{"id":40214,"date":"2013-09-23T18:27:39","date_gmt":"2013-09-23T22:27:39","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=40214"},"modified":"2013-09-23T20:49:26","modified_gmt":"2013-09-24T00:49:26","slug":"a-limit","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/09\/23\/a-limit\/","title":{"rendered":"a limit…"},"content":{"rendered":"\n

<\/a><\/p>\n

It’s not a bad definition as definitions of subjectivity<\/em> go. But the most important part of this Wikipedia entry may well be the broom. Somebody thought this article didn’t live up to Wikipedia’s standards, though they couldn’t exactly come up with a reason. I’ll make a stab at a reason. Wikipedia’s quality standards are based on being objective<\/em>, and subjectivity <\/em>isn’t objective<\/em> – by definition. I can’t even write a sentence about subjectivity<\/em> without encountering that impossibility. That last sentence started with "I" which is the object "me" [there I go again, "I" and "me" are objects]. But enough of that or we’ll all go to sleep.<\/p>\n

Subjectivity<\/em> is the stuff of philosophy, religion, psychoanalysis, books like Douglas Hofstadter’s Gödel, Escher, Bach: An Eternal Golden Braid<\/a>, not blogs, or dictionaries, or encyclopedias. But there is a practical point worth bringing up, "Is subjectivity<\/em> in the domain of medicine, amenable to medical diagnostic classifications like the DSM-5<\/font><\/strong> or the ICD-10 Chapter V<\/font><\/strong>?" Obviously a lot of people believe the answer is "yes," because those books exist and are the topic of much effort, worry, and controversy. The controversy part is in the background of many of the things discussed here as well as most of the comments. That’s not why this particular blog came into being or continues. It’s here because of something to do with objectivity<\/em>. I discovered to my great dismay that people were tampering with the processes we use to approximate objectivity<\/em> [clinical trials of medications] and perverting them to their advantage – a financial advantage. Objectivity<\/em> is a precious enough commodity in psychiatry to deserve preservation at any cost. So I got noisy.<\/p>\n

But back to the relationship between subjectivity<\/em> and medicine. I came into psychiatry at a time of great turmoil, to put it mildly. The more bio-medical psychiatrists were criticizing the psychoanalytic types [with the same criticisms now leveled at our modern bio-medical psychiatrists –  proof]. The post-60s experiential psychologists were attacking both kinds of psychiatrists, and the behavioral psychologists were after all three groups. And that’s a massive over-simplification of the complex circus that was everywhere around. I knew I was in the right place because all that same stuff had been swirling around in my head too. It was fine with me to be in a place where it was all being talked about out loud.<\/p>\n

All doctors deal with human subjectivity<\/em> every day. I hadn’t realized that so fully in training. But in medical practice I realized that people seek medical attention cued by anxiety and fear. Sometimes it’s objective – noticing a scary mole they hadn’t seen before, or seeing their swollen feet – but it’s the anxiety about the observation that signals, "Go to the doctor." More often, it some subjective experience that sets the wheels in motion – a pain, nausea, tingling feet, one of a vast array of symptoms that telegraphs "something’s awry." So subjectivity<\/em> is an integral part of any medical model. Signs<\/font><\/strong> [something objective<\/em>] and Symptoms<\/font><\/strong> [something subjective<\/em>] point to an underlying Disease<\/font><\/strong> confirmed in a myriad of ways. When I was an Internist, every person that was referred to me had symptoms, but the overwhelming majority [75%] didn’t have a disease ["referred to me" because I was a specialist, so all cases came from another doctor]. <\/div>\n

For many, reassurance was the finest of treatments. Like my often told story of the dermatologist who said when I raced to his office with a newly discovered malignant melanoma on my leg, "You think you psychiatrists are the only ones that can cure anxiety. Watch this! That ain’t cancer." But for a notable number of patients, that kind of reassurance didn’t help. And when I started nosing around, there was plenty enough to find that had to do with their subjective discomfort. So when I got to psychiatry and encountered the arguments of Dr. Szasz about the Myth of Mental Illness, I wasn’t much moved. His point is well known to all: because psychiatry operates with no objective<\/em> markers of disease, mental illness is not medical, not science – it’s subjective<\/em>. I didn’t miss his point about the legal position of psychiatrists giving opinions about involuntary hospitalization, testamentary capacity, legal competence or his ideas about the difficulties of the medical model of disease. In fact, I was already there. But the rest of it didn’t seem pertinent, at least to me. Patients with negative subjective<\/em> experience without objective<\/em> findings were the ones that drew me to psychiatry in the first place. They had come to my medical office in droves – close to the majority. I guess I saw psychiatry as the medical specialty that dealt with subjectivity<\/em> and that was fine with me.<\/p>\n

