1 Boring Old Man » need not apply…

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Posted on Sunday 8 January 2012

I’d like to return to the neo-Kraepelinian creed [The Dictionary of Disorder] that drove the DSM-III revision:

^{The Tenets of the neo-Kraepelinian approach:}

^{1. Psychiatry is a branch of medicine.}

^{2. Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.}

^{3. Psychiatry treats people who are sick and who require treatment.}

^{4. There is a boundary between the normal and the sick.}

^{5. There are discrete mental illnesses. They are not myths, and there are many of them.}

^{6. The focus of psychiatric physicians should be on the biological aspects of illness.}

^{7. There should be an explicit and intentional concern with diagnosis and classification.}

^{8. Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.}

^{9. Statistical techniques should be used to improve reliability and validity.}

In my way of thinking, a science is defined not by it’s methodology or theories. It’s defined by the data-base it studies, the targeted phenomenology. So chemistry studies the behavior of chemicals by whatever methods it can happen on to. Physics is the study of the phenomena in the physical world. Zoology is the science that studies animal life; Botany studies plant life. etc. etc.

My particular area of interest has been psychoanalysis. I see it as a science because it has a defined data-base – the private mental experience of the human being. Its methodology is listening in so far as possible to that experience and constructing hypotheses and interventions based on the data. It is not defined by the theories of Freud or anyone else for that matter, any more than psychology is defined by B.F. Skinner or Physics is defined by the thoughts of Albert Einstein. Psychiatry is the study of the broader data-base of abnormal thinking, emotional experience, and behavior – "mental" "illness." And nobody has a bit of trouble knowing which cases fall in the realm of psychiatry, even in lay circles.

When I read the Tenets of the neo-Kraepelinian approach, I want to say, "Says who?" Admittedly, it does only say "approach," but there’s little question that they mean "The Approach" or "The Correct Approach." So when I see a little girl whose life is constricted by a preoccupation with the idea that "the sky is going to fall," my approach "should be on the biological aspects of illness" [chicken little…, follow-up…]? Or when I see a depressed little boy who is eating too much, I should have "an explicit and intentional concern with diagnosis and classification" [it just didn’t come up…]? Those are the kind of cases where my mind calls out, "Says who?" or retorts "ain’t going to happen." I believe the word solipsism applies here [roughly, overvaluing one’s own view as if it’s the only real view]. So I would add things to those Tenets. 6. The focus of psychiatric physicians should be on the biological aspects of illness if there are any biological aspects in the particular case at hand. 7. There should be an explicit and intentional concern with diagnosis and classification if the condition being looked at can be classified as like other similar cases.

There is a particular area where this approach really galls me – Post Traumatic Stress Disorder. It is a very real mental illness, the source of a lot on mental anguish. People with P.T.S.D. have had an experience that left them with residual symptoms:

^{repetative experience [eg repetative nightmares]

altered states of consciousness [dissociation]

trauma specific fears

an altered sense of themselves and the world}

A blog is no place to be encyclopedic about this, but some high points. These patients have unique mental illnesses because the symptoms are based on their specific trauma. Whatever happened to them, it happened unexpectedly and overwhelmed their mind. They spend their time trying to prevent the past – prevent being reexposed to the thing that overwhelmed them. They almost always report feeling broken eg "like a windshield in a wreck – lots of little cracks." They frequently say about their trauma, "I should have been able to handle it" or "It happened so long ago, I should be over it." The biological researchers focus on two things: some biological explanation as to why those afflicted are vulnerable to developing PTSD; some biological factor that explains the resiliency of others who didn’t develop PTSD.

Since the formal description of the syndrome during World War I, psychiatrists and the military have explored this question exhaustively. It was a move forward to get off the biology kick – "Shell Shock" and Resiliency [AKA "Courage"] – and recognize that PTSD is an acquired psychological disorder that can afflict anyone under the right circumstances. So if the biologists think they’re going to find something biological, they’d best find it before they start crowing about it. People with PTSD already think they’re defective, or lack some kind of "resiliency." Part of their recovery is to understand that they are not defective. We don’t need Dr. Charles Nemeroff telling them that they are [because he’s in love with neuroscience]:

Post-traumatic stress disorder: the neurobiological impact of psychological trauma
^{by Jonathan E. Sherin, MD and PhD and Charles B. Nemeroff, MD, PhD}
Dialogues in Clinical Neuroscience. 2011 13(3): 263–278.
[full text online]

^{The classic fight-or-flight response to perceived threat is a reflexive nervous phenomenon thai has obvious survival advantages in evolutionary terms. However, the systems that organize the constellation of reflexive survival behaviors following exposure to perceived threat can under some circumstances become dysregulated in the process. Chronic dysregulation of these systems can lead to functional impairment in certain individuals who become “psychologically traumatized” and suffer from post-traumatic stress disorder (PTSD), A body of data accumulated over several decades has demonstrated neurobiological abnormalities in PTSD patients. Some of these findings offer insight into the pathophysiology of PTSD as well as the biological vulnerability of certain populations to develop PTSD, Several pathological features found in PTSD patients overlap with features found in patients with traumatic brain injury paralleling the shared signs and symptoms of these clinical syndromes.}

A careful parsing of his "body of data accumulated over several decades" comes up mighty thin [but we’re used to that].

But beyond my Nemeroff moment, there’s a larger point. The Tenets of the neo-Kraepelinian approach are, by my definition, unscientific. They define a methodology, not a data set. The neo-Kraepelinians raled unmercifully at the psychoanalysts for stressing their methodology rather than looking at the data. They were correct in the circumstances where that happened. But they do the exact same thing. There are evidences for a biological substrate in a number of mental illnesses, but certainly in nowhere near the majority of people with mental illness. If I wrote The Tenets of the neo-Freudian Approach or The Tenets of the neo-Beckian Approach as if either was the whole story, they would have a justified hissy-fit.

I’m sticking to my guns here – 6. The focus of psychiatric physicians should be on the biological aspects of illness if there are any biological aspects in the particular case at hand. People come to us because they "hurt in their mental." If you don’t want to see or treat all people with mental illness, add a sign to your shingle that says, "people with non-biological mental illness need not apply."

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