Embracing psychiatric uncertainty

I always get troubled looks from psychiatry residents when I point out that our field is the domain of the uncertain and the not-well-understood — and that it will always remain so.  As soon as the cause of a disease is known, it automatically leaves psychiatry for another specialty.  General paresis (advanced syphilis), once identified as an infectious disease, became the domain of internists.  Senility (dementia), multiple sclerosis, and many other apparently psychiatric conditions went to the neurologists.  Thyroid disorders belong to endocrinology.  Brain tumors and hemorrhages are surgical conditions.  And so forth.  I have little doubt that schizophrenia will someday be understood as due to a slow virus, a complex genetic error, or something else.  At that point it will no longer be a psychiatric condition.  It will join neurology, internal medicine, or some other specialty.

This makes my residents squirm in their seminar chairs, particularly when I point out that the closest analogy to psychiatry’s status in medicine is philosophy’s status among the humanities.  Philosophy consists of questions in the humanities that we don’t yet know how to answer.  Once we do, that area is no longer considered philosophy.  “Natural philosophy” is what we now call science.  It isn’t considered philosophy anymore.  Logic was one of the classic branches of philosophy; now it is better understood as a branch of mathematics.  In the same way, psychiatry consists of questions about human thoughts, feelings, and behavior that we don’t yet know how to answer, not down to the level of mechanism anyway.  Once we do, that area is no longer considered part of psychiatry.

It’s no mystery why the residents are uncomfortable.  They want and expect certainty.  Why did they study all that organic chemistry, memorize all the bones and muscles, spend years learning to diagnose and treat, if in the end they can’t make definitive statements about their chosen specialty?  Many will cling to pseudo-certainties for reassurance.  Simple-minded factoids like “alcoholism is a disease” or “depression is due to a chemical imbalance” give them something to hang onto.  Unfortunately, we don’t really know what causes depression, and alcoholism is disease-like in some respects, but not in others.  Most of our field is complicated, messy, and not well understood.  Moreover, this need for certainty in an uncertain field leads many psychiatrists, including and perhaps especially those well out of training, to convey unwarranted confidence regarding diagnosis and treatment recommendations.  We can come across as smugly self-assured.

Frankly, this very uncertainty — mystery, if you will — is one of the things I like about psychiatry.  It isn’t a settled area.  It is endlessly debatable, much like an undergraduate philosophy course.  Yes, there are concepts and terms to learn, principles to refine and employ, scientific studies to evaluate.  There is a body of knowledge, a history, practice guidelines to teach and learn.  Most of all, there are real patients to help.  Yet as in philosophy, experts in psychiatry can and do disagree.  Our diagnostic categories are revised periodically. Treatments come and go.  Unscientific fads influence the field, as when American psychiatrists used to diagnose schizophrenia more liberally than our British counterparts, when multiple personality disorder suddenly became common in the 1980s and just as suddenly faded away, and in the way ADHD, PTSD, and bipolar diagnoses are so popular now.

Confident pronouncements of certainty have no place in psychiatry.  Humility is the only honest attitude to take to this work.  At the same time, the questions we face are fascinating, patients are suffering, and neither can wait for definitive knowledge.  We must do the best we can with imperfect knowledge, with limited data and educated guesses, with hunches and subtle impressions.  As in life generally, we cannot wait for certainty before acting.  As in life generally, this makes psychiatry risky, vibrant… alive.

8 comments to Embracing psychiatric uncertainty

  • Kristopher Brazil

    Hi Dr. Reidbord,

    I thoroughly enjoyed your article and its unique outlook on psychiatry. It takes a fresh mind to be able to step back and evaluate what is going on in a field of study and to be able to analyze what you find in turn. I also approach the unknown characteristics of psychiatry with great alacrity. This article, however, helped me realize that my interest in psychiatry is a reflection of my interest in philosophy. How those two tie together is wonderfully understood in your article. It could be argued that the great minds behind these two professions far exceed those of any other profession in searching for truth through creativity, innovation, and understanding.

  • TK

    Nice piece. Your best writing yet. Do you think that someday, a thousand years from now, psychiatry will be essentially out of business? That seems to be the logical progression of what you’re writing. I’m not so sure, and I’m not so sure that science will be able to crack e.g. the conundrum of severe psychosis.

