David Healy: The shipwreck of the singular
Hector Warnes’ comment
My congratulations to Professor Healy for his overview of etiological trends and changing fashions in Psychiatry. His essay has shown us a healthy skepticism or eclecticism, not taking sides either with the biological or with social reductionism, a touch of dualism (the within or without controversy), a sense of humor and a pessimistic finale: “Until such treatments become possible patients will be left shipwrecked” (p.53). Healy evokes Birnbaum’s (1923) attempts to sort out pathogenic from pathoplastic factors in mental illness, to underline the risks of polypharmacy and to mitigate the trend that a “biobabble would replace a psychobabble” (p. 31) and further, “a dialectical pull between the individual and the environment”. Kurt Schneider (1954) objects to Birnbaum’s distinction between pathogenic and pathoplastic factors on the ground that Birnbaum “ignores the fact that pathogenic as well as pathoplastic factors determine the form of an illness” (p.42). Etiology leads us to admit that most illnesses are not unitary, even in the case of tuberculosis. Statistical correlation has to be distinguished from causation and idiopathic refers to admitting that we don’t know the etiology as yet. Most cases are, therefore, poly-factorial with varying degrees of primary, secondary or tertiary strength of the noxae or the lesion (often biochemical, molecular or autoimmune) which ends up becoming a circular process, one feeding the other into pathogenic activity, of course, under the command of the central nervous system.
“Since the last two World Wars we were inclined to recognize that mental disorders might arise from without and that childhood trauma might lead to psychological problems later in life” (p.19). With amazing clarity, Healy promenades us through all the issues of prevention (primary, secondary and tertiary), cross-cultural issues (it was Kraepelin, who first studied the prevalence of mental illness in Java), the social versus the physical vectors of illness and the rise and fall of the prevalence of illnesses, not always related to poverty, migration, overcrowding or marginality. I must said that Psychiatry has divorced itself from Neurology and has remained fractured and unhappy, to the point that it has grown its own anti-psychiatric movement unlike any other speciality in Medicine. Everywhere we find ‘antibodies’ that attack our own nuclear socio-medical model in the tradition of Virchow. Most likely, Healy would agree that Psychiatry is the Cinderella of Medicine.
Apart from the great advances of the era of Psychoneuropharmacology and the Neurosciences, which have rescued us from disaster, the cure (not the control) of the classical mental illnesses has remained elusive and even we have been overwhelmed with the rise of the autistic spectrum disorders, attention deficit hyperactivity disorder, addictive disorders and suicide. There has also been a diagnostic shift: many patients previously diagnosed as schizophrenia are now being diagnosed as bipolar disorders and neurasthenia or hysteria has been removed from the 5th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association. Follow-up studies have further confounded our earlier diagnoses. Let us face it: we have not seen any real ´breakthrough’ like in other branches of Medicine.
On page 13, Healy stated that “the virtual elimination of mortality linked to bacterial infections, some of the greatest hazard to health from pollution linked to new industries such as the lead and tobacco industries”.
However, let us be aware of the rise of antibiotic resistance and superinfections in Hospital Wards.
We should not lament too much because General Paralysis of the Insane, Pellagra Psychosis, Wernicke’s encephalopathy and many other exogenous psychosis can be treated successfully in most cases, although in Medical wards. A part of Psychiatry has been taken over by Neurology, another part by Medicine and at least a third of it by Psychologists.
Koch’s postulates are not invariably confirmed (he himself became aware of the limitations of his postulates) because there are many asymptomatic carriers or viruses, fungal or bacterial infections, which because of the organism’s immuno-competence does not allow the illness to develop. The most rigorous researchers agree that the Koch’s postulates are sufficient but not necessary for the development of an illness. In this regard, the field of epigenetics have gained importance, particularly, the studies of Ogino, Lochhead, Chan, Nishihara, et al (2013) regarding risk factors for any illness, which are no more, no less than multiple epidemiological associations.
There is a book that applies particularly to our field: Edward O. Wilson’s book ‘Consilience’, published in 1998. Wilson, a socio- biologist, defines human nature as a collection of epigenetic rules and proposes the synthesis of knowledge from different specialized fields of human endeavor. He thus defines consilience as “literally a ‘jumping together’ of knowledge by the linking of facts and fact-based theory across disciplines to create a common groundwork of explanation” (p. 7). More than the genes in many illnesses, it is the epigenetic factors such as old age, viral infections, diet, degree of resilience, stress, etc. that trigger the genes into activity or lead to the mutation of some of them.
Birnbaum K. Der Aufbau der Psychose. Berlin: Springer; 1923
Ogino S, Lochhead P, Chan AT, Nishihara R, et al. Molecular pathological epidemiology of epigenetics: emerging integrative science to analyze environment, host and disease. Mod. Pathol. 2013; 26: 465-84.
Schneider K. Primary and Secondary Symptoms in Schizophrenia. In Hirsch S, Shepherd M, editors. Themes and Variations in European Psychiatry- An Anthology. Charlottesville: University Press of Virginia; 1974, pp. 40-4.
Wilson EO. Consilience: the Unity of knowledge- New York: Alfred A. Knopf; 1998.
April 07, 2016