Andrzej Kapusta
Anthropological and Social Consequences
of Psychopharmacology Development
Tekst nie publikowany wygłoszony na międzynarodowej konferencji poświeconej filozofii medycyny Second World Congress of Philosophy of Medicine, która miała miejsce w Krakowie w 2000 roku.
Psychiatry does not have a consistent and unified model or doctrine with uncontroversial theorems and practices. There are various schools of thought, different views on mental distress: biological/medical psychiatry, psychoanalysis, cognitive and behavioristic therapy, anthropological psychiatry. We can find sharply different perspectives, from which each of the schools understands the aims of psychiatry. Each of these schools has introduced its own unique terminology and perplexities relating to the multitude of tremendous bodies of literature. Different theories and procedures imply not only theoretical differences but distinct assumptions concerning human nature, divergent valuations, individual visions of good life and good society. The question is to what extent these different approaches are integratable in theory and practice (Lipowski 1989)? Is it possible to tolerate a certain fragmentation and pluralism in psychiatry (Havens 1987)? Are the alternative approaches not really distinct approaches (paradigms) after all (Reznek 1991)? As they do not conflict with the medical interpretation of mental health, the latter approach does not have serious opponents.
Psychiatry needs to find its place within the universal philosophy of humanity (Browning 1991), a self-conscious and integrated attitude toward its own theory and practice. It needs a standpoint that can effectively question motives, basic beliefs, and potential blind spots. Mental health care as a part of the conversation that shapes the life of our society needs to see dilemmas presented by the schools, to become aware of and thoughtful about the true status of mental health profession.
The problems and dilemmas presented by mental health care are innumerable, but I will present only the principal ones:
(1) How to interpret the triumph of the biological psychiatry which investigates possible pathophysical grounds to mental disorder? Is psychiatry simply a specialty within medicine, on a par with cardiology, orthopedics and gynecology? What are the limits of biological psychiatry? The question is whether psychiatry became a discipline based on biology? Is mental disease just a brain disease? Consequently, the proper way of relieving these peculiar symptoms is to correct the underlying disturbance of brain function using physical treatments such as medication.
(2) Is it acceptable to make any considerable integration among psychosocial and biomedical interventions? Does the diversity of patient-sufferers along with psychiatry’s present epistemological status argue for a thoughtful therapeutic eclecticism or therapeutic pluralism – refinement methods and medicines? An eclectic psychiatrist tries to fit whatever seems likely to work for the patient. It is a moderate type of psychiatry deliberately avoiding more extreme wings of various schools. We have to choose between grasping the ideas of all the schools to “homogenize complexities” and mastering the diversity or discovering when to employ what methods.
(3) What is the role of psychopharmacology in psychiatry development? How does the new research extend to the way we experience ourselves and others? What was the influence of “cosmetic psychopharmacology” on the popular culture? Did the pharmaceutical revolution change the face of madness?
Psychiatry was always conceptually marginalized from the rest of medicine. At the end of the twentieth century biological thinking gave it the capacity to be as science-driven as the rest of medicine (Henk ten Have 1995). And now it is rejoicing in its newly found legitimacy. In their desire to be accepted as real clinical scientists, biological psychiatrists were building a dogmatic edifice on meager scientific foundations. Yet we cannot provide a credible scientific explanation for the representation of our fears, motives, aspirations and thoughts in our brains (Wiggins 1994, Claridge 1995). The scientific image of mental health cannot be achieved at present, its certainty was pushed beyond what the data could support. Biological psychiatry teaches people to think about problems in definite, but scientifically unreliable ways. Many critics feel that most of the so-called therapies are employed without any adequate empirical foundation. The overabundance of conflicting theoretical perspectives has raised many doubts about the status and aims of mental health care. How can one talk the faulty neurotransmitters in schizophrenia, and at the same time have people writing purely psychological accounts of the disorder – and even have others saying that it doesn’t exist.
