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Thursday, 25.05.2017

David Healy: The  Shipwreck of the Singular

Per Bech’s comment

 

In his book Intelligence: The psychometric view, Paul Kline (1991) concluded that the concept of intelligence was used by people long before Spearman in 1904 at Wundt’s laboratory in Leipzig developed factor analysis to identify the general factor of intelligence. However, Kline (1991) emphasized that this concept was more precisely measured by factor analysis: “In the light of all the evidence, to write intelligence off as a redundant abstraction seems absurd”.

Now, the concept of “nervous breakdowns” as discussed by David Healy is also a concept people used long before Freud and Kraepelin developed psychoanalysis and psychometric analysis, respectively. They both referred to the diagnostic categories of “nervous breakdowns” listed in Table 1 with reference to the current ICD-10 classification.  Mental disorders where the etiology is part of the diagnosis have been excluded, i.e. organic mental disorder, substance use disorder, and reaction to severe stress.

 

Table 1

The diagnostic categories of nervous breakdowns in ICD-10

Code Number

Diagnosis

F48

Neurasthenia

F45

Somatoform disorder

F42

Obsessive-compulsive disorder

F41

Panic disorder

F40

Phobias

F33

Depression

F30

Mania

F20

Schizophrenia

 

As noticed by Roth (1967): “In his long lifetime, there is not a single new entity that Freud defined despite his remarkable inventiveness and imaginative insight”, i.e. even Freud accepted the diagnostic categories in Table 1, which Kraepelin also used in his prognostic studies. However, when Kendell (1983) focused on the failure in the DSM-III to define mental disorder and its consequences, he concluded: “Until we are able to define what we mean by mental disorder, the term is bound to remain a term of convenience, at the mercy of social forces and political pressures of very varied kinds”. These words are indeed prophetic in regard to David’s very comprehensive story of the “Shipwreck”.

Among these forces and pressures David focuses on the Industry, Biological psychiatry, Social psychiatry, and especially on Big Pharma and Big Risk. When going through these factors, I read the paper by Shepherd (1995) for the first time. Here Kraepelin is blamed for the holocaust although he died in 1926. In another case, it was Mogens Schou and his demonstration of the anti-manic effect and prophylactic effect of lithium in both mania and depression that Shephard (Blackwell, Shepherd 1968) discussed with the same venom. Neil Johnson (1984) has described Shepherd’s attacks on Mogens Schou at several meetings in Europe. However, David makes no reference to lithium which is probably the most specific drug we have in psychiatry without Big Pharma’s involvement. The study by Eve Johnstone and her group (1988) is a most elegant confirmation of the work performed by Mogens Schou. In a randomized, controlled, double-blind trial, all patients consecutively admitted with psychosis were either treated with lithium, pimozide, a combination of these two drugs, or with placebo. Assessed by rating scales, but not by diagnosis, pimozide was superior on the Manchester version of the Brief Psychiatric Rating Scale (BPRS) and lithium was superior on the Mania Scale (MAS).  It is actually such a study involving the total flow of the patient group under examination, David is looking for.  It is also seen from his perspective that newer drugs, such as the antipsychotics olanzapine and quetiapine or the antiepileptic valproate, were found inferior to lithium in another UK study when used in the maintenance therapy of patients with bipolar disorder (Hayes, Marston et al. 2016).

It was good to see in the Shepherd (1995) article that Kraepelin’s pharmacopsychology had obtained the high research perspective it deserves. Kraepelin’s approach forms the background for the Pharmacopsychometric Triangle illustrated in Figure 1 (Bech 2012, Bech 2015). Our research unit introduced in clinical psychiatry the item response theory models by which the scalability of rating scales (whether the total score of the items is a sufficient statistic for measurement) can be psychometrically tested. Examples of these scales are the Bech-Rafaelsen Mania Scale (MAS), the brief Hamilton Depression Scale (HAM-D6,) and the brief Positive and Negative Symptom Scale (PANSS6) (Ostergaard, Lemming et al. 2015) which all have acceptable scalability in measuring outcome of treatment.

 

At (A), the desired clinical effect (the magic bullets of Big Pharma); the undesired side effects (Big Risk) at (B); and the patients’ own self-reported well-being at (C), which can be seen as expressing the balance between desired versus undesired drug effects. The rating scales used by the clinician in (A) versus (B) cover items requiring an action of the part of the therapist.

In his 1967 paper, Martin Roth (1967) makes a major attempt to describe the nature of the clinical interview for a case of “nervous breakdown”. This interview consists of: “the implicate formulation of hypotheses at frequent intervals, these lead to modification in the direction and character of the examination according to whether the clinical findings elicited provide support or refutation …Hypotheses formulated at one point in the interview may be abandoned shortly after, others pursued to a further stage”. Therefore, Roth recommends the use of brief scales when performing his type of interview.

