David Healy: The Shipwreck of the Singular
Hector Warnes’ comment on Robert Cloninger’s comment
Professor Cloninger rightly observes that Healy´s paper isflawed with dichotomies which “undermine the integrated understanding of precise person-centered care.” What Professor Cloninger identifies as dichotomies are encountered every day in our praxis: nature versus nurture, biomedicineversus social medicine, biology versus epidemiology and so on.
I do agree that the same cause may have multiple outcomes (multifinality) and that different causes may have the same outcome (equifinality): “Such complexity of non-linear dynamical systems is a strong characteristic of all common medical disorders in general and health-care systems”(Cloninger, Salvador-Carulla, Kirmayer et al. 2014).
The deterministic and reductionistic approach has been challenged even in experimental or molecular biology; the physical, mental and social well being are, as Prof. Cloninger puts it,“inextricably intertwine and highly correlated.”He insists on the search for excellence and continuity of care, a person-centered and people-centered health care.
Professor Cloninger integrated understanding of precise person-centered care.
He concedes that Healy “is rightly concerned about the negative influence of market forces onwhat we do in clinical practice.” Further, he noticed that in his experience “diagnosis in clinical practice is more often, but not always, dehumanized, impoverished and unreliable compared to the rich information previously available, when people actually listened to their patients in a person-centered manner.”
This sober appreciation becomes a demand for an impossible task: “to establish a balance among biological, psychological and social approaches to health care.”In our short history of psychiatry, I have not seen such.
I would further agree with Professor Cloninger that we need to identify subpopulations that differ in susceptibility to diseases and responses to various treatments. Though Cloninger quoted that they found eightsubtypes of schizophrenic disorders with distinct clinical features associated with specific clusters of genes, I am plagued with doubts because if the gold standard of science is prediction and verification, it is currently far from our vision.
There is little precision or reliability in predicting disease causation or outcome measures, perhapsbecause the variables are too many to control or deal with.
Cloninger's quest for integration has so far been a fiasco maybe because of competing schools of therapies, personalities involved, chemical agents, social settings and backgrounds all playing havoc with the chronic patient. It is not unusual that the matching of a good doctor and a difficult patient does help the patient more that the latest drug available, which when prescribed by another doctor would have been useless.
The reductionist trend still prevails in spite of the dictum of Gestalt psychology:
“the whole is greater than the sum of its parts.” Integration is difficult to achieve because of discontinuity of care, social-family dysfunction and lack of specificity in the selection of the best approach for the particular patient.
Although the message of Healy is pessimistic, his metaphor of the unpredictable sea tempest and the likelihood of a shipwrecked patient should be analysed more thoroughly. We all would like our patients to reach a secure and safe harbour, to feel containment and protection and at last self-realization. We are unfortunately uncertain and most of the time we facethe future in probabilistic terms.
In other words,epigenetic changes are influenced by life style, age, the evolution of the illness, the environment, the family, the inevitable adversities of life and so on. Epigenetic changes are likely to activate or deactivate genes in a random or unpredictable way.
Fortunately for us, neurogenesis and neuroplasticity are sometimes set in motion in the most fortunate manner. There is a balance between the genome and the connectome. The latter includes the mapping of all neural connections within an organism's nervous system:the network or connections forming the human brain, the capacity of connectivity that would make the crucial differences in health and or illness.
We also know that the genes can be turned on and off and that epigenetic modifications are triggered by histone changes, DNA methylation and gene silencing or activity. Lin Lu et al. (2003) have demonstrated clear modifications of hippocampal neurogenesis and neuroplasticity by social environments.
Finally, I must confess that Mario Bunge, who would be considered a philosopher supporting the theory ofan Emergentist Psychoneural Monism,captured me in fascination for his views of the mind-brain interaction when he wrote:
“All mental states, events and processes are states of or events and processes in the Central Nervous SystemThe states, events and processes are emergent relative to those of the cellular components of the Central Nervous System”(Bunge 1980).
The so-called psycho-physical relations are interactions between different subsystems of the Central Nervous System or between many other components of the organism and its environment.
I appreciate very much the optimism of Professor Cloninger and in particular his outstanding contribution to our field, but I must also give credit to Professor Healy’sbrilliant assessment of our current reality and some of his dismal predictions of a shipwreck in sight. I would not say that he has gone too far, nor that he is Cassandra in our midst.
Bunge, Mario. The Mind-Body Problem, a psychobiological approach. Pergamon Press, 1980.
Cloninger CR, Salvador-Carulla L, Kirmayer LJ, Schwartz MA, Appleyard J, Goodwin N, Groves J, Hermans MHM, Mezzich JE, van Staden CW, Rawaf S. A Time for Action on Health Inequities: foundations of the 2014 Geneva Declaration on Person- and People-centered Integrated Health Care for All. International Journal of Person-centered Medicine 2014; 4(2): 69-89.
Lin Lu, G. Bao, H. Chen, et al Modification of hippocampal neurogenesis and neuroplasticity by social environments. Experimental Neurology, vol. 183 (2), pp. 600-609, Oct. 2003.
September 13, 2018