Psychiatry has become more scientific and technological since the introduction of neuroleptics in the 1950s. The discovery of the antipsychotics, antimanics, and antidepressants not only put psychiatry on a much more stable scientific footing, but made it possible to help people with garden-variety anxiety and dysphoria. The appearance of safer drugs with less troublesome side effects, has led to an unlimited expansion in treatment options. The consequences of the new research are not only technical, but also ethical and philosophical problems. Thus, it is important to concern with philosophical arguments to account for good psychopharmacological theory and practice.
I will examine the very foundation of biological psychiatry and the role of psychopharmacological revolution in carrying psychiatry into the biological era. The discovery of neuroleptics formed a pharmacological basis for the biological psychiatry. It is now widely held that mental symptoms are nothing more than brain illnesses manifesting in a particular way. Shorter writes: “Yet the scientific interest they generated, and the profits that accrued from their [drugs] sales, contributed to putting psychiatry on a much more solid scientific footing than had previously been. This was a footing in the neuroscience” (Shorter 1997, page 262).
Biological psychiatrists tell us how care should be provided and how the disease should be conceptualized. Just like psychoanalysis converted patients’ symptoms into signs of an unconscious process, the biological approach to psychiatry turns them into signs of a pathological physiological process. But modern psychiatry is making essentially unproven claims despite the fact that it has yet to convincingly prove the biologic cause for any single mental illness.
The purpose of this essay is to present a critique of the restricted medical model of psychiatry and to outline some anthropological (and ethical) implications for contemporary psychiatry. Finally, the conceptual framework for integrated model for psychiatry is considered.
Biological psychiatry: questions on the foundations
With the discovery of chlorpromazine and the other early psychoactive drugs, the study of psychopharmacology came into its own. For many, the introduction proclaimed a drug revolution in mental health care. The new discipline set out to determine the mechanism of action of the various antipsychotic and antidepressant drugs. For the most part the new psychopharmacology was driven by the drug business. Only progression in neurobiology would permit the design of drugs specially tailored to block whatever biochemical or anatomical pathways were causing psychotic illness. While the research on brain chemicals, or neurotransmitters, was going on, the whole mechanism of neurotransmission itself, involving receptors for these chemicals at downstream neurons, was being uncovered. Chlorpromazine inaugurated a revolution in psychiatry. It did not cure the diseases causing psychosis, it did only abolish their cardinal symptoms so that patients with underlying schizophrenia could lead relatively normal lives. Observation, however overly simplified, inevitably led to the implication of dopamine in the biochemistry of schizophrenia and intense investigation has been generated to the point where a dopaminergic hypothesis is now widely regarded within biological psychiatry as an established “finding” in the etiology of schizophrenia. Genetic studies have demonstrated hereditary transmission of disorders, effective pharmacotherapeutic agents have been developed and now are in widespread use, and coherent biological theories have been formulated to explain both pathogenesis and the actions of psychotropic medication. For the first time ever, psychiatry seems to match the other specialties of medicine in the scientific rigor of its research and knowledge, the reliability of its diagnoses, and safety efficacy of its treatments. Unfortunately, the field of study investigating mental disorder from the position of the established biological sciences has produced many findings of CNS dysfunction, but none specific for a disease and none shared by everyone with the diagnosis. Direct evidence for a specific neurotransmitter or receptor abnormality is not yet available. And understanding why some drugs work and some do not, and how the ones that clearly work manage to attain their task, is generally beyond the current capabilities of science. From this point of view, many personal problems seem identical to biological problems, the crucial disturbance lies in the balance between catecholamine and other neurotransmitters. But no testable specification of the impedance has ever been offered. Patients have been diagnosed with chemical imbalances despite the fact that no test exist to maintain such a claim and there is no real conception of what a correct chemical balance should look like.
We can only expect that the growth in neurobiology research will lead to advances in neuropharmacology, so that we can also expect the development of new and better somatic therapies. N. Andreasen explains: “Psychiatry today is much like general medicine forty or fifty years ago – on the brink of discovering its own version of insulin, penicillin, blood transfusion, and cardiac pacemakers” (Andreasen 1984, page 260).
Because biological psychiatry has not strong theoretical and empirical basis we may suppose that there are some extra-theoretical grounds for viewing so-called mental illness phenomena as if they were biological diseases (Tommy 1995). We can find ideological, social and political motives for that conception.
