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Carlos R. Hojaij: From Biological Psychiatry to Psychiatric Biology*

 

         In the Editorial ”Understanding Schizophrenia: A Silent Spring,” a commentary on contemporary research and its results for that enigmatic illness, Nancy Andreasen (1998) asks a few questions to complement the picture:

"What is silent in this exuberant scientific rite of spring?”

“Where is the good, old-fashioned clinical research?"

"Where are the studies that examine epidemiology, descriptive psychopathology, and course and outcome?”

         Andreasen finishes the editorial by making a significant call: “Therefore, we need to make a serious investment in training a new generation of real experts in the science and art of psychopathology. Otherwise, we high-tech scientists may wake up in 10 years and discover that we face a silent spring. Applying technology without the companionship of wise clinicians with specific expertise in psychopathology will be a lonely, sterile, and perhaps fruitless enterprise.”

         It is now nearly 20 years since the questions were asked and the call was made. Now we ask: what has been done so far? How much have we improved in terms of psychopathology? How much have we touched the schizophrenia core? How better -if so- are we understanding the schizophrenic under a psychopathological dimension?

         That remarkable editorial was another assertion for a re-composition of the whole theoretical constitution and the practical role of Psychiatry. It is interesting to note how Psychiatry, after a period of immense enthusiasm looking for the specific organic factors for mental illness (following a restricted medical model under the philosophical influence of positivism), passing through the rich period of the Jaspersian psychopathology and consideration (sometimes abusive) of cultural, social and existential perspectives, returns to a restrictive organic model. This involution happens to be in a period of intense development of Neuroscience and at a time of extraordinary progress in biology (molecular and evolutionary). This involution is contradictory, since modern Biology takes into consideration the whole Man as a product of Nature.

         At the beginning of this second millennium, Biological Psychiatry still runs the risk of irreversibly becoming a reductionist, mechanistic activity. The substantial input of Neuroscience into Psychiatry created the illusion that everything is there in the images of the brain, in the interior of the molecules and the solution is the mechanical change promoted by drugs. Most papers in Biological Psychiatry essentially exclude the main object: the Man. Most papers in Biological Psychiatry practically exclude the main purpose of the research: to convert the results to the benefit of Man. Most papers in Biological Psychiatry take Biological Psychiatry as a simple element or a consequence of neuroscience, excluding the main part of Man, that is to say, the consciousness. Oddly, research on consciousness nowadays is mainly found in Neurology.

         It is possible to define three levels of knowledge in Medicine and, as a consequence, in the foundations of a scientific Psychiatry: a preliminary descriptive knowledge of the disease; an investigative knowledge of the causes of the disease; and a comprehensive theoretical knowledge about the disease. In the 19th Century Psychiatry received the descriptive input of the French school followed by the comprehensive organization of the German school and the inquisitive search for the causes based on the positivist organicism. After a period of intense descriptive, scientific psychopathological research with quite a few results in terms of aetiology, Psychiatry evolved to a phase of discovering the interior of the brain and proceeded to a quite empirical psychopharmacotherapy before reaching the current sophisticated stage (but dominated by the “me too” drugs). The decade of the brain-enchanted psychiatrists proceeded to such a degree that Neuroscience became the discipline having the key to all mental problems. We could say: the brain is killing Man.

         Biological Psychiatry is living in a period that excludes the first phase of knowledge, giving only importance to etiological investigation. Schizophrenia is the best example: thousands of papers have been written concerning brain mechanisms and images, comparative pharmacological profiles of drugs and very few about psychopathology. The consequence? Until now, we continue to ignore what schizophrenia is. What is even more preoccupying is the loosening of the ability to recognise a schizophrenic patient, to talk with a schizophrenic patient and to treat a schizophrenic patient. The so-called antipsychotics (because they do not eliminate the psychosis) go directly to the psychotic symptoms and make the schizophrenia mute. If a schizophrenic is unrecognized because scientists are not making use of the main psychiatric tool, psychopathology, how can it be expected that a real understanding of the causes of the illness will be reached? Depression is another good example: usually there is little discussion in clinical practice about the many different kinds (qualitative variations) of depression. If someone is depressed (no psychopathological discrimination at all) it is enough to prescribe a so-called antidepressant; the depression will be mute.

