws on “cannot issue” firearms to certain purchasers

☐  Eliminate gun purchase bans for perpetrators of domestic violence

☐  Eliminate gun purchase bans for convicted felons

References:

1:  Friar NW, Merrill-Francis M, Parker EM, Siordia C, Simon TR. Firearm Storage Behaviors — Behavioral Risk Factor Surveillance System, Eight States, 2021–2022. MMWR Morb Mortal Wkly Rep 2024;73:523–528. DOI: http://dx.doi.org/10.15585/mmwr.mm7323a1

2:  Lithwick D, Stern MJ. The Group Helping the Supreme Court Rewrite America’s Gun Laws Is Worse Than the NRA.  Slate June 15, 2024.  https://slate.com/news-and-politics/2024/06/supreme-court-nra-gun-laws-bump-stocks.html

3:  McClellan C, Tekin E. Stand your ground laws, homicides, and injuries. Journal of human resources. 2017 Jul 1;52(3):621-53.

4:  Rosenthal L. The limits of Second Amendment originalism and the constitutional case for gun control. Wash. UL Rev.. 2014;92:1187.

5:  Rowh A, Zwald M, Fowler K, Jack S, Siordia C, Walters J. Emergency Medical Services Encounters for Firearm Injuries — 858 Counties, United States, January 2019–September 2023. MMWR Morb Mortal Wkly Rep 2024;73:551–557. DOI: http://dx.doi.org/10.15585/mmwr.mm7324a3

6:  Andrade EG, Hoofnagle MH, Kaufman E, Seamon MJ, Pah AR, Morrison CN. Firearm laws and illegal firearm flow between US states. J Trauma Acute Care Surg. 2020 Jun;88(6):752-759. doi: 10.1097/TA.0000000000002642. PMID: 32102044; PMCID: PMC7799862.

"States with stricter firearm legislation are negatively impacted by states with weaker regulations, as crime guns flow from out-of-state."

 

Graphics Credit:

From Wikimedia Commons per the posted Creative Commons licensing agreement. Click on the graphic for all details including author, color coding, and specific CC license.

Philosophy of psychiatry: rhetoric or reality?

 

“If you laid all philosophers end-to-end it would be a good thing.”  Anonymous philosopher lecturing medical students somewhere in the Midwest in the 1980s. 

 

This post is a partial commentary on a paper about the philosophy of psychiatry (1) that was recently published.  Since I am not a philosopher and do not aspire to be one – I thank the authors for commenting on what they believe the key issues and limitations are. Over the years I have written about philosophical conjecture about psychiatry and consider much of it to be serious overreach. This paper will allow me to make some general observations.  The authors in this case have all published previous work on the subject and given the number of co-authors this is considered a state-of-the art review.  The review is open access and can be read at the link in the reference.

In their introduction the authors – consider metaphysical, epistemological, and ethical issues to be critical at the grey zone between medicine and philosophy.  They mention Karl Jaspers as a seminal figure in the field but emphasize their focus in the paper will be on conceptual competence defined as: “the transformative awareness of the ways by which background conceptual assumptions held by clinicians, patients, and society influence and shape aspects of clinical care” (2).  To their credit they explicitly comment on controversies about what the parameters of good philosophy are and whether progress is made over time.

Their first point is on the boundaries of disorder.  They make the usual observations about Kraepelinian and neo-Kraepelinian and conclude that “neo-Kraepelinians (NKs) claimed that precisely defined diagnostic criteria could be used to discover the specific biological causes of psychiatric syndromes and establish psychiatry as a branch of medicine.”  There is plenty of evidence that the NKs were much more sophisticated than that.  From one of their references (3): 

“The medical model is not based on any assumptions about etiology. It can accept social and psychological causes as well as physical and chemical events.  It can accept single causes or multiple causes.  It can even be applied when the etiology is unknown as in many clinical investigations.”

Guze specifies in several places that the diagnosis is for describing what is known about the patient and treatment planning. He suggests that medicine and psychiatry may evolve to provide more information on pathophysiology and testing but does not link it to diagnostic criteria apart from how it might be studied. He does not suggest that biological causes are necessary to establish psychiatry as a branch of medicine – his entire monograph is about why psychiatry is already a branch of medicine.