Biological Psychiatry and Psychopharmacology
Biological psychiatry can only develop throughout unbiased observation in the laboratory, by way of collecting facts and deducing conclusions. The scientific approach in psychiatry was very productive but just like in the rest of medicine, the patient is not adequately addressed since the scientific conceptual tools of medicine are unsatisfactory and too simple. Causal thinking and technical approach of the natural sciences are highly valuable and useful but the positivist view on mental disorder doesn’t account for psychopharmacological theory and practice. This position is unable to explain biopsychological aspects of psychopharmacotherapy (i.e. placebo response). Contemporary psychiatry is rather pragmatically oriented, that is, it is exclusively concerned with the effectiveness of the intervention, its usefulness for future research and the success in administration of psychotropic drugs. Medications are quick and easy for a clinician to prescribe, easy for the patient to take, and usually successful in reducing the patient’s symptoms.
Drugs are not only medication which alleviates certain pathological symptoms. They are also helpful in the task of cognition of the brain. They are sort of “physiological scalpel”, a kind of a tool for neurobiological investigation and systematic experimentation into the chemistry of the brain. Brain chemistry means neurotransmitters, the chemicals that transmit the nerve impulse from one neuron to another across the synapse. By comparing various drug actions, correlations are established between organic-cerebral substrate factors on the one hand, and behavioral qualities and behavioral frequencies on the other. The use of drugs as research tool is an important avenue into understanding how the brain works. Neuroscience and clinical psychiatry have fed into each other and their interaction raises new issues and opens new possibilities for the other. When pharmacological treatments are deemed effective for a psychiatric condition, a stimulation is given to biological research.
In the biological model, the patient’s response to medication is not interpreted as a reflection of the significance for the psychiatric patient-social interaction or establishing control over particular deviant’s behaviors. For the positivist view, psychopharmacology may clearly offer medical intervention for patients with psychiatric disorder. A demonstration that psychopharmacological intervention is useful for the treatment of psychiatric disorders provides further evidence that such disorders are simply physical in nature. In psychopharmacology, the general ideology holds the assumption that psychiatric dysfunction has a biochemical basis and drug treatment can be developed to correct homeostatic dysregulation and thus restore mental health. Fancher writes: „Without the rationale of correcting biological abnormalities, clinical psychopharmacology has difficulty defending itself against the charge that it provides boutique drugs for the respectable classes – the psychic equivalent of steroids” (Fancher 1995, page 261).
But psychiatrists are not really basic scientists; they are clinicians (opposed to non-clinical neuroscientists). Many of pharmacological theories are hypothetical and need more testing. Anyone involved with the prescribing and monitoring of drugs that act on the brain should realize that they are acting on the most complex organ in the body, and there are likely to be many subtle effects of drug treatment. However, psychiatry is a very practical field, much more concerned with results than theories and whatever works will be used. Making patients feel good, helping them to feel better is a part of its duty. Much of current psychiatric practice consists of applying treatments with recognized effectiveness for certain loosely specified psychological conditions, but without much attention to the underlying nature of the disorder being treated. Then, we have to distinguish between neurobiology or neuroscience (area of knowledge), as a scientific discipline concentrated on understanding the biology of the nervous system, and clinical psychopharmacology (practical applications), which intends to develop drug treatment for brain disorders. It is not necessary to have erudition about drug-theories in order to be experienced in administering drugs and controlling their effects. There is a strain in groups with both clinicians and neurobiologists. And many neurobiological theories and results of research did not have clinical applicability.
Contemporary biological psychiatry didn’t lead to any coherent understanding of most psychopathology; psychiatry requires theoretical clarity and technical confidence of general medicine. Psychopharmacology goes beyond neurochemical entities and takes into account biopsychological structures and mechanisms. We can recognize expanding nosological indications for taking drugs for personal comfort or enjoyment. New generations of drugs relieve many symptoms that previously resisted therapy. The utility of drug treatment has been often overvalued and overestimated.
