Psychiatry and Society

Following a prior posting about the role of psychiatry in society I received a number of comments that I would summarize as reflective of the view that psychiatric illness, maybe not in its entirely but at least to some extent, is a social construct. Also, according to this view, psychiatry is seen as possibly abusing its medical affiliation status by assigning diagnostic labels even to minor emotional and behavioral deviations. Further, such (mis)labeling is thought of as a likely direct contributor to subsequent mental problems.

In this post I will try to briefly address this very important criticism of psychiatry.

The idea that “mental illness is a myth” (championed by psychiatrist Thomas Szaz) traces its origin to abuses or mistakes that have been made by psychiatrists. Masturbation, homosexuality, drapetomania (the runaway behavior of slaves) in this country or the 'sluggish schizophrenia' diagnosed in political dissidents in USSR are examples of labels that have been thought as psychiatric disease in a specific social and cultural context. Further, we now know that chronically institutionalized patients end up displaying symptoms that are a reflection of the institutionalization process rather than of any underlying preexistent biological dysfunction. Psychiatrists should be aware of this past history and remain vigilant about the potential for social abuse that is incumbent in a diagnostic process that is not based on hard biological markers.

However, diagnostic and therapeutic blunders are not limited to psychiatry. In the history of medicine, fevers have been lumped together for centuries under a unique diagnostic category, even though we now know that a fever might be the reflection of very different underlying biological dysfunctions. From a time span of almost 2,000 years—antiquity up to the late 19th century—doctors used bloodletting, an intervention that we now know might do more damage than good, as the preferred intervention for a variety of illnesses. The point is that the science of medicine in general, and psychiatry is no exception here, has progressed by learning from its own mistakes. Further, in the words of Leon Eisenberg in his classic “Psychiatry and Society” article published in the New England Journal of Medicine in 1977, “the fact that a concept or a technology can be misused does not prove its invalidity.”

The charge about mislabeling minor deviations of though, emotion or behavior as mental illness is a more nuanced one. First most philosophers of mind would nowadays agree that all mind functions—including emotions, thought, and behavior—are brain based. Any mental manifestation is a reflection of underlying brain activity. The question then is when one differentiates a pattern of brain activity, what are appropriate criteria to differentiate normal from abnormal?

Now, when it comes to psychiatry, this question cannot be entirely answered by science. And that is because labeling can work both ways. The current discussion about refining the diagnostic criteria for autism in DSM V is a good illustration of this issue.

On one hand, labeling might result in self-fulfilled prophecies. A mental illness diagnosis, that is not warranted, would metaphorically dis-empower a patient who might feel hopeless in wining a fight with an overwhelming biology gone astray. At the same time, a mental illness diagnosis that is warranted would metaphorically empower a patient who would realize he is not a bad person and can, with proper support, win the fight with what would otherwise be an overwhelming biology gone astray.

“Relaxed” diagnostic criteria, while they might mislabel normals as having some sort of mental distress, would also capture the entirety of those who truly suffer and offer justification for social validation and support. Strict diagnostic criteria, while reducing the risk of misdiagnosis, would increase the risk of false-negatives, or of having patients with real mental illness failing the “diagnostic cut” and ending up ineligible for social benefits or other types of support.

The psychiatrist is first and foremost a doctor to his patient. As such his primary responsibility is to help his patient feel better. Not a straightforward responsibility when it comes to patients who are a danger to self or others because of their mental illness. The psychiatrist needs then to protect the patient against himself and others, as society values are not necessarily aligned with a de-stigmatizing view of socially disruptive behavior, even when its due to mental illness.

At the same time, the psychiatrist is a member of society at large, and thus a product of a specific set of values informed by the time and the place. The prevalent cultural view on the sick role, disability, autonomy, competence to give informed consent for treatment, among other values, will inform his practice of psychiatry alongside with his biopsychosocial assessment and plan.

References:

Eisenberg L. Psychiatry and society: a sociobiologic synthesis. N Engl J Med. 1977 Apr 21;296(16):903-10.

© Copyright Adrian Preda, M.D.