The next transition is to Insel and the RDoC.  The criticism seems to be that Insel was criticizing biological psychiatry but I doubt that any biological psychiatrist would see translational neuroscience as being inconsistent with a brain and biological centric psychiatry. The field is described as “lurching from one model to another”.  Excluding homosexuality as a diagnosis is given as a notable example of diagnostic controversy rather than psychiatry (specifically Spitzer) getting it right and leading society in general by about 40 years.  There are still plenty of people who have not caught up.

The first main section of their paper is the nature of mental illnesses.  They define strong naturalism as the factual and value free description of a disorder like what occurs in the natural sciences. They equate biological psychiatry with neurobiological dysfunction – even though those psychiatrists clearly had a much more sophisticated view of psychopathology.  I have quoted their reference to Guze above – here is an additional quote from prominent biological psychiatrists of the 20^th century:

“It should be emphasized…that the demonstration of…[a catecholamine] abnormality would not necessarily imply a genetic or constitutional, rather than an environmental or psychological, etiology of depression…it is equally conceivable that early experiences of the infant or child may cause enduring biochemical changes and that these may predispose some individuals to depressions in adulthood…[and] any comprehensive formulation of the physiology of affective state will have to include many other concomitant biochemical, physiological, and psychological factors.” (4)

That sounds like pluralism rather than naturalism to me.  There are several additional factors that suggest that the idea of strong naturalism is an exaggeration of the position of late 20^th century biological psychiatrists.  Some of those factors include: the concept of heterogeneity in diagnostic categories was widely known at the time, endophenotyping was introduced in 1966 as a purely biological concept (5) that was later applied to medicine and psychiatry (6).  Clinical trialists were certainly aware of heterogeneity and significant problems with recruiting patients into studies based on severity and placebo response.  The general comparison to medical conditions where a significant portion were idiopathic and had speculative pathogenesis and to this day are still diagnosed based on clinical description is an additional factor.  Any intern on medicine or surgery knows pathophysiology and the suggested mechanism of action of medications is typically speculative and no two patients with the same diagnosis are exactly alike.  A key concept in training is that physicians are required to recognize that pattern and make the necessary adaptations.

The authors introduce the definition of strong normativism as basically “no natural, objectively describable set of biological processes that we can characterize as “dysfunctional”, and hence disorder attributions are thoroughly value-laden.”  They do not elaborate – but this definition is clearly counter to the experience of any physician who has treated life threatening or severe illnesses.

Szasz is introduced at that point because of his suggestion that mental illnesses do not exist but rather represent “judgments of deviance based on sociocultural norms”.  They suggest that he is both a strong normativist and a strong naturalist rather than just being wrong.  Szasz’s philosophy (if that is what it was) fails several tests, but for the purpose of this post is probably the best example of controlling the premise rhetoric to prove a point.  The Szasz definition of disease as actual observable pathology allows him to trivialize any condition not meeting that criterion (and there are probably more outside of psychiatry than within) and call it a value judgment.  That is not consistent with diagnostic systems present before him or what historical neuropathologists thought (7).

What follows is a section on the naturalist-normativist debate including a table of the contrasting points. The basic problem with this dichotomy is that the normativist position as described by the authors is such a caricature when compared with medical and psychiatric training that it really cannot be seen as a viable position by anyone but Szasz.  They produce a couple of examples of hybrid positions as though they have never been considered in the past.  The description of Wakefield’s suggestion that dysfunction that is harmful to the individual is required for disorder, but since depression is an evolutionary response to adversity it is not dysfunction.  That ignores empirical research that suggests that it can be both as well as the problems associated with speculation in evolutionary psychology. The discussion of values in the normative model leaves out a lot and ignores psychiatric training. If the goal is to inform psychiatric practice by this kind of debate there are better ways to go. Psychiatrists walk into the room with a patient and their goal is to understand that patient well and treat that patient well. That involves communication skill, developing a therapeutic alliance, therapeutic neutrality, and providing the patient with enough information so that they can provide informed consent.  That interaction is both scientifically and professionally informed.

The next concept the authors discuss is essentialism or the idea that naturally occurring kinds have an evident essence. They acknowledge that when it comes to medical disorders straightforward classification is generally problematic but for some reason it is more problematic for psychiatry. They suggest that:

“If psychiatric classifications such as the DSM and the ICD were demarcating natural kinds, we would expect each diagnosis to correspond to an entity that exists in the structure of the world, independent of human interests.”

