During the development of the
Dear resident, you know better than this "old man" (my title since my 40s when my son reached his teen years) that we live in a complex cosmopolitan world flooded with Internet data such that a Korean pop star can become a worldwide sensation commanding the attention of millions but perhaps be forgotten just as soon. Cataclysmic economic and cultural changes are happening right before our eyes. European countries are floundering but we do not know how far they will fall, while East Asian countries are ascending but we do not know to what heights they can rise. Meanwhile, psychiatry is dominated by the United States (US), while European psychiatrists hold on to their memories
Being a good psychiatrist is a very complex thing, so being raised in a complex world flooded with information is a good thing, but... (there is always a "but" in life) unless you are different from the European and cosmopolitan US residents this "old man" has lectured, your training is seriously flawed. You have 1) no serious understanding of and no "love" for statistics, which is the basis of the scientific approach in medicine, 2) no understanding or interest in the history of the last 2500 years of Western civilization that generated current psychiatric thinking and its flaws, and 3) the tendency to get bored with long, complex readings.
This article places additional information on the more complex issues in tables that can be ignored, but there the interested reader will find some historical context and suggestions for additional reading. Be aware that I am not going to say any more about statistics in the text, since you might immediately stop reading but, unfortunately, an Italian "dude" in the 16th century called Galileo Galilei originated the scientific method of inquiry after stating that the laws of the universe are essentially mathematical laws. Thus, if you want to be a scientist (besides a psychiatrist) you need to thoroughly understand and systematically use statistics. Since most of you only want to be good psychiatrists and do not aspire to become scientists, I have good news. Living in a rapidly changing world that is becoming extensively computerized is not a threat to your jobs; you will not be able to be replaced by computers because psychiatrists must understand people and have a profound understanding of the language and culture of each of their patients. Computers cannot do that. My two older children want to become physicians. My son has a very high IQ, loves computer games and gets bored with homework. He wants to study medicine and become a neurosurgeon to use his computer gaming and programming skills. His sister, my older daughter, has a brain not well suited for reading but corrected that by reading two books a week for years. She is completely fluent in two languages, has lived in two countries and studied a university major in a third language. Unknown to me, she decided to become a physician and a psychiatrist. She has a bright future as a psychiatrist; she can work in the Americas and in large portions of Europe and Africa. There is no way that she can be replaced by a computer. However, I am not sure about the future of neurosurgery in 25 years; a completely automatic robot may retire my son, at least from his surgeries, before he receives the "blessing" of being called an "old man" by his son.
If you are still with me and agree that we live in a complex, rapidly-changing automated world and want to explore with me whether psychiatry is scientific, you are on a complex ride, since I am attempting to sell you things that your professors in medical school and the attendings in your psychiatry residency have not disclosed to you. They assume that psychiatry is scientific. But after publishing more than 200 articles in PubMed, seeing psychiatric patients for 30 years, and working in two countries as a psychiatrist and researcher, I am nearly convinced that the idea that current psychiatry is scientific may be seriously flawed unless you have a good understanding of science's limitations. This is not an original idea; in the last few years, during which the
If you want to determine whether psychiatry is scientific or not, you need to first define what psychiatry is and then define what science is, followed by defining the intersection between them. Unfortunately a third player, medicine, must be brought into this already complex "couple" relationship. In the US, a series of popular books labeled "For Dummies" tries to provide brief, simplified explanations of complex topics for non-experts. Similarly, this article provides brief, simplified versions of topics that are written for psychiatry residents and may be considered as "for dummies" when read by highly critical "experts" on a topic.
To start clarifying whether psychiatry is scientific we must first define psychiatry. It is obvious that psychiatry is a medical specialty. The late Samuel Guze, a US psychiatrist who was chairman at Washington University in St. Louis, wrote an excellent book titled
Next, this section provides simplified histories of psychiatry, medicine, and the first mention of the resistance that a German resident encountered when he tried to introduce scientific thinking to psychiatry 100 years ago.
I know that you may not like history and think it is irrelevant, but I have bad news for you. All psychiatric concepts and even psychiatric language is seriously contaminated by the vagaries of human history, in this case, mainly French and German history.