Both Freud and Kraepelin were physicians. The family doctor, the physician, is the most competent person to evaluate and treat a case of ‘nervous breakdown’ because he or she is able, on the one hand, to screen for somatic disorders which might complicate the case, and, on the other hand, to assess the pharmacopsychometric triangle (Figure 1). The physician is also competent to diagnose “recovery”.

As discussed by David, the issue of social psychiatry as rebadged by the Global Mental Health movement is a very serious factor to take into account with the establishment of a Department of Public Mental Health (PMH) at King’s College London in 2009. It has nothing to do with the well-being therapy developed by Fava and his group in Bologna (Topp, Ostergaard et al. 2015, Fava, Bech 2016).

In his Persuasion and Healing, Frank (1961) made an attempt to define mental disorder with reference to Table 1. He used Kraepelin’s hierarchical rank order. Thus, the neurotic disorders (F40-48) were considered to be disorders characterized by unsuccessful adaptation to stress. Failures of adaptation are here determined by an imbalance between environmental stress and the person’s susceptibility to it. With regards to the ICD-10 F codes of depression, mania, and schizophrenia (Table 1), Frank (1961) took into consideration a more and more biologically orientated factor. The neurotic disorder he called “demoralization”, which refers to persons conscious of having failed to meet their own expectations or those of others. They feel powerless to change the situation or themselves. They are candidates for psychotherapy. Concerning the diagnosis of “recovery”, Frank (1961) stressed very clearly that the different schools of therapy had little in common in the definition of “recovery”.

It was Wilhelm Wundt who with a degree in medicine established the first University Laboratory in Psychometrics in Leipzig in 1879. He was, as were Kraepelin and Freud, familiar with Kant’s dialectic of “das Ding an sich” versus “das Ding für uns”. Bryan Magee, the distinguished Honorary Senior Research Fellow in the History of Ideas as King’s College, London, has in his monograph on the philosophy of Schopenhauer (1983) shown how Freud, Kraepelin and finally Ludwig Wittgenstein reached a realistic phenomenological perception of mental states (“das Ding für uns”) by taking into account that in our consciousness we continuously have “das Ding an sich” in operation. The skilled perception in operation when physicians such as Freud, Kraepelin or Frank arrive at the diagnosis of “nervous breakdown” and, after the appropriate treatment, arrive as the diagnosis of “recovery” is very clearly formulated by Wittgenstein in his Philosophical Investigations(1953), paragraph 275:

“Look at the blue of the sky and say to yourself “How blue the sky is!” – When you do it spontaneously – without philosophical intentions – the idea never crosses your mind that this impression of colour belongs only to you. And you have no hesitation in exclaiming that to someone else. And if you point at anything as you say the words you point at the sky. I am saying: you have not the feeling of pointing-to-yourself, which often accompanies ‘naming the sensation’ when one is thinking about ‘private language’. Nor do you think that really you ought not to point to the colour with your hand, but with your attention. (Consider what it means to ‘point to something with the attention’).”

 

It was actually Goethe who stimulated Schopenhauer to develop his dialectic on “das Ding für uns”.  In the process of writing his novel on “nervous breakdowns”:  “The sorrows of young Werther”, Goethe himself suffered from a deep depression, which is covered in the first part of the novel. Concerning his own depression, Goethe actually says in “The sorrows of young Werther”: “Wir wollen es also, … als eine Krankheit ansehen und fragen, ob dafür kein Mittel ist”. However, by the very process of writing the novel, he “recovered”.  In the terms of Freud, this constitutes a contra-phobic reaction. Before Freud, Shelley also described this reaction from Goethe in the words: “…to hope till hope creates from its own wreck the thing it contemplates” (Bevan 1938).

 

To write mental disorder off as a redundant abstraction would seem as absurd as Kline (1991) found it would be for intelligence. We have the mental categories (Table 1), but we also have, as concluded by David, an increasing need to relearn the skills of perception when listening to, seeing, and touching patients. However, only skilled physicians have the license to treat patients, and only patients can be in the process of “recovering”. The physicians are recommended to follow the triangle outlined in Figure 1. They should never forget Kelly’s “first principle”: “If you don’t know what is wrong with a patient, ask him or her; he or she may tell you” (Kelly 1955, Bech 1993).

 

In conclusion, this psychometric view of David’s cases of “nervous breakdowns” should be considered as one way to obtain a non-reductionistic contact between the individual family doctor and his or her patient. With “das Ding an sich” as the will to live and with “das Ding für uns”, as measured by skilled perception, self-reported or physician-reported. This psychometric view is obviously only one way to look at things, but still a major element with which to get David’s ship afloat again.

 

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Per Bech

May 19, 2016