That quote misses the mark at a couple of levels.  First, a classification system is really not a diagnosis. It is more of a hypothesis and general locator (8). The diagnosis takes additional information including some of the validators that they minimize in this section. Second, in looking at these features it is obvious that many of the big ones – like mania “exist in the world independent of human interests.”  They have after all been described since ancient times across multiple diagnostic systems – long before there were psychiatrists.  The same is true of melancholia and several other disorders. Granted – there was no DSM back then but I cannot think of better evidence that there are natural kinds by this definition that have been updated. Third, it should be obvious that many disorders are clearly there for research purposes and this is evidenced by the fact that only about 50% of the diagnoses are used on a clinical basis and many psychiatrists attest to the fact that they doubt a single case of specific disorders exist (9,10).  Finally, essentialism in biology became a casualty of evolution.  Prior to Darwin, Linnaeus suggested that species were distinct and unchanging entities created by God.  That is an essentialist position. Evolutionary theory changed all of that because species change based on individual variation and new species occur (11). 

Whenever I read about the philosophical concepts behind what constitutes psychiatric illness and classification – I am always left considering why philosophy is prioritized over biology.  Medicine is after all firmly rooted in human biology.  There is no better evidence than the biochemistry, anatomy, and physiology courses taken in medical school basic science.  Biology provides a framework for both hierarchical organization as well as individual classification of diseases including mental disorders (see lead graphic). Modern taxonomic classifications of both date back to the mid -18^th century.

A critical question is whether biological classification has advanced to the point where it is not controversial and purely scientific.  The short answer is no. There is ample evidence that the taxonomy of living organisms is problematic and there are ongoing controversies over the past 50 years.  Although species is a fundamental organizational concept in the field of biology that has not prevented the proliferation of up to 24 different species concepts in recent times (12).  Why would medicine be expected to have a more clearly defined classification system than biology?

Rather than comment on the remaining sections that I am sure that I also have problems with – I am going to introduce and idea that I have not seen written about anywhere.  If you read this an think I am wrong please let me know and send references.  That idea is the application of biological theory to psychiatry. Medicine and psychiatry are after all firmly based in human biology and human biology is a subset of biology in general.  When you attend medical school and complete all the basic science training this basic fact is explicit. There is not much discussion of other organisms unless they happen to be pathogens.  There is also not much discussion of the levels of organization in human biology and the implications that has for medicine.

What does the tremendous complexity of biology have to do with psychiatry? It is evident that various mechanisms make it very difficult to classify biological organisms.  That has resulted in many species concepts and that array of concepts has complicate taxonomy at a time when the biodiversity of the planet remains inadequately characterized. Psychiatry is operating only in one species by the same mechanisms that complicate biology at all levels also complicate biology.  To the purpose of this essay the critical question is why they currently seem less important than the increasing presence of philosophy in psychiatry. Frequently the justification seems to be the old quote about “carving nature at the joints.”  Does that mean we philosophize about it and maintain endless arguments?  Or does it mean we consider that human beings and their mental disorders are based in human biology and try to make sense of it by studying biological principles.  And by biological principles – I don’t mean the typical jargon of biological psychiatry used by critics. I mean theoretical biology practiced by biologists.      

I want to touch on just two concepts from biology that have implications for psychiatric controversies.  The first are the classification systems in biology and the second is stochastics.  There are any number of authors offering descriptions about how psychiatry has evolved in the last 200 years. That generally tracing the origins back to 19^th century European schools of thought and bringing those threads forward.  The focus is generally on nosology including diagnostic systems, treatment settings, and how treatments evolved.  The brief discussion of biological classification here touches on a large literature that has been ignored by medicine and psychiatry.  In the debate of categorical versus dimensional diagnoses and the various philosophical labels a significant number of biological classifiers have been left out.

If I am correct what might have caused this significant omission? First, the focus of medicine has been description based on clinical findings.  I have used this characterization previously:

"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 aberration.  When such categories were sufficiently distinctive, they were termed diseases and given specific names. “