Psychiatric language has two interrelated levels (symptom and diagnosis levels). The description of psychiatric symptoms and signs is usually called psychopathology
As described above, the NIMH is the leading institution for psychiatric research in the US. Not surprisingly, to compete with others for funding, the NIMH leaders
If psychiatry is a branch of medicine, it may not hurt you to have some understanding of the complex relationship between science and medicine. After three centuries of trying to use the scientific method in medicine, there was a major revolution in medicine in the 19th century. This revolution was characterized by the convergence of three ways of thinking, which have been called anatomoclinical (relating signs and symptoms with disturbances in specific organs), physiopathological (relating diseases or their symptoms/signs with disturbances in normal physiology) and etiopathological (finding specific causes of some diseases and their lesions).
In the opinion of this "old man", Paul McHugh, who was Chairman and Professor of Psychiatry at Johns Hopkins University for approximately 25 years, is one of the few US psychiatrists who will be remembered, due to his acknowledgment of the limitations of US psychiatry in the 20th century. During McHugh's career, US psychiatry moved from a non-scientific approach led by psychoanalysts to a simplistic approach led by psychiatrists believing only in the relevance of biology and presenting an overly simplified view of scientific research (see the next section). In one of his last published scientific articles, brief but authoritative, McHugh summarized the problem with US psychiatric nosology and made recommendations.
Nissl was an outstanding neuroscientist in the early part of the 20th century. At that time the major development in the neurosciences was in histopathology after Ramon y Cajal proposed the neuron theory (as in other tissue, the nervous system is composed of individual cells called neurons, rather than the reticular theory, its opposite, that the nervous system is a network without separate cells). You know his name because Nissl developed one of the most important staining methods for cell bodies and was one of the major neuropathologists of his day. In 1904, when Kraepelin moved to Munich, Nissl became the Chairman of the Department of Psychiatry at the University of Heidelberg. In 1906, a recently graduated medical student, Karl Jaspers, moved to Heidelberg after his physician recommended it. Jaspers had been diagnosed with bronchiectasis at a time were antibiotics were not available; thus he was not expected to live much longer than his early 30s. His physician recommended "a rigid and restricted working routine that was intended to prolong his life" and got him a job as a trainee (today he would be called a resident) in the Department of Psychiatry.
Jaspers thought that the discipline of psychiatry "was crying out for a systematic clarification of current thinking".
Jaspers had the revolutionary idea that "to make real progress psychiatrists must learn to think". "Jaspers ought to be spanked," replied his contemporaries.
Trying to explain what science is will require not a book but an encyclopedia, since the definition of science is even more complex and controversial than that of medicine or psychiatry. This section's purposes are to briefly and simply: 1) define science, 2) review its history, and 3) review the history of scientific education in medical training.
Truthfully, it is not easy to describe what science is or does, which is a difficulty common to all other complex human activities such as art, philosophy or law. It is the reason this "old man" was forced to use as a one-line definition in one of his articles, "Science is a complex trial-and-error historical process led by experts, the scientists,"
Third,
Although Feist
Michael Polanyi began as a physician, then became an internationally known chemist and finally a philosopher of science (see
In the last half of the 12th century, the first universities were founded in Europe. They began to develop the methodological thinking that made it possible to develop the scientific thinking that flowered with Galileo in the 16th century. The scientific developments in the basic sciences of anatomy and physiology, and later of pathology, were incorporated into medical education, leading to the booming medical sciences in the 19th century and, subsequently, the flourishing of medical applications in the 20th century. In this traditional way of educating physicians found in the first two stages, the older the physician, the more wise and experienced he was supposed to be.
Then some physicians at McMaster University in Canada developed EBM in the 1980s and 1990s. The key physicians were Gordan Guyatt, an internist, and David Sackett, a physician and epidemiologist who contributed to EBM's dissemination by moving to Oxford University.
Ioannidis is probably the most influential physician scientist of our day. You are not likely to understand his articles since he loves statistics. He was at the Department of Hygiene and Epidemiology at the University of Ioannina in Greece until he was hired by Stanford University in San Francisco. He has dedicated his career to demonstrating that many published research findings in medicine are false.
If current medicine is 150 years ahead of psychiatry and is full of false findings, this is not good news for psychiatry, which one might expect to be full of false findings in another 150 years.
