David Healy: The Shipwreck of the Singular
Hector Warnes’ comment on Shridhar Sharma’s comment

                 Sharma cites one of Healy’s central points of view:“Clinical practice is becoming degraded and there is an increasing need for clinicians to relearn the skills of listening to, seeing and touching patients.”  He further dazzled us with a historical account of the concepts of disease and citing Hippocrates he writes: “Human well-being is influenced by the totality of environmental factors, living habits, climate and the quality of air, water and food,” a statement which is still valid today. 

            Galen’s four temperaments (choleric, sanguine, melancholic and phlegmatic), along with the degree of emotional sensitivity versus stability (neuroticism) and introversion (inward) versus extroversion (outgoing),have been used since Ivan Pavlov (in dogs) by Carl Jung and Hans Eynsenk in research profiles. Jerome Kagan (Kagan et al. 1994) brought to our attention an excellent study of Pavlov’s types of nervous system of dogs (excitation versus inhibition) and the four Hippocrates-Galen’s temperaments which were further elaborated by Eysenck with his scale of Neuroticism (degree of emotionality versus stability) and C.G. Jung’s degree of extroversion versus introversion. It must be noted that they are not indelible characteristics because, as Jung put it,every extrovert has an introverted quality in his unconscious and viceversa.  Also, Jung further studiedthe functions which are more prevalent in each introvert or extrovert and noted that it could be thinking type, feeling type, sensation type or intuitive type (Ruch 1992), as well explored Pavlov’s and Eysenck’s research and the fourHippocratic-Galen temperaments.  

            Sharma further quotes Virchow who in 1895 wrote: “…Disease is a living entity, which has a parasitic relationship with the otherwise healthy body, to what it belongs and at the expense of what it lives.”  Sharma, with great acuity, writes: “…What is not clear is the specificity of the relationship between particular psychiatric illness and particular physical disease… unless we identify common factors that could have etiological significance and could help us in identifying populations at risk.”

            This statement brings us closer to a holistic view of medicine which was masterfully underlined by Martin Picard and Bruce McEwen in a 2018 publication on psychological stress and mitochondria.  As we know,McEwen wrote extensively on homeostasis and allostasis, from an experimental and clinical point of view, and their role in disease (allostatic load) (McEwen 1998).  The mitochondria, with its own genome, generates signals that enable stress adaptation and mitochondrial dysfunction which affects the brain, the endocrine system and the immune system. 

            The classical concepts of illness, as proposed by Virchow, Pasteur, Semmelweis and many other brilliant investigators who were responsible for the leap forward of medicine, would have to take into account the fact that not   all patients exposed to the same virus or bacteria would develop the disease and that many other factors play a role in disease onset and evolution.

            Most of these factors are carefully sorted out by McEwen.  From George Engel’s 1978 biopsychosocial model to the psychoneuroimmunology frame of reference developed by Hans Selye (1977); to the role of the allostatic load model of chronic stress in disease; to molecular biology, particularly the research on shared molecular neuropathology across major psychiatric disorders by Michael J. Gandal and associates (Gandal et al. 2018) in a control study of 700 patients compared with 700 controls; and, finally, to the outstanding follow-up research on hormonal contraception and depression among nearly four million Danish women who were followed up for an average of 8.3 years (Skovlund et al. 2018).  Those who took the pill were more likely to die by suicide than those who did not.

            There is other research which has shown that perhaps the so-called seasonal affective disorder might respond better to vitamin D at the time of the year when there is little sunshine or that ketamine has a good antidepressanteffect on the elderly patient and so on.

            I would like to congratulate Professors Healy and Sharma for continuing to excite a most vigorous debate on the crucial issues of psychiatry.  We might have different opinions about the major breakthroughs in psychiatry but we are likely to agree on most of the major breakthroughs in medicine as a whole.However, we must not forget Professor Sharma’s sentence quoted above about the specificity and intimate relationship between the brain, the body, the subjective, the intersubjective and the environmental aspects of every disease (Umwelt, Mitwelt und Eigenwelt).

References:

Engel GL. The biopsychosocial model and the education of health professionals. Ann N Y Acad Sci. 1978 Jun 21; 310:169-87.

Eysenck, H.J. and Eysenck S.B.G Manual of the Eysenck Personality. 1975.Hoddard and Stoughton, London.

Gandal MJ, Haney JR, Parikshak NN, Leppa V, Ramaswami G, Hartl C, Schork AJ, Appadurai V, Buil A, Werge TM, Liu C, White KP; CommonMind Consortium; Psych-ENCODE Consortium; PSYCH-BROAD Working Group, Horvath S, Geschwind DH.  Shared molecular neuropathology across major psychiatric disorders parallels polygenic overlap. Science. 2018 Feb 9;359(6376):693-697.

Kagan, J., Snidman, N., Arcus, D., & Reznick, J. S.Galen’s Prophesy: Temperament in Human Nature. New York, NY, US: Basic Books.1994.

Jung, C.G. PsychologischeTypen. RascherVerlag, Zürich. 1921.Translated by H.G. Boyne.

McEwen BS. Stress, adaptation, and disease. Allostasis and allostatic load. Ann N Y Acad Sci. 1998 May 1; 840:33-44.

Picard M, McEwen B. Psychological Stress and Mitochondria: A Conceptual Framework.  Psychosomatic Medicine: February/March 2018 - Volume 80 - Issue 2 - p 126–140.

Ruch, W. Pavlov’s types of Nervous System, Eysenck’s typology and the Hippocrates-Galen temperaments.  New York: Basic Books. 1992.

Selye, H. Stress in Health and Disease. The British J. of Psychiatry. Vol.131, Issue 4, Oct. 1977.

Skovlund CW, Mørch LS, Kessing LV, Lange T, Lidegaard Ø.Association of Hormonal Contraception With Suicide Attempts and Suicides.  Am J Psychiatry. 2018 Apr 1;175(4):336-342.

October 4,2018