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

That has been the historical and primary focus of medicine. Interest in pathogenesis happened in the 19^th century but even then, there were conditions that that escaped that classification.  There has been progress there are still many conditions with no clear pathophysiology and even fewer medications where the mechanism of action is known. One of the primary reasons is that medicine has been based on reductionist biology and even though advances have been made it seems to have reached its limit. What do I mean by reductionist biology?  Simply put it means breaking down complex systems to component parts and studying those parts independently.  In current jargon it has also been referred to as a bottom-up approach.  Second – biological psychiatry is biological in the reductive scientific sense and it needs to be biological in the integrative sense. All biology is not reductive (17,18) – but much of the philosophy I have read seems to think so.  Reductive approaches have led to discrete research programs that produce highly speculative connections to psychiatric disorders. We end up with biological psychiatry as neurochemistry -> neuroendocrinology -> neuroimaging -> genomes, connectomes, proteomes, transcriptomes, metabolomes, etc without any clear underlying connection to all human biology.  Systems biology or network medicine approaches have been used on only a partial basis so far.  Third, rather than make a truly biological connection the field seems to have been sidetracked by philosophy.  Much of that philosophy has been around for 50 years or more and seems satisfied with the role of asking questions and never really providing much of an answer.  Much of the philosophy is vague and untestable.  A secondary role seems to be the criticism of psychiatry with a dependence more on political rhetoric than reality.

Conclusion:

When philosophers criticize medicine and psychiatry, they frequently use the term constructs.  From a rhetorical perspective not, all constructs are alike.  In medicine and biology there needs to be at least some real-world observable basis.  

Rather than strong arguments for philosophy in psychiatry – the authors have argued strongly. I have tried to elucidate the rhetoric involved since my observation is that is the nature of most philosophical arguments directed at psychiatry.  The curious aspect is that most people do not even consider this when reading philosophers commenting on psychiatry.  I sent one of my papers to a friend who has been a psychiatrist as long as I have and he told me that he never considered it an area for analysis. I hope that some of the comments here are useful in considering these arguments and why they should not be blindly accepted.

It seems that in all the philosophical criticism and discussion of psychiatry, van Fraassen's empirical adequacy has been ignored (16, 17).  The reasons for that may be less than obvious.  Van Frassen basically states that an empirically adequate model is just that – it is not a comment on the truth of existence or not.  There is a question of whether the model must be based on direct observation.  The criteria for mental disorders require reporting subjective states that are not directly observable. Van Fraassen’s theory includes the outcomes of experiments and isomorphic models – both of which apply to work in psychiatric nosology. The lack of comment on Van Fraasen’s approach is critical because it reflects how psychiatrists are actually trained and directly counters arguments about positivism and realism. Some references suggest that what appear to be diametrically opposed arguments in philosophy are just sustained with no resolution and that is a significant limiting factor when considering what psychiatrists need to know.           

Not all biology is reductionist and not all philosophy is useful.  Empirical adequacy and biological complexity are the future of psychiatry.

 

George Dawson, MD, DFAPA

 

References:

1:  Stein DJ, Nielsen K, Hartford A, Gagné-Julien AM, Glackin S, Friston K, Maj M, Zachar P, Aftab A. Philosophy of psychiatry: theoretical advances and clinical implications. World Psychiatry. 2024 Jun;23(2):215-232. doi: 10.1002/wps.21194. PMID: 38727058; PMCID: PMC11083904.

2:  Aftab A, Waterman GS. Conceptual competence in psychiatry: recommendations for education and training. Acad Psychiatry 2021;45:203-9.

3: Guze SB. Why psychiatry is a branch of medicine. Oxford: Oxford University Press, 1992. p. 38.

4:  Schildkraut JJ, Kety SS. Biogenic amines and emotion. Science. 1967;156 (3771):21-37.

5:  John B, Lewis KR. Chromosome variability and geographic distribution in insects. Science. 1966 May 6;152(3723):711-21. doi: 10.1126/science.152.3723.711. PMID: 17797432.

6:  McGuffin P, Farmer A, Gottesman II. Is there really a split in schizophrenia? The genetic evidence. Br J Psychiatry. 1987 May;150:581-92. doi: 10.1192/bjp.150.5.581. PMID: 3307978.

7:  Pies R.  Did Szasz Misunderstand Virchow’s Concept of disease? Psychiatric Times. Feb 21, 2024.  https://www.psychiatrictimes.com/view/did-szasz-misunderstand-virchow-s-concept-of-disease

8:  Kendler KS. The Phenomenology of Major Depression and the Representativeness and Nature of DSM Criteria. Am J Psychiatry. 2016 Aug 1;173(8):771-80. doi: 10.1176/appi.ajp.2016.15121509. Epub 2016 May 3. PMID: 27138588.

9:  Munk-Jørgensen P, Najarraq Lund M, Bertelsen A. Use of ICD-10 diagnoses in Danish psychiatric hospital-based services in 2001-2007. World Psychiatry. 2010 Oct;9(3):183-4. doi: 10.1002/j.2051-5545.2010.tb00307.x. PMID: 20975866; PMCID: PMC2948730. 

