Tuesday, August 4, 2009

Psychiatrists, Pain Specialists, and the Physicalist Fallacy: Who Are the "Real" Doctors?

You know the drill, but in case you have repressed it, the antipsychiatry mantra goes something like this: “Real” disease is present only when we can point to a lump, bump, or lesion—or at least, to a specific physiochemical abnormality in association with a specific set of signs and symptoms. Anything else that we call “disease” is simply a label—a “social construct” akin to terms like “primitive” or “fanatic” without any scientific validity. By implication, “real doctors” are those who treat the corresponding “real diseases.” Since, for the major mental disorders, psychiatrists cannot point to causally implicated lumps, bumps, or lesions—or to specific pathophysiological defects—they are not treating “real” diseases; therefore, as the mantra goes, they are not “real doctors”! These arguments compose what I call the “Physicalist Fallacy” of psychiatric diagnosis, which is not to be confused with the concept of “physicalism” per se. The Physicalist Fallacy is a kind of philosophical mongrel with a lineage derived from logical positivism, Cartesian dualism, and a gene or two from “post-modernism.”

Rebuttals to these fallacious arguments have been given at length and I won’t risk inducing stupor and coma by rehashing them here. I won’t even belabor the point that when Eugen Bleuler wrote his classic text in 1911, he referred to “the schizophrenias” (plural); and that abnormal smooth pursuit eye movements (SPEMs) are one of several reasonably well-established biological findings in what is probably a related group of schizophreniform disorders (see "Beyond Reliability: Biomarkers and Validity in Psychiatry" and "How Clinical Neurophysiology May Contribute to the Understanding of a Psychiatric Disease Such as Schizophrenia" for further reading). Rather, to understand why psychiatry is in its present predicament—regarding the public’s jaundiced view of psychiatry and the raging debate over the DSM-V—it is helpful to examine the work of our colleagues in the field of chronic pain treatment. To escape our predicament, we need to examine the philosophers and psychiatrists (such as Karl Jaspers, 1883-1969) who have taken a phenomenological approach to the recognition of “disease”—a point my colleagues Michael A. Schwartz and Nassir Ghaemi have repeatedly stressed. To oversimplify greatly: phenomenology refers to the structure of the patient’s experience—how, for example, self and world are perceived during a bout of psychotic depression.

Based mainly on animal models, there have been major advances in understanding the pathophysiology of chronic neuropathic pain—yet there is a great deal we still do not know. Moreover, diagnosis and treatment of chronic, idiopathic pain (of unknown etiology) remains essentially grounded in the patient’s subjective complaints combined with objective findings in the doctor’s office or bedside examination. This is analogous to the psychiatrist’s initial history-taking and mental status examination. Pain specialists dealing with chronic, idiopathic pain cannot, by definition, point to a specific lump or lesion that explains the patient’s suffering. Yet—with the exception of those thought to be “malingerers”—we do not delegitimize the patient’s complaints. We do not regard individuals with chronic pain as having a “metaphorical” illness. We do not brand doctors who treat these patients as charlatans. On a societal level, we do not find a robust “Anti-Analgesia” movement, bristling with vicious blogs and insulting placards. Why, then, the animus toward psychiatric practice?

The answers are far too complex to cover in this space, but, in my view, relate to at least two factors:

1. Individuals with chronic pain are ordinarily self-identified and voluntarily seek treatment for their condition; in contrast, many individuals with serious psychiatric impairments do not. Indeed, it is the very nature of their illness that they often deny its presence or significance.
2. Legislatures, courts, and common-law tradition have not sought to impose mandatory or involuntary treatment upon those with chronic, idiopathic pain disorders; this is clearly not the case for some individuals with severe psychiatric conditions that represent “an immediate danger to self or others”. (For more on the public’s misunderstanding of the psychiatrist’s role in “commitment” procedures, see "In the US, Psychiatrists Do Not 'Commit" the Mentally Ill").

Arguably, these forensic aspects of psychiatry may call for legislative and societal remedies—but by themselves, do not impugn the legitimacy of psychiatric diagnosis and treatment.

