Psychiatry: A Closer Look

There’s a hole at the bottom of psychiatry— a foundational defect which detracts both from its credibility as mainstream medicine, and, consequently, its reliability as a medical practice. And that hole is its lack of strict adherence to scientific empiricism and its unfalsifiability.

For example, the very method of defining a mental disorder is wishy-washy to begin with. But what sets the psychiatric establishment apart from other branches of medicine is that, given that there aren’t any biomarkers, the only way of interpreting something as a psychiatric illness is via deductive reasoning:

   

1. Administer a drug. 2. Observe the effects it has on the patient. 3. Make a logical inference, based on your understanding of what that drug is doing, about what could be the root cause of the disorder. This is a blot on the very idea of scientific precision. 

Diagnostic framework of psychiatry is riddled with inconsistencies and much more error-prone than that in general medicine. This, in large part, is owing to the fact that even the typical form of a given mental disorder is often obscured by illness manifestation shaped by personality and sociocultural influences. Despite many significant advances in quantitative neuroscience, clinical practice is still based principally on a qualitative assessment of perceived symptoms—  qualitative rather than an objective empirical evidence-based evaluation. Biomedical diagnostic approach in psychiatry is vague, arbitrary and unscientific, diagnoses frequently and uncritically reported as ‘real illnesses’ are in fact made up on the basis of internally inconsistent, disordered and contradictory patterns of largely arbitrary criteria. Symptoms and behaviours that are merely an expression of the disorder are routinely taken for disorders in and of themselves.

To muddy the waters, inadequate and underdeveloped status of mental healthcare— roughly 0.75 psychiatrists per lac of the population— means that the practitioner has limited time to spend on each patient and this precludes structured clinical interviews or exhaustive assessments. Typically a junior resident working with a consultant psychiatrist together make a “provisional diagnosis” after history taking and mental status examination and the patient is treated on the basis of this diagnosis. It’s not unlikely that psychometric tests, structured interviews, and detailed assessment after hospitalization would yield a different final diagnosis— a fact which is grim and disconcerting.

There are no curative psychiatric drugs, only medication in the form of symptom treatment- à la carte clusters of  symptoms are unduly equated with mental illness. At any rate, however, treatments need to be tailored to each individual, not a generic “cluster of symptoms” for elevating the status of the profession to a more exact system of medicine. 
Neurochemical business gone awry… Oor has it?

The history of psychiatry is marked by a desire to understand mental illness at a primarily biological level—as deviations in brain structure, neurochemistry, and genetics. While this theory may hold water, it runs the risk of oversimplifying mental illnesses, mood and behavioural disorders.

Specifically, there’s no definitive experimental proof that establishes neurochemical imbalances as triggering the pathogenesis of mental illness and mood disorders. That psychiatric disorders are discrete brain illnesses caused by chemical imbalances in the brain, and that a new generation of psychiatric drugs stabilises those imbalances, like antacids for acid reflux, is still not proven. It’s like finding that a computer program isn’t working, and trying to fix the circuitry of the motherboard to solve the problem. The problem is in the computer code, and no amount of noodling with the computer hardware can help. Similarly, noodling with brain chemistry, which is what these drugs are aimed at, can’t fix issues of the mind.

But on the other hand, some drugs seem to work well for one patient and not another patient diagnosed for the same condition. Writing a prescription calls for both medical intuition and an in-depth knowledge on part of the psychiatrist. He can never be too sure whether a patient is going to benefit from a treatment or suffer pointlessly from its wide range of well-documented long-term side effects and withdrawal. Psychotropic drugs, when given to the wrong person, can spell disaster.

But it seems to work…

There’s no denying that people who suffer from neurotic/psychotic illnesses including anxiety, mood disorders, behavioural disorders, sleeping disorders,  and so forth, derive immediate relief by popping pills (SSRIs,TCAs). In fact, psychiatric drugs are robust in their action as far as masking the problem goes. But the key point is that they only give the patient an artificial sense of well-being by ridding him of symptoms. They are not designed to root out the problem. Also in some cases the patient builds tolerance to these meds over time and the required dosage goes through the roof to get the same effect as before. The patient is thus left high and dry.

Diagnostic and statistical manual and the boundaries of psychiatry

dsm-5, psychiatrist’s 900-page vade mecum, has set forth new, ever-expanding and arguably unscientific criteria to aid diagnostic decisions. Now, feeling emotionally drained after a breakup, grief after the loss of a loved one, forgetfulness in the elderly and anger issues in kids would constitute psychiatric disorders,  when in fact these all constitute a sane psychological response to adversarial external circumstances and should not, I think, warrant treatment beyond counselling/therapy sessions maybe. Instead, drug pushers find it more convenient and profitable to plaster a smiley face on these unfortunate subjects and “restore their normal self” by putting them on drugs. This is a very dangerous practice: In Kashmir, many diagnostic decisions are made, not by psychiatrists or clinical psychologists trained to make a careful diagnosis, but by primary care physicians who see a patient for a few minutes and dish out a prescription. Pharmacological intervention should only follow when the patient has been assessed thoroughly. A few-minute long false diagnosis by a general physician to decide upon drug prescription could unleash hell since these drugs are very very dangerous, with mind-altering, personality-transforming effects. 