10:  Müssigbrodt H, Michels R, Malchow CP, Dilling H, Munk-Jørgensen P, Bertelsen A. Use of the ICD-10 classification in psychiatry: an international survey. Psychopathology. 2000 Mar-Apr;33(2):94-9. doi: 10.1159/000029127. PMID: 10705253

11:  Hey J.  Genes, categories, and species. NY, NY. Oxford University Press, 2001: p 60-61.

12:  De Queiroz K. Ernst Mayr and the modern concept of species. Proceedings of the National Academy of Sciences. 2005 May 3;102(suppl_1):6600-7.

13:  Mayr E. Biological classification: toward a synthesis of opposing methodologies. Science. 1981 Oct 30;214(4520):510-6. doi: 10.1126/science.214.4520.510.

14:  Mayr E. Biology is not postage stamp collecting. Interview by R. Lewin. Science. 1982 May 14;216(4547):718-20. doi: 10.1126/science.7079730. PMID: 7079730.

15:  Ho CC, Lau SK, Woo PC. Romance of the three domains: how cladistics transformed the classification of cellular organisms. Protein Cell. 2013 Sep;4(9):664-76. doi: 10.1007/s13238-013-3050-9. Epub 2013 Jul 19.

16:  Van Fraassen.  BC.  The Empirical Stance.  New Haven: Yale University Press, 2002.

17:  Monton, Bradley and Chad Mohler, "Constructive Empiricism", The Stanford Encyclopedia of Philosophy (Summer 2021 Edition), Edward N. Zalta (ed.), URL = <https://plato.stanford.edu/archives/sum2021/entries/constructive-empiricism/>.First published Wed Oct 1, 2008; substantive revision Tue Apr 13, 2021

18:  Loscalzo J, Kohane I, Barabasi AL. Human disease classification in the postgenomic era: a complex systems approach to human pathobiology. Mol Syst Biol. 2007;3:124. doi: 10.1038/msb4100163. Epub 2007 Jul 10. PMID: 17625512; PMCID: PMC1948102.

19:  Van Regenmortel MH. Reductionism and complexity in molecular biology. Scientists now have the tools to unravel biological and overcome the limitations of reductionism. EMBO Rep. 2004 Nov;5(11):1016-20. doi: 10.1038/sj.embor.7400284. PMID: 15520799; PMCID: PMC1299179.

 

Dedication:  This post is dedicated to my undergraduate biology Professors at Northland College including Lee Stadnyk, Richard Verch, John Brennan, and Mallanpali Rao. I spent many months studying the comparative anatomy and physiology of invertebrates and the taxonomy and population dynamics of sphagnum moss plant species, aquatic invertebrates, and freshwater plankton with these professors and they were the best.  I also had the pleasure of working on Loblolly Pine (Pinus taeda) and Douglas Fir (Pseudotsuga menziesii) species in Don Durzan’s lab at the Institute of Paper Chemistry. Experience in biology is a grounding in the complexity of living organisms.

Is Modern Psychiatry Too Intellectually Restrictive?

The inspiration for this post comes from my reading the history of psychiatry. That was not a particular interest of mine until I began researching threads of knowledge going back into time. Then I started to look at how American psychiatry evolved and the fact that it did not really exist at the same time psychiatry existed in Europe.  This is historically confusing in the US, where certain movements try to connect psychiatry to historical events where there are no connections.  The development of psychiatry in Europe is a complicated and interesting story.  The most striking feature is that those early psychiatrists were trained in neuroanatomy, neuropathology, neurology, and psychiatry.  Freud was a Privadozent in neuropathology.  Adolph Meyer emigrated to the US as a neuropathologist and eventually became the chairman of psychiatry at Johns Hopkins eventually influencing a significant number of American psychiatrists. 