Labeling Jaspers as a resident is obviously not historically correct since there were no psychiatry residents one hundred years ago, but it is not far from the truth since he was training in psychiatry after completing medical school. His book
Unless you are familiar with philosophical readings, do not try to read
You can read McHugh's books for understanding Jaspers's ideas. The heterogeneity of psychiatric disorders is marvelously described in his excellent textbook
The traditional method of the natural sciences used in medicine is called explanation. For example, if you have Alzheimer disease, this can explain psychotic symptoms. The problem is that, for many of the so-called psychiatric disorders, we have no obvious neuropathological or biological findings. Some psychiatric disorders, such as personality disorders, do not fit the medical model or the methods of the natural sciences. To manage psychiatric patients, a psychiatrist must frequently use understanding, a method from the social sciences such as history, and frequently used by writers to write good novels or theatrical plays. Understanding is used to establish whether a belief could be delusional or could be normal in the patient's culture. It is used to establish whether a depressive mood is part of an adjustment disorder, part of a biological illness such as bipolar disorder, or symptomatic of a severe form of major depressive disorder traditionally called melancholia.
The emigration of German and Centro-European psychiatrists to the US brought psychoanalysis to the US. By the mid-1950s nearly every department chairman of psychiatry in the US was an advocate of psychoanalysis.
The neo-Kraepelinians went to war against US academia, which was dominated by psychoanalysis. A turning point in the war was the publication of Feighner's criteria defining 15 psychiatric diagnoses in an operationalized way.
Andreasen was one of the most influential US psychiatrists during the 1980s and 1990s. She was editor of the
If you ask psychiatric researchers about the challenges of psychiatric research you would probably hear something about the need for more and better technology, but this article proposes a completely different view. This author thinks that the main obstacle to psychiatric advancement is the limitation of psychiatric language. Although this view is called "personal", it is based on ideas that are 100 years old. Descriptive psychopathology, the language developed to try to imitate the anatomoclinical approach of the 19th century medical revolution, reached its culmination in 1912 in France and in 1913 in Germany. As previously described, Jaspers, in the culmination of German descriptive psychopathology, warned us of the precarious position of psychiatry between the natural sciences and the social sciences.
The book reflecting the culmination of French descriptive psychopathology was published in 1912 (one year before Jaspers's book) but it had no impact on English-speaking psychiatry for lack of translation. Chaslin was a seasoned French clinician who, after 25 years of work, published a 956-page book including 350 clinical cases.
German E. Berrios is the retired Chairman of Epistemology and Psychiatry in the Department of Psychiatry at the University of Cambridge in the United Kingdom. At the beginning of this century Berrios reminded us again of the unfortunate methodological position of psychiatry, dealing with hybrid objects (symptoms and disorders),
The science related to methods of knowing is called epistemology. It can be defined as the science that studies the origins and legitimacy of knowledge.
The naïve position that using operationalized definitions of psychiatric disorders resolves all methodological issues in psychiatry is compatible with the simplistic way of thinking of current US psychiatry. However, it is not possible to describe psychiatric concepts independently of the systems used to articulate them.
Berrios wrote two key articles, one on the epistemology of psychiatric symptoms
This "old man" has to acknowledge that he has tricked you. He did not explicitly answer "yes" or "no" to the question, "Is psychiatric scientific?" He is trying to pass along the question to you by providing enough information and additional readings so that you can decide how to answer the question. To be honest, this old man tends to lean to the "no" side; he likes a scientific article written by a psychiatrist and entitled "Psychiatry and the Scientific Fallacy,"
In complete honesty, "the old man" has to acknowledge that the question should be framed differently. The right question is, "Can current psychiatric knowledge survive the critique of an expert using the methods of the natural sciences?" The answer is "obviously not", but it is fair to clarify that much of our other medical knowledge could not survive such a critique, either. As indicated above, psychiatry is 150 years behind medicine and has the added complexity of dealing with a relatively greater proportion of issues better addressed by the social sciences than the natural sciences.