To sum up…

Despite its technical semblance, diagnostic categories, elaborate systems of classification, psychiatry lacks the predictive power and scientific flavour of the life sciences. Much of the theory is forced to agree with the data. Its theories do not explain many aspects of mental health and illness— emotion, cognition,  and behavior, and their relationship with genetics and biology on the one hand, and psychological, social, and cultural factors on the other. The effects of these factors are far too complex to allow case-control studies.

The upshot is this: the methods and techniques of the psychiatric establishment, right down to the details, have failed to pan out. The diagnoses in the DSM have only vaguely been classified as discrete illnesses; the geneses of mental disorders remain in doubt; MRI scans haven’t been helpful; long-term outcomes are unsatisfactory; and the notion that psychiatric drugs fix chemical imbalances remains ever more speculative. 

Current psychiatric practice should be thoroughly revised or even disallowed. It’s inaccurate, corrupt and dangerous: inaccurate because it’s based on ill-defined concepts and models, and pseudoscientific claims about what causes mental aberration; corrupt because it’s deeply involved in a mutual enterprise with pharmaceutical companies and receives kickbacks for overprescribing drugs; dangerous because it can potentially ruin lives due to its wide margin for misdiagnosis and error.

Psychiatry: the road ahead

Without trying to sound too academic, I think an intervention at the level of the mind (instead of the physical brain) is likely going to work. Current psychiatry is ill-equipped to take its enquiries in that direction. Its treatments work as mere band-aids of the mind, and seldom work in the long term (superficially alleviating the symptoms by “fixing brain chemistry” doesn’t amount to curing the illness, right?) , its methods and techniques are, for the most part, improvisational, and its scientific validity highly questionable. As long as psychiatry does not look beyond just lab tests and  psychological questionnaires, it is plausible to think that in future we’d come to regard psychiatry as bearing the same relationship to medicine as alchemy does to present-day chemistry. 

What seems promising, though, is adopting computational methods to understand the workings of the brain and the pathophysiology of brain tissue and brain dysfunction. The fact that the brain operates as a large-scale network of individual neural circuits, and the fact that neurons fire together in a very deterministic, albeit complex manner in response to external stimuli makes it amenable to mathematical modeling. Specifically, we can model the complex neural circuits comprising of thousands of neurons by employing the mathematical theory of Dynamical Systems and make use of computer simulations. The interplay between these circuits in brain networks can be assessed via functional neuroimaging. This can be potentially  revolutionizing as it can give an indication about specific biomarkers linked to disorders. The major challenge is to understand the causal links across various levels of analysis: the molecular level (genes and drugs,) the level of neurons and synapses, circuits and networks where signs of pathophysiology may be evident, and finally the level of cognition and behaviour, which is where psychiatric symptoms are observed. What must be thoroughly understood is how brain dysfunction originates at the micro level of synapses and neurons and how it propagates upward to ultimately affect cognition and mental health. Granted, this approach won’t likely explain the machinery behind how exactly consciousness arises at a purely biological level but at least we can predict in advance the likely deviations from a healthy brain and exactly pinpoint the source of trouble to be able to do something about it long before the problem manifests behaviourally in the subject.

But as I mentioned earlier the present discussion may sound all too academic and theoretical to be of any practical utility but make no mistake, we need to be able to revisit the following most fundamental, most challenging, and most complex intellectual challenges man has wrestled with since the discovery of fire, and the invention of the wheel. Only then can we elevate the status of psychology in general,  and psychiatry in particular, to as loftier a standing as, say, the theory of gravitation, whose core features and implications are empirically identifiable and falsifiable. Chief among these challenges are:

1. How can we meld mind and our subjective consciousness with objective and empirical scientific method?

2a. How can we successfully and demonstrably correlate chemical and physiological workings of the brain with the mental experience?

2b.Is there any correlation at all or is this only a presupposition?

3. How exactly does brain give meaning to perception? 

Unless we approach these as open problems in mainstream neuroscience and not just philosophy, we can be but little sure about the future of psychiatry.

Given the present state of the sciences and philosophy we’ve not come very far from where we started out, in this regard. Some remarkable advances in the field notwithstanding, we’re still in the dark and no one seems to have any clear idea about how to effectively piece together the valuable nuggets we’ve discovered so far in psychiatry and related fields into an internally consistent and coherent whole, least of all the author of this critique.

(The author is an occasional contributor to GK writing mainly in the areas of philosophy, mathematics, and academia.)

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