The Trouble with Psychiatry

The trouble with psychiatry is epitomised by the Diagnostic and Statistical Manual of mental disorders – DSM for short – which is issued periodically by the American Psychiatric Association. The most recent edition, the DSM 5, was published in 2013.

New editions of the DSM do not represent real progress in psychiatric knowledge so much as shifting terminologies, conventions and theoretical allegiances. ‘Hysteria’, for example, has now been replaced by ‘conversion disorder’, and the very existence of ‘homosexuality’ as a disorder disappeared with the third edition. The fate of ‘narcissistic personality disorder’ is currently in the balance. How can it happen that whole mental disorders simply disappear? It is certainly not because we have cured them, of course. Usually, it is because the DSM editors decide that they never really existed in the first place.

That is the trouble with psychiatry – it does not deal with proper diseases, like strokes and infections. It lumps together constellations of different ways of being in the world and treats them as if they were medical syndromes. Proper syndromes are constellations of symptoms and signs which point to the presence of an underlying pathological entity. Increased muscle tone, slow movement, resting tremor, and a shuffling gait, for example, point to the presence of Parkinson’s disease (i.e., progressive degeneration in a part of the midbrain). But what does at least five of the following point to?

1) low mood 2) lack of pleasure or interest in the world 3) weight gain or weight loss 4) sleeping too much or too little 5) psychomotor agitation or retardation 6) loss of energy 7) feelings of guilt or worthlessness 8) reduced ability to think 9) thoughts of death

According to DSM 4 it points to the presence of ‘major depressive disorder’; and guess what?, more than 20% of Americans qualify for the diagnosis at some time in their lives.

This, like the disappearance of homosexuality as a disorder, raises the question: what exactly do psychiatrists mean by a ‘disorder’? The very word begs the question of its opposite: ‘order’ or normality. That is the trouble with psychiatry, it has no valid clinical basis for determining abnormality, and a purely statistical definition hardly helps when more than 20% of the population, on this definition, suffer from a major abnormality.

We might forgive psychiatrists if they admitted that their diagnostic categories were really conventional, social constructs. But no, psychiatry is increasingly moving toward the view that all mental disorders are really, at bottom, brain disorders; and the brain, surely, is an object, a physical thing. What then is the difference between psychiatry and neurology?

The answer, increasingly, seems to be nothing. The conventional answer used to be that neurologists treat ‘structural’ diseases of the nervous system while psychiatrists treat the ‘functional’ nervous disorders. In the latter cases, the brain is structurally sound but it is not functioning properly.

The trouble with this distinction is that it is rapidly disappearing. Brain functions are increasingly being understood in terms of their microscopic structural and molecular organisation. Depression, for example, is reduced to neurotransmitters, like serotonin, and the genetic polymorphisms and chemical precursors of serotonin-production. Psychiatry is, in a word, rapidly becoming a clinical branch of molecular neurobiology; and the really interesting thing is that the same applies to neurology. We are increasingly reducing so-called structural diseases like Parkinson’s and Alzheimer’s to their molecular neurobiological underpinnings too.

This makes psychiatrists really happy – it makes them feel like ordinary doctors at last. But what does this all mean for the notion of mental disorders, and why do we still have a separate medical speciality called psychiatry? I am not at all sure they could tell you.

So let me try. I think the difference between neurology and psychiatry is not about structure versus function but rather about observational perspectives – about having a brain versus being a brain. To be a brain is to be a subject, which implies a person, an individual. Of course, the brain of the human being is the same thing as the brain that can have Parkinson’s disease, but the being of the brain is such a specialised thing that it deserves a separate speciality.

Let me clarify: the being of the brain – also known as the mind – arises from a network of circuits with highly specific functions. The main functions in question are: (1) consciousness, the core of which is the pleasure/unpleasure series associated with the periacqueductal grey; and (2) intentionality, which comes in seven major varieties, each of which is associated with a basic emotion -- namely curiosity/interest/expectancy; consummation/pleasure/lust; exuberance/joy/play; care/love/nurturance; panic/sadness/grief; trepidation/fear/anxiety; and irritability/anger/rage.

Each of these circuits has a specific neurochemistry, and a profoundly important role in life situations of universal significance. It is surely no accident that the pharmaceuticals that psychiatrists use manipulate precisely these systems. I therefore cannot fathom why they do not base their classifications on the orders and disorders of these systems. These are the true ‘natural kinds’ of psychiatry. That is why each of them is associated with specific, meaningful clusters of symptoms and signs which cut across all the artificial constructions of the DSM. The anxiety in ‘ obsessive compulsive disorder’ , for example, turns out to be of the panic variety – which belongs together with sadness and grief, and therefore with depression. That is why OCD and depression co-occur so very frequently. Yet in the DSM they are classified under totally different headings, namely ‘anxiety disorders’ and ‘mood disorders’, respectively.

The basic emotional systems that underpin the mental aspect of the brain, and therefore emotional or mental disorders, are all individualised by experience and regulated by (mainly inhibitory) forebrain structures that are also heavily experience-dependent, and only reach maturity in the third decade of life. This, the famous ‘plasticity’ of the human brain, is the source of the social and cultural dimension of mental illness. It is also the source of our agency – of our famous free will. To deny this dimension of psychiatry is simply to deny how the brain works. Psychiatrists should rather embrace the importance of the epigenetic environment, and especially the importance of early parental influences. It is facts like these that justify the separate existence of their speciality.

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