What Is Modern Psychiatry Seeking?

[btdt]

From thelastpsychiatrist.com November 9, 2006:

 

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What Is Modern Psychiatry Seeking?

 

The fiction is that psychiatry is looking for more efficacious treatments.  It is not.  It is looking fordifferent treatments; the paradigm does not allow for the creation of better treatments.  For example, psychiatry can applaud itself from moving from a “noradrenergic hypothesis” to a “serotonin hypothesis” of depression, but it’s still the same paradigm.  While first line medications have changed, they have not changed because of improved efficacy.  Nothing has ever found anything to be more efficacious than the previous standard (SSRIs. vs. tricyclics, atypical antipsychotics vs. chlorpromazine, etc.)  nor has any “model” been more or less correct than any other.  That some medications have less side effects and greater versatility is useful, but a) this is almost never the result of intentional scientific discovery but rather the fortunate by-product of the invention of (yet another) efficacious treatment; this greater tolerability in no way reflects the accuracy or inaccuracy of an existing model.  That Zoloft is more tolerable than imipramine has nothing to do with the viability of the “serotonin hypothesis.”  And yet how many times have I heard that antipsychotics treat depression with no more rigorous explanation than because of their “activity” (note the vague term) on serotonin?

 

Psychiatry, which seeks to be like physics, becomes instead a caricature of it.   It, too, tries to focus on expanding knowledge and not re-evaluating its principles.  But unlike physics, psychiatry has no formal principles.  They are made up.  It is, strictly speaking, not a science but a paradigm, no different than psychoanalysis.  It may seem as though Freud concocted the notion of the unconscious out of thin air and developed an entire field around it, but modern psychiatry has done nothing different in concocting the notions of kindling or “upregulation of receptors” as first principles and then constructing an equally arbitrary field around them.  That medications help patients has everything to do with the medications and nothing to do with the incense and liturgy that surround them.

 

Paradigm shifts do not occur in physics because the principles do not change.  Newtonian mechanics will always be useful for prediction because it is correct for the cases in which it is applicable (i.e. for measurable bodies.)  It is furthermore not susceptible to political influence.  Psychiatry is the opposite.  The decision to accept or reject the paradigms in psychiatry are very clearly political, not evidentiary.  We as individuals accept the idea that antiepileptics are mood stabilizers because psychiatry has decided to adopt this position, not because the evidence requires us to accept it (in fact, the evidence should require us not to accept it, or at least seriously question it.)  No physicist could hope to “practice” physics without having read and understood what came before, without having worked the “block on an incline” problem.  But there is no theoretical nor practical requirement to practice psychiatry of reading the papers on, for example, mood stabilization, let alone what came before.  All that is required is to know what the current practice is (“Guidelines recommend prescribe antiepileptics.”)  This may seem like science, i.e. “scientists have determined that antiepileptics are mood stabilizers, so we will trust their word and prescribe them,” but it is very clearly politics.

 

The current problem of psychiatry is that it seeks to be something that it is not: science.    It may be, at some future date, readily described by scientific principles, but this is assuredly not the case now.  It is most certainly a sociological construct, a paradigm, with a shared educational system, shared assumptions, and a mechanism to communicate discoveries (i.e. journals, meetings.)  It also has a common language.  But it lacks the  predictive ability common to other disciplines.

 

An argument against the notion that psychiatry is an arbitrary paradigm is that it is a reflection of what actually occurs in the brain.   This is sophistry.  For example, saying   the “serotonin system is relevant in mood disorders” is empty because it lacks context.  Does it mean that no other system is relevant?  Or that it is the most relevant?  Or even necessary?  Sufficient?  What about Wellbutrin? Are you saying psychotherapy alters serotonin?  (And not dopamine?  Etc) ....

http://thelastpsychiatrist.com/2006/11/massacre_of_the_unicorns.html#comments

Edited May 11, 2014 by Altostrata
added credit and ellipses