That said, we should strive to be as parsimonious and “objective” in our diagnostic categories as possible. To paraphrase Ockham’s Razor, we must not “multiply entities unnecessarily” in creating our disease categories. We should certainly avoid creating new categories that are not grounded in careful empirical and phenomenological investigations. But whereas our long-term goals should include pinning our DSM categories to specific biochemical and genetic markers, we should reject the positivist “lumps and labs” model of disease. Our focus, rather, must remain on relieving suffering and incapacity in its infinite experiential presentations. In this, we need to learn from our colleagues in the chronic pain field.

Note: I wish to thank Michael A. Schwartz MD and S. N. Ghaemi MD for their helpful comments on this piece; however, I alone am responsible for the views expressed.

Ronald Pies, MD
Editor-in-Chief, Psychiatric Times


  1. As a Canadian, here our universal health care system is placing a huge strain on psychiatry – one must have a psychiatric diagnosis to receive coverage. My concern in not the objectivity argument, but the time it takes "to make an accurate or close to accurate diagnosis."

    Most psychiatric cases are not easy to diagnose because they take time. When I first began my psychiatric journey in 1960 at the age of 12, a psychiatrist would meet with a "prospective" patient for a minimum of eight visits over about eight weeks before deciding if s/he would accept this person as a patient.

    This practice continued to the best of my knowledge until about 1990 or maybe later. I wouldn't know, as it was then that I began seeing my current psychiatrist – and continue to do so.

    My point is this. Now, snap judgements, relatively, are often made here about a diagnosis. Medications are dispensed. Today, I read that according to a new study in the August issue of "Archives of General Psychiatry", in the U.S. from 1995 to 2005, the use of antidepressant medication rose by 75%, while the use of "talking therapies" decreased by 35%" in those using those medications.


    Is this healthy and healing?

    TV advertising of medications probably plays a role in this – about $8 billion according to a recent article in the New York Times, and the "McDonaldization of Psychiatry" – so my concern is what if the wrong medications are given because time is not taken to make a good diagnosis?

    And will the new DSM-V help or hinder this process?

    Who can afford the time, let alone the money, eight visits to a medical professional just to make that diagnosis and see if a psychiatrist will take you on as a patient?

    It's hard to imagine. People are anxious for relief. They have been brainwashed into believing that "a pill will cure the ill". And too many people are given medications on a "let's try it and see if it works" basis. Is this healthy? Perhaps dispensing medication with therapy should be the rule, not the exception. And not just a 15-minute consultation and a prescription. A 55-minute therapy session and a prescription.

    I agree – "objectivity" has no real place in medicine when we are all so different – physically and emotionally. We are all individual packages, unique wholes – body and mind and soul and spirit. There really is no "disconnect".

    One reason there is a "Physcialist Fallacy" perhaps is that most psychiatric patients have had more than four or five different diagnoses. It's not easy. It takes time and experience to diagnose. Family doctors perhaps should not be making these decisions alone, but in concert with psychiatrists and psychologists – all working together. Not to mention a psychopharmacologist. Shouldn't this be the standard?

    Sandy Naiman

  2. from Ron Pies MD:

    I thank Sandy Naiman for her thoughtful comments on my blog, and on some of the problems involved in arriving at an accurate (and helpful) psychiatric diagnosis. I fully agree with Sandy that there is no place for "snap judgment" diagnoses, either in psychiatry or in any area of general medicine.

    Unfortunately, as we both recognize, such perfunctory diagnostic conclusions are probably all too common, in today's environment of "McDonaldization". It is also true that many people diagnosed with psychiatric disorders have received multiple (and sometimes conflicting) diagnoses--as is also true in several other medical specialties, such as the chronic pain field.

    It is natural for this diagnostic ambiguity to generate frustration or even anger, not to mention anxiety, on the part of those who seek professional help. Unfortunately, as Sandy suggests, this discontent may contribute to the "Physicalist Fallacy" (the "lumps or labs" criteria for ascribing disease). On the positive side, such frustration may also spur scientists to investigate the underlying causes of psychiatric illness more diligently.

    This is not to say, of course, that only "biological" causes should count, or that psychiatric illnesses are just "chemical imbalances". I fully agree with Sandy Naiman that we, as physicians, must address "body and mind and soul and spirit." Indeed, that was really the central argument I directed against the Physicalist Fallacy.

    As for the role of "objectivity" in psychiatric and medical practice, I believe we need to balance scientific objectivity with the subjective and empathic capacities of the healer. Psychiatry, like other medical specialties, is both a science and an art. Neglect either one, and we do our patients a disservice.

    Ronald Pies MD