In reading about these early psychiatrists, some authors will refer to them as neurologists even though the person in question identified as a psychiatrist (examples include Otto Binswanger ((1852–1929) and Wilhelm Griesinger (1817-1868)).  Others like von Economo (1) were designated psychiatrists and neurologists.  After graduating from medical school in 1901 von Economo spent a year working in an internal medicine clinic and over the next four years worked at various clinics in Europe with Marie, Kraepelin, Alzheimer, and Oppenheim learning psychiatry, neurology, and hypnosis. He returned to the University of Vienna in 1906 and was appointed Professor of Neurology and Psychiatry in 1921. This was an observation from his book Encephalitis Lethargica (2):

"Towards the end of 1916 the wards of the Vienna Psychiatric Clinic contained quite a number of patients with a strange variety of symptoms - cases which had apparently only one feature in common - a difficulty to fit into any known diagnostic scheme.  They had been admitted under the most varied descriptions, such as meningitis, acute disseminated sclerosis, amentia, delirium &c.  The patients all showed a slight influenza-like prodromal condition with trifling pharyngeal symptoms, a slight rise in temperature, soon followed by a variety of nervous symptoms, though generally one sign or another pointed to the midbrain as a source...."

From there von Economo goes on to describe encephalitis lethargica in great detail.  He was subsequently nominated for the Nobel Prize in Medicine four times for this work.  He also worked on neuroanatomy - where he made additional discoveries. His education and career contrasts well with current psychiatric education in the US where it seems that too little content is being spread over too many years - even more if you want to be certified in both neurology and psychiatry. He apparently got what he needed in 4 years while living in 4 different European cities.  Places like the Vienna Psychiatric Clinic also do not exist today - where the only solid criteria for admission is dangerousness and all admissions need to be medically cleared  by somebody (physician or extender) that may be oblivious to neurological and psychiatric presentations of acute illness. 

More to the point – they were probably neuropsychiatrists and that has relevance for the system of board certification in the US.  Prior to board certification most psychiatrists in the US were neuropsychiatrists and practiced neurology and psychiatry. That all changed in 1934 when the American Board of Psychiatry and Neurology (ABPN) – made the rule that all psychiatrists practicing both specialties must pass both board certification exams.

Reading the paper (3) about Bleuler was interesting because it is an easy read that emphasizes several concepts in psychiatry that just repeat if you don’t understand them.  First is the age-old debate about categorical versus dimensional diagnoses.  The author’s conclude that Bleuler supported dimensional diagnoses but it seems they are describing his process as one of detailed formulation rather than dimensions. This was rooted in his method of clinical psychiatry. I suppose a four dimension scale could be envisioned based on Bleuler’s “4 As” (see below) – but my interpretation is that he was looking for detailed medical, family, social, and developmental history.  He is described as a clinician who had close contact with patients rather than an experimentalist – that is the data he was interested in.

Second, the richness of the psychiatric landscape during Bleuler’s time cannot be denied. The psychiatrists were writing and researching across the spectrum of neurology, neuroscience, psychology, and theoretical psychiatry. There was no shortage of ideas about describing clinical phenomena or possible treatments.  Bleuler had contact with many prominent psychiatrists of his time and his opinions about some of their theories was known.

Third,  Bleuler’s approach could be considered pluralistic to use today’s jargon.  He was  clearly engaged in doing the subjective realm and individualized evaluations.  He thought that schizophrenia could be an exaggerated neurosis from psychological conflicts.  He believed that the disease process had a biological basis but he was focused on a psychological treatment.  He also did not see schizophrenia as having a uniformly deteriorating course. His thoughts about the biology of the disorder were undoubtedly affected by the facts that he was not an experimentalist, there were no useful biological treatments and despite many autopsy studies there were no good gross anatomical or histological correlates of schizophrenia.

The patterns and themes noted in this paper run throughout the history of psychiatry.  Since psychiatry became the default profession for treating severe mental illnesses, there have been hypotheses about the nature of the illnesses, how to medically evaluate them, and how to treat them. As illustrated on this blog, there are often critics outside of the field who seem to ask these questions as if no psychiatrist has ever thought about them in the past.

In many ways the intellectual landscape of turn of the century psychiatry was richer than it is today. We currently have a refined product in terms of classification, but many of the questions relevant of psychopathology and neuroscience remain open. The basic problem of biological complexity is not easily answered and it is only recently being approached.  Biological and psychotherapy options appear to have been maxed out by heterogeneity problem.  From a historical perspective, what is most alarming to me is that there has not been a synthesis of these questions and approaches to bring current psychiatrists and trainees up to speed.  Much of the time seems to be spent on the same research techniques and critiquing endless clinical trials.

