THE FUTURE OF PSYCHIATRY IS THE BIOPSYCHOSOCIAL MODEL D B Double.

THE FUTURE OF PSYCHIATRY IS THE BIOPSYCHOSOCIAL MODEL

D B Double

My argument

Psychiatry has always had a biomedical emphasis

My argument


There has always been a biopsychosocial minority view

My argument


There has always been a biopsychosocial minority view

The future needs to be shifted away from biomedical to biopsychosocial

John Haslam (1764-1844)

Insanity is "a corporeal disease".



Mental illness is "the peculiar and exclusive province of the medical practitioner" (his emphasis)



Mental illness is "the peculiar and exclusive province of the medical practitioner" (his emphasis)

“[M]adness has always been connected with diseases of the brain and of its membranes”


"[T]he various and discordant opinions, which have prevailed in this department of knowledge, have led me to disentangle myself as quickly as possible from the perplexity of metaphysical mazes."


"[T]he various and discordant opinions, which have prevailed in this department of knowledge, have led me to disentangle myself as quickly as possible from the perplexity of metaphysical mazes."

"[F]rom the limited nature of my powers, I have never been able to conceive . . . a disease of the mind." (his emphasis)

Henry Maudsley (1835–1918)

Donated money to found Maudsley hospital - centre of treatment and research rather than confinement and "asylum".



Expanded scope of Journal of Mental Science to include psychology and philosophy



Expanded scope of Journal of Mental Science to include psychology and philosophy

"The explanation, when it comes, will not come from the mental, but from the physical side”

Aubrey Lewis (1900-1975)

Inaugural chair from 1948 of Institute of Psychiatry which was “Maudsley Hospital Medical School”



Postgraduate psychiatry for “ardent, critical, lively, disputatious and reflective, eager minds.”



Postgraduate psychiatry for “ardent, critical, lively, disputatious and reflective, eager minds.”

Lewis’s sceptical approach to psychiatry may not be enough

Wilhelm Griesinger (1817-1868)

Mental pathology and therapeutics (original German edition 1845)



“Mental diseases are brain diseases”



“Mental diseases are brain diseases”

"It is only from the neuropathological standpoint that one can try to make sense of the symptomatology of the insane”

Ernest von Feuchtersleben (1806-1849)

The principles of medical psychology (originally German edition 1845)



"The notion, mental disease, must be deduced neither from the mind nor from the body, but from the relation of each to the other."



"The notion, mental disease, must be deduced neither from the mind nor from the body, but from the relation of each to the other."

"Psychopathies have no seat; they are combined constitutions which appear in the disturbance of these functions by which the mind is manifested, that is, in the collective personality."

Pluralism in psychiatry (1900-1970)

Psychoanalysis – Freud first spoke publicly in USA at Clark University in 1909



Pragmatic approach of Adolf Meyer - Psychobiology



Pragmatic approach of Adolf Meyer - Psychobiology

Focus on the person

The current scene

1) Underwhelming evidence of efficacy of medication

The current scene


2) Lack of appreciation of environmental factors in psychiatric disorders

The current scene



3) Non-standardised use of operational diagnostic criteria

The current scene




4) Lack of ability to examine the structure and function of the mind directly


About a third of published studies show no difference between antidepressants and placebo



Mean drug–placebo difference in improvement scores is only 1.8 points on the Hamilton Rating Scale for Depression



Mean drug–placebo difference in improvement scores is only 1.8 points on the Hamilton Rating Scale for Depression

Raters' expectations and patients' suggestibility could entirely explain the small effect size

2) Lack of appreciation of environmental factors

Work of the geneticists has been replete with uncritical dogmatic statements and lack of scientific rigour



Despite the hype, genetics of psychiatric disorders so complex that accurate prediction may not be possible



Despite the hype, genetics of psychiatric disorders so complex that accurate prediction may not be possible

Genes only set the boundaries of the possible; environments define the actual


Diagnostic criteria do not solve the dilemma surrounding psychiatric classification



The basic issue is about the meaning of psychiatric diagnosis



The basic issue is about the meaning of psychiatric diagnosis

Too easily assume a diagnosis is an entity of some kind

4) Lack of ability to examine structure and function of the mind directly

Structural and functional cerebral abnormalities are at best subtle rather than gross.



Brain cytoarchitecture itself is fashioned by input from the social environment



Brain cytoarchitecture itself is fashioned by input from the social environment

Even psychosis should be understood in psychosocial terms, rather than reduced to brain abnormalities

Conclusion - Biomedical psychiatry as the Emperor’s new clothes

“Biomedical psychiatry is naked," the child said.

Conclusion - Biomedical psychiatry as the Emperor’s new clothes

“Biomedical psychiatry is naked," the child said.

Biomedical psychiatry could not admit to that. It thought it better to continue the procession under the illusion that anyone who couldn't see its clothes was either stupid or incompetent

Birth pang of a new age?

Questioning the biological basis of mental disorder does not necessarily amount to denial of the reality of mental illness or invalidation of the practice of psychiatry



Avoid the need to objectify those identified as mentally ill



Avoid the need to objectify those identified as mentally ill

Recognise the inherent uncertainty in psychiatry and medicine

THE FUTURE OF PSYCHIATRY IS THE BIOPSYCHOSOCIAL MODEL D B Double.

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