Psychiatry and the Body

You often hear the statement, “There are no biological tests in psychiatry,” sometimes phrased as “There are no biomarkers in psychiatry.” And Key Opinion Leaders (KOLs) usually make the statement with a kind of finality, as though declaring, once and for all, that the earth circles about the sun. (“KOL” was originally an industry-insider term for prominent psychiatrists willing to step onto the podium in return for a $5000 check. It has become a sardonic sneer.)

The stock phrase that “no biological tests exist in psychiatry” has become a mantra, one of those pieces of conventional wisdom that ensures the field remains “on the couch,” dependent for clinical data on what the patient says. Just imagine cardiology dependent on patients’ verbal accounts of their chest pain. “Hurts here, doc.” Hmmmm, is it heartburn or a heart attack?

The claim of “no biological tests” is so universally made that non-specialists imagine that it must be true. But it’s not. It’s false.

Wow. An error of this magnitude creates hostages. It builds walls that have separated psychiatry from the rest of medicine and given the field a knowledge base with a lot of goofy ideas about unconscious conflict and toilet training somehow gone terribly wrong. The hostages are called patients, who for years were treated as no other patients in medicine, lying on a couch with the clinician, half asleep, seated behind them! How did we go adrift here?

A recent article in the Australian & New Zealand Journal of Psychiatry by Dr Bernard Carroll, a psychiatrist and endocrinologist, says that valid biological tests, including the dexamethasone suppression test (DST), do exist. But almost nowhere in medicine, including psychiatry, are such tests absolute proof of the existence of a given disease. Carroll writes, “Most laboratory tests are probabilistic, not pathognomonic [100% proof] markers of disease” (Carroll, 2013).

In other words, you as a clinician have to work your way along a chain of evidence before you reach the clinical diagnosis.

But that chain of evidence today in psychiatry should involve the physicality of the body: the understanding that mental illness is seated in an organ, the brain, and elsewhere in the body too. Lots of serious depression, for example, involves an axis that runs from the hypothalamus in the brain to the adrenal glands seated atop the kidneys ().‎ This is the reality that separates psychiatry today from the world of Freudism.

It’s not that the KOLs of today, who scorn biological tests, are themselves psychoanalysts. Indeed, many of them have become wealthy on fees from industry, which of course embraces biological models (how else could you understand mechanisms of drug action?). But the KOLs have on their shoulders a heavy heritage of indifference to the body. For decades, the body did not exist in psychiatry. Only the “mind” mattered. And now that the KOLs and their acolytes are all prescribing Prozac, they’re obliged to come to grips with drug interaction, side effects, and all the rest of the biological kit.

But the KOLs face the body reluctantly, with distaste. Many have forgotten how to do a neurological exam and in any case would not perform one even if they remembered. And now the Nosological Rebels, of whom Carroll is a leader, come along and say, “We have tests for knowing if your patient is really depressed.” The tests are comparable to the electroencephalogram in neurology, for knowing if your patient’s seizures correspond to a focus in the brain.

But, hey, these tests mean that you’re going to have to take blood samples and urine samples and get up from your armchair. A century of psychiatry’s history screams “no!” at these ideas. Don’t expect the KOLs to be drawing bloods anytime soon.