At a global level, the intellectual landscape of the field seems constricted.  The board certification process has certainly been part of that as well as the general goals of standardization.  There has been an enormous effort on standardizing nomenclature at the cost of de-emphasizing psychopathology. Clinical practice has been standardized largely based on settings and administrative codes. Documentation has been standardized by the same codes and electronic health records.  Much of the documentation is essentially worthless in describing patient progress or the unique features of the individual and is essentially there to satisfy business administrators.  The training of new psychiatrists is standardized in some areas - but there are very few specifics in terms of what trainees need to see in order to be good psychiatrists.  For example, there is an apparent assumption that if you spend a month or two in a neurology clinic - you will have adequate exposure to accurately assess neurological problems presenting as psychiatric problems and make the correct triage or treatment decisions.   

 I don’t think expanding the intellectual landscape for residency programs would take much.  It will take a bit of integration.  The sanctioning bodies of medical education have made the task harder than it should be by not specifying all of the important educational topics and letting the programs each sort it out on their own.  That means residents will see certain concepts inconsistently if at all, presentations and seminars will depend on the availability, interest, and quality of the teaching staff, and even then, topics are likely to be followed too rigidly.

The first question is what exactly should that landscape be?  Residency requirements by the ACGME are surprisingly vague.  They are focused primarily on clinical experiences based on clinical populations and settings, availability of supervision, and overriding goals of excellence, motivation, and interest on the part of the teaching faculty. There are some broad technical markers of specific experiences by psychiatric subspeciality or skill (eg. psychotherapy, managing drug interactions, etc).  I know that the residency directors meet frequently and it would not surprise me to find out that there are more detailed approaches shared among them – but if that occurs, I do not know where to access it.

My suggested approach at integration would be teaching the historical controversies and concepts that are still relevant all at once.  There are several integrative papers in the literature already.  There are also still some big concepts that need formulation and discussion like the biological diversity and heterogeneity issues that run throughout all of medicine. A potential academic model for this approach already exists and I suggest it is in the Voet, Voet, and Pratt - Fundamentals of Biochemistry - 6th edition.  One of the issues that frequently arises during discussions of this nature is how much philosophy needs to be included. My reading of the literature suggests that if anything there has been an excess of philosophy being applied to psychiatry.  At times psychiatry is made to seem like psychiatrists themselves have never considered the obvious questions. Teaching residents about psychiatry and the way that psychiatrists have attempted to formulate and solve problems seems like as good a place to start as any to me.

It can start with the names in this paper.    

Pattern matching also needs to be reemphasized. The reason a psychiatrist can diagnose bipolar disorder is that they have seen many cases and many variations - not because they have read the DSM.  The same is true for all of the mimics of bipolar disorder including neurological conditions. I am concerned about the level of exposure that residents have to acute neurological problems, especially now that many inpatient neurology services have been replaced by hospitalists with neurology consultants. There is a long list of acute neurological presentations that every psychiatrist must see and diagnose in training and distance from our neurology colleagues makes that more difficult. 

 

George Dawson, MD, DFAPA

 

References:

1:  Kaya Y, Uysal H, Akkoyunlu G, Sarikcioglu L. Constantin von Economo (1876-1931) and his legacy to neuroscience. Childs Nerv Syst. 2016 Feb;32(2):217-20. doi: 10.1007/s00381-015-2647-0. Epub 2015 Feb 24. PMID: 25707481.

2:  von Economo C.  Encephalitis Lethargica.  Oxford University Press, London. 1929. page B.

3:  Heckers S. Bleuler and the neurobiology of schizophrenia. Schizophr Bull. 2011 Nov;37(6):1131-5. doi: 10.1093/schbul/sbr108. Epub 2011 Aug 26. PMID: 21873614; PMCID: PMC3196934.

Open Access <-you can read this paper

Supplementary:

I just accessed and read the following paper this morning several days after the above post.  It is an open access paper that can be read and downloaded.  It basically makes the same argument that my post makes - an integrated approach to psychiatry and neurology (and neuroscience) is preferable.  It is written from the neurology perspective and that may be why the suggested remedies fall short.  Integration between the specialties is really not possible as long as one (psychiatry) is disproportionally rationed and is under an administrative burden that divorces it from clinical reality. 

Perez DL, Keshavan MS, Scharf JM, Boes AD, Price BH. Bridging the Great Divide: What Can Neurology Learn From Psychiatry? J Neuropsychiatry Clin Neurosci. 2018 Fall;30(4):271-278. doi: 10.1176/appi.neuropsych.17100200. Epub 2018 Jun 25. PMID: 29939105; PMCID: PMC6309772.