    • While I’d be hard pressed to predict what anything will be like 1000 years from now, I expect severe psychosis will be understood sooner than the subtleties of normal personality will be. If I’m right, the biological aspects of psychiatry will be adopted by other specialties of medicine, leaving the psychological aspects for psychiatrists and psychologists to ponder far longer into the future. I’ve seen a few sci-fi depictions of psychotherapy of the distant future. They show the therapist electronically monitoring the patient’s reactions to evocative video or holographic images. This is a model that makes sense to us now; we “merely” lack the mapping from these reactions to diagnostic understanding. But stimulus-response analysis could turn out to be entirely the wrong idea in the long run… only time will tell. Thanks for writing.

  • JAK

    I have absolute certainty about the fact that Psychiatry is a crock of B.S….

    [Sorry, remainder deleted. No roundhouse invective in my forum. Also, I spared you the public disclosures about your own past that you saw fit to publish. — S.R.]

  • Another very interesting post, but I’m still not sold.

    You noted several areas in which other specialties now care for what were originally considered psychiatric illnesses, and you are correct up to a point. But if the other specialties are caring for these, then why am I caring or and admitting the same people to the hospital when their behavior becomes extreme?

    I think that our profession (rightly or wrongly) is as it is because we agree to address problems of behavior. Even if we discover some basic neuroscientific way to address borderline personality, I don’t see neurologists choosing to work with it. I believe that we are who we are because we like (I hope) to straddle the gap between objective and subjective and meet our patients at a level that is not purely neuroscience, physiology, or fantasy. I believe that, as long as there is a thought of humanity as something that transcends machinery, there will be psychiatry.

    Thanks for directing me here. I just discovered your blog today and am still digging.

    • Our disagreement, if any, seems mostly semantic. My post was about etiology, not symptom management. Certainly psychiatrists deal with behavioral issues arising from many causes: brain trauma, metabolic abnormalities, neoplasms, toxicity, etc. But we are consultants in such cases. The underlying causes of these behavioral problems are not psychiatric. An agitated, delirious MICU patient is still a “medicine patient”; treatment of the underlying disease process is the province of the internist.

      Occasionally patients with, say, Huntington’s Chorea are admitted to the psychiatry unit. Regardless, everyone still agrees that Huntington’s is a neurological disease, not a psychiatric disorder. Likewise, if someday we discover the neuroscience (and effective neurological management) of borderline personality, such patients may still be hospitalized in psychiatric units from time to time. But fairly soon we’ll agree to call it “borderline neurodystrophy” instead, and will refer such patients to neurologists (or neurosurgeons, or allergists, etc, as the case may be) for definitive treatment. Just as we do now for neurosyphilis, Huntington’s, glioblastoma, septic delirium, and so forth.

      I agree with you 100% about psychiatry straddling subjective and objective, and transcending the machinery. In this sense all patients, and much of healthy human behavior too, falls under psychiatry’s purview. But if we speak more narrowly about what constitutes a psychiatric disorder, as opposed to some other kind, we are left with those syndromes that organic pathophysiology cannot yet explain.

  • Tony

    One thing confuses me about psychiatry and its DSM. The DSM refuses to diagnose a person as a psychopath, instead claiming that antisocial personality disorder and psychopathy are the same thing. Hare, the lead researcher in psychopathy, begs to differ with American psychiatry. There are people who exhibit behaviors of antisocial personality disorder and who receive the label. There are others who exhibit physical signs–low subcortical arousal (low blood pressure, body temp, etc), anomalies in the EEG, among many other things. Are these people with these physical signs within psychiatry’s purview?

    • There’s only one thing that confuses you about psychiatry and its DSM? I can claim dozens. Anyway, the issue you raise is that personality pathology is boiled down in DSM-IV to a limited number of personality disorder categories; those categories aim to avoid explanatory theory and rely on clinically observable signs and symptoms. Leading researchers tend to have theories of psychopathology, as well as research findings that may not be commonly known or appreciated. They therefore differ with DSM diagnosis. In addition to Hare and psychopathy, leading researchers of borderline personality disagree with how that disorder is defined in DSM-IV. I wouldn’t be surprised if this were true for other personality disorders as well.

      Many psychiatrists feel DSM does a particularly poor job with personality disorders. The upcoming DSM 5 may introduce a new, more complicated personality assessment scheme that employs dimensional ratings, but it’s been widely criticized as cumbersome and impractical. While some personality categories will be dropped, “antisocial” will remain. See: http://www.dsm5.org/proposedrevision/Pages/proposedrevision.aspx?rid=16#

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