The media often seem to promote new “wonder drugs” or other apparently amazing advances in psychiatric treatment. Drug companies can impose a great deal of the shape of our thinking on mental illnesses. Good marketing such ideas as the amine hypothesis of depression or improving the image of the product, can capture a field, before the evidence is provided on an issue or even in the face of considerably contradictory evidence (Healy 1996).
Since taking drugs in order to solve problems may create its own ethical and practical problems, and because the disease model of mental illness may have serious negative implications for the way in which people are treated generally, it seems important to do critical reading of biological psychiatry. As Healy said: “It is rarely noted that the catecholamine hypotheses have survived disproof of their initial premises in much the same way that the development of psychoanalysis was not deflected by the disproof of the occurrence of sexual traumata at the origin of the neuroses” (Healy 1996, page 66).
The critique of the biological model
Biological psychiatry investigates possible pathophysiological bases to mental disorder. In this model psychiatric disturbances are regarded as brain disorders; the main assumption is that psychiatric dysfunction has a biochemical basis. The contemporary medical model seeks to objectivize diagnostic categories by an act of biological reductionism. The general issue is whether phenomena at one level of description can be explained at another more “basic” level. In biological psychiatry the discussion is whether it is appropriate to try to explain at least certain psychological experiences in terms of cellular and molecular processes. The earlier psychoanalytically based medical model, which dominated psychiatry during the fifties and sixties, argued that mental illness manifested emotional and behavioral “symptoms” that were the result of unconscious psychological conflicts (Kellerman 1988). The current biological medical model of psychiatry attempts to avoid some ethical implications of psychoanalysis (a value judgment about the way people live and think) by asserting that mental illness is physical illness (but not like physical illness).
The exclusively physical account of psychological disorder is supported by a number of lines of argument. One of the probably most important is that drugs can cause a specific reduction in symptoms of mental illness. Then, if a condition is helped by drugs, this is taken as an evidence of its biological abnormality: If it responds to medication, it must have a biological cause (Rose 1995).
The assumption that psychopathology is biological, that all mental disorder is brain disorder, is a part of a much larger metaphysical question. In the biomedical model biology is the foundation, and psychological and social dimensions of sickness are seen as only epiphenomenal. For biological psychiatry to make sense, mind must not be something different from matter. The emphasis on biological, even genetic influences and “somatic” treatment in narrowly defined “biological” perspectives reflects and enforces a technoeconomic orientation favoring machinelike perspectives on human problems and their solutions, and favoring a naturalistic, materialistic conception of psychopathology. But this antidualistic position does not tell us anything about the nature of psychopathology, since mental health is also a biological one. One important supposition of the thesis that “mental disorder is brain disorder” is that “all mental events are brain events”: consequently, everything is biological! Biological psychiatry practitioners have accepted the materialist concepts that are the basis of modern medicine as unquestionably true. R. Fancher points out that to understand the specificity of biological psychiatry we have to distinguish between two different assertions: “psychopathology is biological” and that it is “biologically pathological”. “Thus, if biological psychiatrists are only saying that dualism is false, they are not telling us anything about what distinguishes psychopathology from mental health and how to conceptualize and treat it” (Fancher 1995, page 265). Stating that psychopathology is “biologically pathological” anticipates that the brain machinery is not working as it should. We assume that a neurotransmitter system is impaired and this dysregulation makes people feel depressed; we have biologically-impaired patients. When a drug works, it does so by restoring effective regulation to the dysregulated system.
Following, to some extent, from the last suggestions, it seems probable that clinical response to medications can be used as a factor in the differential diagnosis of psychiatric disorders. In a similar vein, drugs work on biological illness but not on psychological and sociological troubles. Thus, we can distinguish between biological illness and psychosocial difficulties on the basis of pharmacological response. Medication can also be used in differential diagnosis within psychiatry.