For the majority of you who will only become medical practitioners in the field of psychiatry and not scientists, the important question is not about science; it is, "How can 21st century psychiatrists better help their patients?" The answer proposed by this "old man" is complex. To start with, as "heroes of uncertainty"
This article has attempted to provide a brief, simplified, thought-provoking description of very complex topics for interested 21st century psychiatry residents. The scientific validity of psychiatry has been systematically questioned in the US media during the last few years as the
To start determining whether psychiatry is scientific, it is first defined as a medical specialty using a unique language that has two interrelated levels (symptom and diagnosis levels). The description of psychiatric symptoms is usually called descriptive psychopathology and was mainly developed by French and German psychiatrists in the 19th century. The psychiatric symptoms and signs are organized into psychiatric diagnoses. This is called psychiatric nosology. The foundation for psychiatric nosology was laid at the beginning of the 20th century by a German psychiatrist named Kraepelin. Kraepelin also led the first organized attempt to incorporate the neurosciences into psychiatry at the German Institute for Psychiatric Research. Current attempts by the NIMH to include the neurosciences in psychiatry are marketing the same empty promises used by Kraepelin 100 years ago. Unfortunately, current US leaders do not acknowledge that psychiatry is 150 years behind medicine and that the task is much more complicated than in medicine. This was described by a German psychiatry resident, Jaspers, in 1913, when he published a textbook called
Defining science and what is scientific is even more complex than defining psychiatry or medicine. This is common to all other complex human activities such as art, philosophy or law. Science is a "complex trial-and-error historical process" in which the role of the scientist is crucial. Science cannot explain the "important things in life" and cannot explain itself. Scientists are subjective human beings no different from other human beings and with similar vested interests. Science is threatened not only by those who do not believe in science but also by those who believe too much in it and consider it a source of truth without limitation, which is called "scientism."
A simplified and easy-to-remember theory of scientific discovery (the cha-cha-cha theory) proposed that major advances in science can be explained by a complex mix of 1) "charge" (discoveries solve problems that are quite obvious but the way in which to solve the problem is not so clear), 2) "challenge" (discoveries are explained by a new acknowledgment of the limitations of scientific thinking), and 3) "chance" (serendipitous findings made by "prepared minds"). Unfortunately, the most important aspects of psychiatry, its effective treatments (electroconvulsive therapy and major psychopharmacology agents), were discovered by "chance" rather than scientific planning.
Knowing the role of mentoring is crucial in understanding the history of scientific education for physicians in Western civilization over the last 2,500 years. The history of medical education can be described as three progressive stages: 1) mentoring with another physician; 2) the development of Euopean universities, which slowly introduced scientific thinking in medical education; and 3) the reliance in recent years on the idea that EBM is the answer to all our problems. EBM is seriously limited because medical evidence itself is limited, particularly in psychiatry, and because of physicians' limited skills as practitioners of EBM. In turn, these physicians let experts with statistical expertise from the outside reinterpret reality for them. Ioannidis, a physician with statistical training, has demonstrated that many published research findings in medicine are false. If current medicine is 150 years ahead of psychiatry and is full of false findings, this is not good news for psychiatry, which can expect to be full of false findings after another 150 years.
Jaspers's
The neo-Kraepelinian revolution challenged US academia, which was dominated by psychoanalysis, leading to the
This author thinks that the main problem limiting psychiatric advancement is the antiquated language used in psychiatry. This was emphasized 100 years ago by Jaspers and Chaslin (a French psychiatrist) but has been ignored since it makes psychiatry's scientific methodology very weak. Berrios reminds us again that the unfortunate methodological position of psychiatry, dealing with hybrid objects (symptoms and disorders),
East Asian 21st century psychiatry residents may be particularly ready for the task of recreating the language of psychiatry (a "challenge", according to the cha-cha-cha theory) since they may not be particularly attached to: 1) the 19th century language of descriptive psychopathology developed in France and Germany, 2) the early 20th century Kraepelin nosology and its failure to incorporate the neurosciences in Germany, or 3) the late 20th century US neo-Kraepelinian nosology (
The author acknowledges Lorraine Maw, MA, and Margaret T. Susce, RN, MLT, at the Mental Health Research Center at Eastern State Hospital, Lexington, KY, who helped in editing the article.
History of the relationship between psychoanalysis and science
Including neurosciences in psychiatric nosology
*In 2011, Fibiger
Defining science
Problems with EBM: a personal view
EBM: evidence-based medicine