It wasn’t Dr. Szasz that changed psychiatry exactly, but his argument had something to do with it. The psychoanalytic paradigm had reached the stage of exhaustion, its limits and holes showed more than its assets. The Washington University group known as the neo-Kraepelinians were joined by Dr. Sptzer [DSM-III] and many others, and psychiatry changed – not in response to Dr. Szasz, but in reaction to his position. The neo-Kraepelinians of the time even put it in writing<\/a>,  "Klerman [1978; in Blashfield, 1998] identified 9 tenets of the neo-Kraepelinian approach":<\/font> <\/div>\n
    <\/p>\n
  1. \n
    Psychiatry is a branch of medicine.<\/div>\n<\/li>\n
  2. \n
    Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.<\/div>\n<\/li>\n
  3. \n
    Psychiatry treats people who are sick and who require treatment.<\/div>\n<\/li>\n
  4. \n
    There is a boundary between the normal and the sick.<\/div>\n<\/li>\n
  5. \n
    There are discrete mental illnesses.  They are not myths<\/font><\/strong>, and there are many of them.<\/div>\n<\/li>\n

    <\/span> <\/p>\n

  6. \n
    The focus of psychiatric physicians should be on the biological aspects of illness.<\/font><\/strong><\/div>\n<\/li>\n
  7. \n
    There should be an explicit and intentional concern with diagnosis and classification.<\/div>\n<\/li>\n
  8. \n
    Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.<\/div>\n<\/li>\n
  9. \n
    Statistical techniques should be used to improve reliability and validity.<\/div>\n<\/li>\n

    <\/span><\/ol>\n

    If you had asked me in 1980 what they meant by "the biological aspects of illness"<\/font><\/strong>, I would’ve said I thought they were talking about causality. At the time there was much discussion about the catecholamine and the dopamine hypotheses, and what I called the NIMH Neuron Slide<\/font><\/strong> was in most presentations. There were some potential biomarkers in melancholic depression – the dexamethozone supression test and REM Sleep Latency. But in retrospect, maybe they were talking about "biological"<\/font><\/strong> treatments all along, because that’s how things have played out. I think if you had asked them then, they would’ve said "both," but that’s just a guess. There is one thing I’m sure of – anything "psychological" as opposed to "biological" was not, in their opinion, a legitimate part of psychiatry.<\/div>\n

    <\/p>\n

    I feel as detached from these lines of thought [Szasz and\/or the NeoKraepelinians] as I did when I heard them for the first time thirty or forty years ago. And I’ve heard them so much over the years since that I bet if we had a role-playing game, I could pass for someone who was a zealot in either camp. In fact, I could likely be more convincing in one of those roles than if asked to play my own [role]. Those positions are so definite and clearly defined. Mine isn’t. But one thing I would say is this:<\/div>\n
    \n
    A science is not defined by it’s methods or its procedures. It’s defined by what it observes. Botanists observe plants. Zoologists study the things found in Zoos [AKA animals]. Physicists study the things that happen in the physical world. Neuroscientists study the things that have to do with the brain and nervous system. Entomologists study insects. Physicians study people who are sick, have diseases or dis-ease. I came to psychiatry  drawn to study and to work with the people who had mental illness [hurt in their mental by their report]. And I learned about learning theory, and psychoanalysis, and existentialism, and brain chemistry, and hormones, and medicines, and sociology, and about war and its consequences, and about sex, and violence, and about human relationships, and a jillion other things. And I heard a library full of of narratives along the way, each one with its own twists, turns, and tangles. So I guess I see psychiatry as the science that looks at people who hurt in their mental, and its methods as anything that addresses that data field. By my read, that might be simplified to the study of painful human subjectivity. From my perspective, it’s part of medicine because I try to do something about it – just like I do when I put my Internist hat back on. Same basic rules. And what I do depends on the case, not my favorite basic science. <\/div>\n<\/blockquote>\n
    I am sure that’s not what every psychiatrist would say, even my best friends or closest colleagues. The biologists would go one way, the analysts another, and the psychologists in many other directions. But the difference doesn’t seem to matter either way. I doubt any of them are devoted to Thomas Szasz or are neoKraepelinians, but I’ve never asked.<\/div>\n

    <\/p>\n

    For readers who come here frequently, you’ll have guessed that this post is partially about the onslaught of contentious comments in the recent weeks. I finally lost patience. It wasn’t the Szasz, so much as it was using the comment section here as a private, agenda-driven blog. So for only the third time in eight years, I did something I didn’t want to do and blocked that commenter. And this particular post is to say that while this blog is mainly about corruption in medicine and specifically in psychiatry, I obviously talk about what’s on my mind like in this post and enjoy reading about what’s on your minds as well, even the negative stuff. But I apparently have a limit to my willingness to be endlessly preached at… <\/div>\n","protected":false},"excerpt":{"rendered":"

    It’s not a bad definition as definitions of subjectivity go. But the most important part of this Wikipedia entry may well be the broom. Somebody thought this article didn’t live up to Wikipedia’s standards, though they couldn’t exactly come up with a reason. I’ll make a stab at a reason. Wikipedia’s quality standards are based […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-40214","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/40214","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=40214"}],"version-history":[{"count":24,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/40214\/revisions"}],"predecessor-version":[{"id":40238,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/40214\/revisions\/40238"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=40214"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=40214"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=40214"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}