Review of 'Psychiatry on the Edge' by R. W. Pies. Double D( 2015)

這是Duncan Double(2015)的評論 : 關於紐約(SUNY)大學教授 Ronald William Pies在 (Psychiatric Times, 2005的錄音2006年改寫成文章Mastering the Critique of Psychiatry : A Review of Psychiatry on the Edge)，Pies倡議應該把精神科醫師改為“encephiatrics,”大腦問題的治療者 “healers of the brain.”。另外提出一種論述 “polythetic pluralism” in psychiatry, 在精神科的診斷與治療上面應該有不同的介入方式，自由的分享某些想法給大家，並不是單一說法可以定義精神醫學的存在性。“several different approaches to diagnosis and treatment, sharing some features in common, no one of which defines the ‘essence’ of psychiatry”但Double並不認為他是人文取向，(I don’t think he is person-centered enough in his approach.) Pies只是對於精神醫學是on the Edge，不能整天只會說chemical imbalance或是CBT。 Ronald William Pies was editor-in-chief of Psychiatric Times from 2007 through 2010. He is a professor in the psychiatry departments of State University of New York (SUNY) Upstate Medical University and Tufts University School of Medicine. Psychiatry on the Edge contains slightly modified versions of several of his articles published in Psychiatric Times from 2006. In an interview (Psychiatric Times, 2005), Pies explained that he is a general psychiatrist with a “very strong interest in the biological functions that underlie thinking and feeling” (p. 2). He has promoted “encephiatrics,” which means psychiatrists becoming “healers of the brain.” This doesn’t just mean providing psychopharmacology; it includes talk therapy. He believes that neurology and psychiatry should reunite, and should never have been separated, although, if this happened, there would be a need for “certain kinds of linguistic and philosophical ‘bridging devices’” (Pies & Daly, 2010, para. 9 of Pies statement in support of resolution). In the book, Pies says brain imaging in the last 30 years has improved biological understanding of mental illness. Although for a variety of practical and theoretical reasons, biological markers have not found a useful place in everyday psychiatric practice, he sees progress as having been made in this regard with tests such as abnormal smooth pursuit eye movements in schizophrenia and derangements of hypothalamic-pituitary-adrenal function in melancholic major depression (p. 154). Over the same period, he notes that cognitive behavioral therapy (CBT) for anxiety and depression has grown. Clozapine has been developed as what he considers “the most effective medication for schizophrenia” (p. 153). As far as he is concerned, electroconvulsive therapy (ECT) still maintains efficacy in treatment of severe depression. He also points to the increasing use of transcranial magnetic stimulation and ketamine infusion for the treatment of depression and other disorders. He is, therefore, quite biological in his approach to psychiatry. However, he says he is agnostic about whether mood disorder is caused by a “chemical imbalance,” which is a term that is “simplistic and a bit misleading” (p. 32). He believes the chemical imbalance notion “was always a kind of urban myth” and never “seriously propounded by most well-informed psychiatrists” (p. 30). Doctors know it’s an oversimplification, he says, but use it so patients don’t feel so blameworthy. He does agree this is “a little lazy” (p. 33) on the doctors’ part and doesn’t excuse their behavior, but says they are very pressed for time with so many patients to see. He recognizes a problem with the hypothesis in that patients may come to think they have no control over their illness. However, he’s clear that the catecholamine hypothesis of depression was only ever a hypothesis and not a developed theory. In fact, he emphasizes that it merely proposed an association rather than a causal relation. If there is a biochemical abnormality, this imbalance could just as easily be caused by environmental and psychological factors as genetic and constitutional processes. This isn’t a reductionist hypothesis as far as he is concerned; instead, he calls it a holistic model. Pies endorsed the removal of the bereavement exclusion from the definition of major depression in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association, 2013), and a whole chapter of the book is devoted to this topic. Allen Francis, chair of the DSM-IV Task Force, amongst others, has been concerned about the overmedicalization of mental disorder and sees the removal of the bereavement exclusion as a step too far. However, Pies does recognize the distinction between grief and major depression. He also requires a sound foundation to psychiatric classification. His argument is that context does not determine mental disorder. He appreciates that careless diagnosis and overdiagnosis do occur, but generally he regards “medicalization” in psychiatry as a myth, because whether a presentation is understandable or not