This “logic” gives the patient a deceptive impression that his or her biological imbalance is the cause of his or her illness. But working out how a drug improves certain conditions will not necessarily tell us much about the etiology or even pathogenesis. The therapeutic effect of a drug can be indirect or just unrelated to the cause of the condition. Patients have been diagnosed with chemical imbalances in spite of the fact that no test exists to support such a claim, and that there is no real conception of what a correct chemical balance would look like. In the interview by D. Healy, Pierre Pichot said: „we have no conclusive proof that the disturbances of the neurotransmitters which have been observed – and eventually corrected by our drugs – constitute the central biological mechanisms, whose end result are the behavioral disorders. I do not deny that they exist nor that our drugs modify them but it is possible that they are only witnesses and consequences of underlying more basic disturbances” (Pichot 1196, page 18).Even if dopamine is proven to be involved in schizophrenic process, it is involved, as well, in every kind of human behavior and is always a part of a very complicated neurotransmitter story. Although it has been shown that phenotiazines bloc CNS receptor sites activated by dopamine, this still doesn’t necessarily mean that schizophrenia is a biological disease. Correlation does not inevitably mean causation. Dopamine and serotonine were only two of many transmitters involved in these complex psychiatric disorders and probably did not play a leading role. This “blame-the-victim’s-body” philosophy ascribes a constitutional dysfunction to mental disorders, the problem is assumed to be “inside” the body of the patient rather than the product of an “outside” interaction.
Problems following biomedical reductionist approach include nonspecificity of many psychotic symptoms to medication (i. e. antidepressant imipramine is effective for panic disorder). Another example of the weakness of our knowledge of the biochemical mechanism in the brain is the fact that all drugs have “side effects”. The extreme position taken by the anti-drug movement presents the radical view that drugs are “chemical lobotomizing agents” with no specific therapeutic effects on symptoms or problems but with a plague of brain damage. Even the most medically orientated psychiatrists suppose that drugs are inducing changes at a more general level than the “pathological” process. So-called side effects are just biological consequences of introducing drug into the body. Specific chemicals are acting on specific brain processes not to prove the pathological change but to cause a specific state change, to alter specific processes. As Fancher wrote: “Since a great deal about what drugs do in the brain is beyond our current knowledge, claims of specificity are, in fact, culture bound” (Fancher 1995, page 274). Defining and naming the syndrome has a great value-laden component. Accordingly, we may suspect that phenomena that comprise disorders, and their underlying generative structures and mechanisms, are partly biological, but we can perceive such entities using historically specific social forms.
The antydualistic materialistic stance of biological psychiatry does not deny that many problems of many patients are related to psychological and social conflicts. The mind is only an organization of physical elements, but these have been ordered into chemical components, organic systems, psychological operations and mental abilities. Only physical elements ever exert in minds, and there is no immaterial ghost in the brain. But doctrinal belief perceives biological factors in mental illness as more real and valid. However, from a theoretical point of view it is possible to be a physicalist and to refute reductionism. We may hold that mental categorisation fails to correspond to physical categories, and abstracts from physical embodiment. There are mental states relative to physical phenomena, which cannot interact merely functionally at their own level of analysis, but may also influence physiological processes in the brain. We need to deal with the most complex aspects of human biology. Fancher observes that: “If everything is material, it does not follow that biology has priority in understanding the mind and its problems. Quite the contrary. It means that psychology (and other sciences) have as much claim to explain material states as biology has to explain psychological ones. We are all talking about the same thing, though we are saying very different things about it.” (Fancher 1995, page 283) Just as biological systems show a relative independence from their constituent chemicals, so psychological functioning appears to have a certain independence from the underlying neural correlates it organizes. The foregoing remarks bring me naturally to one of the main topics of this essay: there are good reasons why the biological psychiatrists may assume that all sorts of important factors, including social and economic conditions, family constellations, educational experiences, climate, geography, and much more, can influence health and illness. Samuel Guze argues that resistance to biological psychiatry is often unfounded or unduly pessimistic: “many assume that the medical model excludes from consideration the patient’s psychosocial environment and subjective experiences. Some even go so far as to equate the medical model with an exclusive focus on body chemistry and the prescribing of psychoactive drugs. Nothing could be more incorrect” (Guze 1992, page 23).
