Carlos R. Hojaij: Towards a Psychiatric Biology*
Seventeen years ago, I published an Editorial in The World Journal of Biological Psychiatry (2000) commenting on how the predominance of neuroscience under an exclusive objective and materialistic perspective was reducing psychiatry to a simplistic medical intervention, leaving behind its fundamental humanistic aspects. The main issue for this “going off track” was the disregard for Psychopathology.
Reviewing the paper and confronting it to the current reality, it will not be a surprise that psychiatry is in a worse situation. In everyday clinical practice, the patient is seen as just a bureaucratic classified object and a depository of drugs. I think it would be valid to go back to some observations of this Editorial, which could be useful as one more warning, starting with the serious and striking one made by Nancy Andreasen.
In Understanding Schizophrenia: A Silent Spring Andreasen (1998) comments on current research and its results concerning that enigmatic illness and asks what is missing in the picture: ”What is silent in this exuberant scientific rite of spring?” Starting the second answer to such a puzzle, Andreasen asks two other questions: “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.” Andreasen's remarkable editorial can be considered another claim for a re-composition of the whole theoretical constitution and 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 essential facets, turns back to a restrictive organic model. This involution is occurring 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 turning point of this second millennium, Biological Psychiatry runs the risk of becoming a reductionist, mechanistic activity. The big input of Neuroscience into Psychiatry is creating the illusion that everything is there in the images of the brain, in the interior of the molecules and that the solution is the mechanical change promoted by drugs. Most papers in Biological Psychiatry appear to exclude the main object: the Man. Most papers in Biological Psychiatry appear to exclude the main purpose of the research: to convert results to the benefit of Man. Most papers in Biological Psychiatry take Biological Psychiatry as a simple element or a consequence of neuroscience, almost excluding the main part of Man, that is to say, the consciousness. Oddly, research on consciousness is found in Neurology nowadays.
It is possible to define three levels of knowledge in Science 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 descriptive input from the French school followed by the comprehensive organisation of the German school, and the inquisitive search for causes based on the positivist organicism. After a period of intense descriptive scientific psychopathological research with quite a few results in terms of etiology, Psychiatry evolved to a phase of discovering the interior of the brain, preceded by a quite empirical psychopharmacotherapy. The decade of the brain enchants psychiatrists to such a degree that Neuroscience is seen as having the key to all mental problems. In accepting this vision, it could be said: the brain kills the Man.
Biological Psychiatry now exists 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, along with comparative pharmacological profiles of drugs, and almost nothing about psychopathology. Consequence? Until now, no one has been able to state what schizophrenia is. What is even more concerning is the loosening of the ability to recognise a schizophrenic patient, to talk to a schizophrenic patient and to treat a schizophrenic patient. The so-called antipsychotics go directly to the psychotic symptoms. If a schizophrenic is unrecognised because psychiatrists 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: there is no longer a discussion about the many different kinds (qualitative variations) of depression. If someone is depressed (with no psychopathological discrimination at all) it is enough to prescribe a so-called antidepressant.
Of course, Psychiatry is far from the third level of knowledge, the theoretical level, as Psychopathology, the science of Psychiatry, is quite ignored.
Centuries ago, Paracelsus (2007) conceived "diseased" 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, toxics); 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 in parallel with the philosophical (interactionism) conception of the world (or cosmos) developed by Popper (1977). According to him, 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 (1977) conceived the elements of Nature and composes three worlds: the first world of physical objects (open systems of new molecules that interchange some parts with the environment); the second 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 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 the Man mentally ill; which conceives the 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 must incorporate the current knowledge of Biology and conceive Man in his whole dimension, where the psychic life and spirituality are consistent and real parts.
Psychiatrists are clinicians who, in daily life, deal with the suffering of different types of patients with different types and levels of culture; clinicians dealing with the whole life of their patients. 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 any other) or, guided by medical art, just a kind of pressing hand on his shoulder.
Biological Psychiatry should move ahead and become Psychiatric Biology. The patient comes first... always.
References:
Andreasen N.: Understanding Schizophrenia: A Silent Spring (AmJ Psychiatry, 155:12, December 1998).
Ball P. : The Devil’s Doctor - Paracelsus and the World of Renaissance Magic and Science. Arrow Books, London, 2007.
Popper K. & Eccles J.: The self and its brain. Springer-Verlag, Berlin-Heidelberg-New York, 1977.
*Based on an editorial published in Carlos Roberto Hojaij (2000) Editorial, The World Journal of Biological Psychiatry 2000; 1(4): 170-1.
July 20, 2017