shouldn’t determine whether it is a mental disorder. From my point of view, he may not do enough to avoid the reification of diagnostic concepts, but like him, I am not wanting to totally abolish psychiatric diagnosis, merely recognize it for what it is (Double, 2002). I think, though, that Pies may not fully acknowledge how much the DSM process has been taken over by biomedical assumptions. I find this difficult to gauge fully, however, from the book, without knowing more about his clinical practice. His biological approach and emphasis on psychopharmacology suggest to me that he is not psychosocial enough in his assessment and treatment of patients. Pies makes a case for a “polythetic pluralism” in psychiatry, by which he means using “several different approaches to diagnosis and treatment, sharing some features in common, no one of which defines the ‘essence’ of psychiatry” (p. 41). He sees himself as one of a number of “pluralistic unifiers” in psychiatry, including several Psychiatric Times colleagues. This position is advocated as a response to critiques of psychiatry, which he is happy to lump together as manifestations of “anti-psychiatry.” Although he accepts that the critiques contain “at least a grain of truth —and some contain a few drams” (p. 153), he doesn’t accept their claims about what is wrong with psychiatry. As someone who is critical of the biomedical model in psychiatry, my problem is the validity of Pies’ polythetic pluralism. I do think it would be an advance if psychiatry was more pluralistic than the current biomedical dominance in psychiatric practice. Pies wants to avoid remaining “ensnared by the terms ‘mind’ or ‘brain’” (p. 31), and says we would be better served by using the term “brain-mind.” Of course, the brain is the origin of the mind, and I agree mind and brain should be integrated, not separated. However, Pies hasn’t solved the mind-body problem. Minds are enabled but not reducible to brains. I don’t think “polythetic pluralism” acknowledges this conceptual position sufficiently. The split between biomedical and psychosocial understandings has been present since the origins of modern psychiatry. It can’t be overcome by supposing both medication and psychotherapy are effective in psychiatric treatment. In fact, I think that Pies is still essentially trying to justify a biomedical approach to psychiatry by adding the personal dimension and calling it “polythetic pluralism.” But, I don’t think he is person-centered enough in his approach. This is evidenced, for example, as I have mentioned above, in his belief in biological markers and his failure to reject firmly the notion of “chemical imbalance.” He sees psychiatry standing “‘on the edge’—of promise and peril, progress and regress” (p. xi). I suspect he would regard my questioning of whether the neural substrate in mental illness is any different from our “normal” behavior as “over the edge”! He might also designate my position as what he calls “anti-psychiatry.” However, I think that having a proper conceptual understanding of mental illness is the only way to make true progress in psychiatry. A strength of this book is that it is an attempt to engage with the critique of psychiatry. Collecting together various articles that have been published on different topics over the years may not make a very coherent apology for psychiatry. Pies’ theoretical position, however, does show through in the various essays. I remain to be convinced that he is successful in defining a valid response, but he makes an attempt to master the critique of psychiatry. It’s worth looking at the book to understand how he tries to do this. I would have preferred that he took on board more of a critical perspective, rather than, in my view, still essentially defending biomedical psychiatry. References American Psychiatric Association. (2013).Diagnostic and statistical manual of mental disorders(5th ed.). Washington, DC: Author. Double, D. B. (2002). The overemphasis on biomedical diagnosis in psychiatry. Journal of Critical Psychology, Counselling and Psychotherapy,2, 40–47. Retrieved fromhttp://www.critpsynet.freeuk.com/Overemphasis.htm Pies, R. W., & Daly, R. (2010, March 4). Should psychiatry and neurology merge as a single discipline? Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/neuropsychiatry/should-psychiatry-and-neurology-merge-single-discipline Psychiatric Times. (2005, November). Through the times with Ronald Pies, M. D. Retrieved from http://www.psychiatrictimes.com/articles/through-times-ronald-pies-md/page/0/1 Review of 'Psychiatry on the Edge' by R. W. Pies. Double D 24 Feb, 2015 Psyc CRITIQUES January 26, 2015, Vol. 60, No. 4, Article 4 http://dx.doi.org/10.1037/a0038619 © 2015 American Psychological Association