From the theoretical point of view a separation or almost rivalry between biological and non-biological explanations is unfounded. Brain systems are shaped not only by the physical factors but also by family relationship, chance events, and social contexts. Life situations in which we are prone to feel stress may cause dysfunctions in our neurochemistry that result in disordered thoughts and behavior. The individual’s brain may response individually to the circumstances of his or her life. There is no single explanation that fits all expressions of mental illness. Then, none of so-called psychiatric disorders can simply be reduced to genetic, biochemical, or physiological disturbance.
Today, we know that strictly biological explanations of psychiatric disturbances have their own limits; they are too restricted and abstract. Mental phenomena may address their physical underpinnings but they must also address more complex structures and mechanisms. From the fact that some important facts and important things can be expressed in biological terms we can’t conclude that psychological and sociological terms are not needed. Unsuspected brain pathology can sometimes very accurately imitate disorders of the personality; and vice versa, an apparent organic disease can turn out to be strictly psychogenic. We know that the biological explanation has its limits, because we still can’t translate biochemical processes involved in psychopharmacology into the psychological ones. And it is unjustified to throw out the existing psychological explanations and to suppress psychological traditions of the discourse. On the other hand, the antidualistic materialistic (broad) approach of biological psychiatry explicitly recognizes the broad spectrum of factors relevant to psychiatric disorders. Maybe we require a new more adequate science and new vocabularies to integrate the rival points of view. Leon Eisenberg argued: „Indeed, problems in living necessarily influence brain state and structure-unless, of course, one believes that mind floats about in an incorporeal ectoplasm. Recent research on psychiatric disorders as different as depression, panic disorder, and schizophrenia exemplifies the ubiquity of brain/mind interactions” (Eisenberg 1986, page 503).
Anthropological consequences
The controversy over Prozac’s (Fluoxetine hydrochloride) possible effects on personality and possibility of “transforming” our nature by using drugs, led in some quarters to enthusiasm for physical, specially pharmacological remedies, for almost every form of psychological distress or deviation. Peter Kramer (1993) suggests that the new generation of antidepressant not only changed undesirable traits of personality, not only moved patients closer to health, but let us tailor our personalities to our own specification, made people who are not suffering from a definable mental illness feel “better than well”. It can make non-depressed people function for better, turning pessimists into optimists, shy, introverted people into socially secure extroverts. Prozac raised debate about drug use. There is a collision of values concerning the use of drugs, which was classified as “pharmacological Calvinism” (that use of psychotropic drugs is morally wrong) and “psychotropic hedonism” (Dunn 1998, Ghaemi 1999). But biological psychiatrists don’t want to reveal ethical consequences of “cosmetic psychopharmacology” development: the idea that we don’t know whether new “designer medications” are simply manipulating human nature, just modifying our responses to the world. The debate over Prozac clearly shows that we have double standard for psychiatric disorders. The modern Western civilization has an unstable approach to the use of pills and the use of drugs that affect mood and behavior especially. As Sievier writes: “We condone medically unnecessary cosmetic surgery without question, despite well-known risks of anesthesia and the operation itself, yet are very critical of individuals who seek help for depression or anxiety if they are not so severely ill as to require hospitalization. A person who smilingly announces to acquaintances that her life has been transformed by a medication like Prozac immediately invites skepticism , resentment, or the suspicion that, after all, she must be a very shallow person” (Sievier 1997, page 241).
Biological psychiatrists say that drugs only normalize imbalances or dysregulations in particular brain chemical systems. They are just like Aspirin which can’t lower your temperature if you don’t have a fever. The possibilities of “mood brighteners” have been oversold and these drugs have shown little evidence that they can make patients feel “better than well”. The drug indeed had a profound consequence for personality, but in ways that have proved devastatingly harmful. (A few pilot studies hint at increases in well being among volunteer subjects receiving SSRIs, but it is unclear how many of these had mild depressive symptoms). Antidepressants by helping to rebuild neurochemical regulation, are restoring normal balance rather than inducing some artificial state.