         Of course, Psychiatry is far from the third level of knowledge, the theoretical level, as psychopathology, the science of Psychiatry (practice), is quite ignored.

         Centuries ago, Paracelsus (Hall,1980)  conceived disease and healthy to be determined by five entities: astral (determinants from the cosmos in the genesis of disease); venemi (elements from the world, harmful substances, toxins); natural (pre-established determination, natural destiny, pathological inheritance); spiritual (diseases provoked by psychic and spiritual cases); and god (covering the four previous entities and dealing with healing, return to normality). This is a visible, holistic approach having its similitude with Hippocrates (Entralgo,1976), and runs parallel with the philosophical (interactionism) conception of the world (or cosmos) developed by Popper (1984). According to this author, the evolutionary events of Nature may be considered in six steps: production of the first elements, liquids and crystals; the beginning of life on Earth; the sensibility; the appearance of the consciousness; the appearance of language and theories; and the mental products. From then on, the Self (or person) is configured. Continuing his thoughts, Popper conceived the elements of Nature and composed three worlds: the first, the world of physical objects (open systems of new molecules that interchange some parts with the environment); the second, the world of subjective experiences (sensitivity as an animal’s conscious and consciousness; consciousness of death, where mental states are accepted as real since they interact with the body); and the third, the world of products of the human mind (language, theories concerning the Self, Death, Art, Science).

         Without philosophy, any science runs the risk of losing itself in the pragmatic moment. Biological Psychiatry is in need of a philosophical background that gives a comprehensive understanding of Man mentally ill; that conceives Man as one more product of Nature that evolved from fragments of the cosmos to the highly developed complexity of brain and consciousness; a Man that, interacting with the cosmos, is able to develop himself and create the numerous products of his mind. Therefore, numerous factors from the complete environment (from physical, chemical and energetic to socio-cultural and psycho-spiritual) must be taken into consideration in the process of the making of a mental disease. It is already well-known that not only the phenotype is affected by the environment, but the genotype as well. Biological Psychiatry should incorporate the current knowledge of Biology and conceive Man in his whole dimension, where the psychic life and the spirituality are each a consistent and real part.

         In the year 2000, The World Journal of Biological Psychiatry was freely distributed to 6,000 psychiatrists around the world. More than 90% of its readers were clinicians who, in daily life, were dealing with the suffering of different types of patients with different types and levels of culture; clinicians dealing with the whole life of their patients. We are inclined to suppose that nowadays the same proportion of clinicians are reached by or read psychiatric journals. These consultant psychiatrists have in front of them, from the first moment, a whole suffering human being who is asking for help. In the end, the psychiatrists will provide an effective answer to the patient, no matter whether that answer is a real solution emanating from science (the traditional empirical one) or, guided by medical art, just a kind of reassuring hand on the shoulder.

         Biological Psychiatry should go ahead and become Psychiatric Biology. The patient comes first... always.

References:

Andreasen N. A silent spring. Am J Psychiatry 1998; Vol. 155, No. 12, pp. 1657 - 1659.

Entralgo PL. La Medicina Hipocratica. Madrid:  Ediciones Castilla SA; 1976.

Hall MP. Paracelsus, His Mystical and Medical Philosophy. Los Angeles: Philosophical Research Society Publication; 1980.

Popper K, Eccles J. The Self and its Brain: An Argument for Interactionism. London:  Taylor-Francis; 1984.

 

* Based on Editorial published in The World Journal of Biological Psychiatry, 1:4, 170-171, 2000.

July 13, 2017