This position is similar to the classical concept of unitary and stable personhood (Stein 1998). Biological psychiatry holds the idea of human nature, a transcendental ideal, where disease is only a deficit relative to this ideal. Changes in response to medication suggest that altered features were not a part of personality: As Stein argues, “a person with a mental disorder is a person-plus-disorder” (Stein 1998, page 209). He proposes the metaphoric position on personhood as non-unitary and non-stable category, which provides a better explanatory account of psychopharmacology where psychotropic drugs may affects aspect of functioning that are seen as specially humane, even the essence of human being. Underlying biological structures changed by drugs alter “a different set of characteristic responses”. Stein writes: “change in a particular idea after psychotropic medication is neither evidence that such an idea is autonomous and nonpathological, nor (more counter-intuitively) is it evidence that such an idea is non-autonomous and pathological” (page 208). This synthetic or integral view of mental disorder emphasizes biological and psychosociological aspects of mental illness (response to medication is not only reflection for patient of meaningfulness effect of social interaction). The efficacy of drugs suggests that neurotransmitter systems govern our behavior, but biopsychological structures and mechanisms are also important.
Following these theoretical dilemmas and the ambivalent situation of drugs in our culture we face many social problems. The amount of psychopharmacologic medication being prescribed has increased dramatically. The prevalence of some psychiatric disorders, like depression, has increased. There is an expansion of indications for psychotropic drugs. Drugs are prescribed not only for the major affective disorders and psychoses but also for obsessive-compulsive disorder, dysthymia, personality disorders, social phobias.
This state of affairs is clearly not satisfactory, and yet the demands of reality force us to come to terms with it and to deal with it as best we can. One possibility is for the society to break down some of the conceptual barriers that have so far prevented psychiatry and abnormal psychology from arriving at a more effected biopsychology of human personality.
Dilemmas of psychiatry
The limits of biological psychiatry and the presence of many other schools in psychiatry opened some dilemmas. (1) Is it more appropriate for biological psychiatry just to concentrate on strictly biological disturbances, on treating major psychoses? In this case small and undefinable disturbances will be taken by non-psychiatrists (psychotherapists and social workers) or adherents of many psychotherapeutic schools. (2) Is it better to give up the dogmatic restricted biological approach and to enlarge its interests on psychotherapeutical and sociological aspects? This integrative approach penetrates the complexity of the human brain. We can’t only focus on its biochemical aspects, because it is also shaped by psychological processes and social environment. We should find a language which can describe more integrated and emergent processes, and differentiate between levels of human being: biochemical, physiological, and interpersonal aspects. The integrative view is similar to Engel’s biopsychosocial model in which nature is ordered as a hierarchy of systems. Each level in the hierarchy represents an organized dynamic whole and all levels of organization are linked. This theory conceptualizes mental phenomena as related to the nervous system but different from and irreducible to neurophysiology. Guze points out that biopsychological model de-emphasized the brain and specifies no hierarchy or preference among its various elements. However, for biological psychiatry the brain and its processes are the center of this thinking. He argues: „Cultural anthropology, philosophy, and sociology may all make significant contributions to the fullest understanding of psychopathology and its treatment, but only to the degree that they take into consideration human biology” (Guze 1992, page 64).
The overlapping of effectiveness of biological and psychological intervention raised by the advent of safer psychopharmacological agents with less troublesome effects, has led to employing psychotropic medication in combination with psychotherapy (Gabbard 1999). The questions occurred how to conceptualize models for combined or integrated intervention between medication and psychotherapy. In combined (“a two-track view”) strategy psychotherapy and medication each have different specific targets: medication is a better treatment for some aspects of psychiatric illness, while psychotherapy is better for others. As a contrast with the two-track approach, there has been a demand for an integrated or unified approach where treatment is organized and evaluated in terms of its effectiveness in promoting the overall goal. Medication use becomes a major event also in psychodynamic treatment in spite of the fact that historically medication and the psychodynamic approach were in conflict, both clinically and theoretically.
The experimental scientific approach to mind (based on a computer analogy) supposes that drugs act on brain processes which, in concert with other factors, lead indirectly to improvement in psychiatric disorder. Drug action may not be immediate and inevitable, but “will depend on ‘reprogramming’ ” the mental and behavioral abnormalities that have developed around the basic biological lesion or defect” (Tyrer 1997, page 19). Thus the real improvement in mental disturbances succeeding drug treatment may also depend on environmental and social basis.
REFERENCES
Andreasen N. C. The Broken Brain: The Biological Revolution in Psychiatry. NY: Harper & Row, 1984.
Browning D. S. and Evison I. S. (Eds). Does Psychiatry need a Public Philosophy? Chicago: Nelson-Hall Inc., 1991.
Claridge, G. Origins of Mental Illness. Cambridge: ISHK, 1995 (Second Edition.),
Dunn C. Ethical Issues in Mental Illness. Hants, Vermont: Ashgate Publishing, 1998.
Eisenberg L. Mindlessness and Brainlessness in Psychiatry. British Journal of Psychiatry 148, 1986.
Fancher D. Cultures of Healing: Correcting the Image of American Mental Health Care. NY: Freeman and Company, 1995.
Gabbard G. O. The Psychiatrist as Psychotherapist. In Weissman S. et al. (Eds): Psychiatry in the New Millenium. Washington: American Psychiatric Press, Inc, 1999.
Ghaemi S. N. Depression: Insight, Illusion, and Psychopharmacological Calvinism. Philosophy, Psychiatry, & Psychology 6.4 (287-294), 1999.
Guze S. Why Psychiatry is a Branch of Medicine. NY: Oxford U Press, 1992.
Havens, L. Approaches to the Mind: Movement of the Psychiatric Schools from Sects toward Science. Cambridge, Massachusets and London: Harvard University Press, 1987 (reprint with new pref.).
Healy D. and Doogan D. P. (Eds) Psychotropic Drug Development: Social, Economic and Pharmacological Aspects. London, Chapman & Hall Medical, 1996.
Henk Ten Have. The Anthropological Tradition in the Philosophy of Medicine. Theoretical Medicine 16: 3-14, 1995.
Kellerman H. and Burry A. Psychopathology and Differential Diagnosis: A Primer. NY: Columbia University Press 1988.
Kramer P. D. Listening to Prozac: A Psychiatrist Explores Antidepressant Drugs and the Remaking of the Self. NY: Viking Penguin, 1993.
Lipowski Z. J. Psychiatry: Mindless or Brainless, Both or Neither. Can. J. Psychiatry Vol. 34 (249-254), April 1989
Pichot P. Psychopharmacology and the History of Psychiatry. In The Psychopharmacologists, Interviews by Dr David Healy. Chapman and Hall, 1996.
Reznek. L. The Philosophical Defence of Psychiatry. London and NY, 1991.
Ross C. A. and Pam A. (Eds) Pseudoscience in Biological Psychiatry : Blaming the Body. New York: Wiley & Sons, 1995.
Shorter E. A History of Psychiatry. From the Era of the Asylum to the Age of Prozac. New York: John Wiley & Sons Inc, 1997.
Siever L. J., Frucht W. The New View of Self: How Genes and Neurotransmitters shape Your Mind, Personality, and Your Mental Health. NY: Macmillan, 1997.
Stein D. J. Philosophy of Psychopharmacology. Perspectives in Biology and Medicine, 41, 2 (200-211) Winter 1998.
Tommy S. On the Notion of Mental Illness: Problematizing the Medical Model Conception of Certain Abnormal Behavior and Mental Affliction. (Avebury Series in Philosophy) Hants, Vermont: Ashgate Publishing, 1995.
Tyrer P. T. (et al.) Drug Treatment in Psychiatry : a Guide for the Community Mental Health Worker. Oxford; Boston: Butterworth-Heinemann, 1997.
Wiggins O. P. and Schwartz M. A. The Limits of Psychiatric Knowledge and the Problem of Classification. In Sadler J. Z. et al. (Eds) Philosophical Perspectives on Psychiatric Diagnostic Classification. Baltimore and London: The Johns Hopkins University Press, 1994
——————————————————————————————–
Materiał udostępniany na zasadach licencji
Creative Commons 2.5 Uznanie autorstwa-Użycie niekomercyjne
——————————————————————————————–