Rethinking Psychiatry - Another Look at Paradigms

Yesterday, I re-ran an earlier blog post that talked about paradigms and how psychiatry is ripe for a new one. Thomas Kuhn (pictured here) literally owns the word paradigm. In his seminal 1962 book, The Structure of Scientific Revolutions, Kuhn points out that far from being an objective and dispassionate exercise, scientific research operates from existing conceptual frameworks until they are no longer sustainable.

Thus Ptolemy to Copernicus, Newton to Einstein, and so on. Almost inevitably, the old order is toppled by those outside the field or those just entering the field, who have little or no stake in the status quo.

In psychiatry, we have seen a similar transition from Freud to biological psychiatry. But that paradigm is being challenged by breakthrough discoveries in brain science and what could become "the new science of the mind," as put forward by 2000 Nobel Laureate Eric Kandel, who stated at a conference I attended:

A major need of psychiatry in the future is to put the psychotherapeutic arm of psychiatry on the same solid biological footing as the pharmacological aspect of psychiatry.

In January, after I posted my piece for the first time, Willa challenged the notion of psychopharmacology on a solid biological footing, noting that in medicine "the paradigms dictate the treatments." Unsuccessful treatments, she said, do not challenge the paradigm. "They simply are problems to be solved within the existing paradigm." Thus unacceptable side effects induce researchers to find new meds rather than lessening the reliance on meds.

Yesterday, in response to my second posting, Tony added that every FDA medication in essence carries the warning that says: "We have no idea how this stuff works, but it does... kinda, sorta a little better than a placebo..."

Obviously, we have a lot of frustrated and very well-informed patients challenging the biological psychiatry mindset in the form of the recovery movement. Had psychiatry come up with new meds that worked a lot better than the old ones, with practitioners smart enough to work with us, the current paradigm might be more secure right now.

Mark added another twist to this, of transpersonal psychiatry (that expands on Freud and Grof and others) vying for attention with the new brain science. In Mark's words:

My personal view is that the biological researchers are trapped by their paradigm to look only at the brain. They cannot conceive the possibility of mental disease having any other source than the physical matter of the brain itself. By their paradigm, they not only believe that but refuse to look at any other evidence which would point to the contrary.

He concludes: "The race is on. Let the best emerging paradigm win."

Mark's post really got me thinking. Are the various paradigms-in-waiting mutually exclusive? Or do we see a grand unified theory on the horizon? My bets are on the latter. Here's how I see it:

To my knowledge, every brain scientist is operating off a genes-environment paradigm, which takes into account both biology and how we respond to the world around us. In the old days, psychiatry distinguished between biological causes to mental illness (such as neurosyphilis) and what they saw maladaptive reactions to stress and interpersonal relations.

This harkens back to the old mind-brain distinction. Since we lacked the tools to see into the brain, the first DSM of 1952 classified depression and schizophrenia and bipolar and the like as "reactions" rooted in neurosis or psychosis or personality rather than biology.

Biological psychiatry tipped over that Freudian paradigm, but in the process lost track of the fact that there was a lot of validity to Freud and his followers. Our behaviors are indeed shaped by our environment and buried traumas. The catch was that the only known therapy of the day - psychoanalysis - did not work for serious mental illness. Thus a paradigm ripe for tipping.

The biological psychiatry paradigm naively assumed we could simply find something wrong in the brain and fix it, with no regard to environment, without being able to pinpoint cause and effect. Thus an antidepressant for depression, a mood stabilizer for bipolar, and so on. The catch was that even magic bullets are problematic if someone has to contend with an abusive relationship or a toxic work situation.

The new brain science has broken down the mind-brain distinction. We now know that some of us inherit vulnerable brains that are prone to breaking down under stress, which in turn manifests as various forms of illness episodes and maladaptive behaviors. Those with more resilient genes are far more likely to take stress in stride. This new brain science validates the "diathesis-stress" hypothesis advanced during the seventies.

These discoveries cut across all psychiatric diagnoses and blur the categorical distinctions, spurring researchers to dig deeper into underlying causes (endophenotype) rather than the outer symptoms of phenotype. This demands a new approach to diagnostic psychiatry, which is more likely to come from outside the field rather than from within.

The new brain science has also revealed that the brain is plastic, capable of reshaping itself. In essence, the brain is software rather than hardware, and we can change the software to make us more resilient and better able to adapt to whatever life may throw our way. It also works the other way - that sustained stress and trauma can change our software for the worse.

Likewise, we can change our environment. If we know, for instance, that we have a genetic predisposition to alcoholism, we learn to avoid situations that put us at risk.

We now have a new model of the brain interacting with the environment and vice-versa, each capable of change, each capable of changing the other. Thus we see the beginnings of a grand unified theory waiting for the next Einstein, where Freud and biological psychiatry are reconciled, along with ancient precepts. Mind and brain are one, leading to new insights into behavioral causes and effects and possible treatments and therapies and self-help tools. This is already well underway.

Those operating within the current paradigm, who simply expect brain science to validate biological psychiatry can be regarded as intellectual dinosaurs. Their days are numbered, but they won't go down without a fight. Some form of Kandel's new science of the mind will emerge and maybe it will no longer be called psychiatry.

But this new paradigm, like all paradigms, will only be a temporary placeholder, awaiting a newer paradigm to unseat it, such is the nature of scientific discovery. Absolute truth will always elude us. The best we can do is proceed on the facts as we know them, with an assist from inspired speculation. This will yield us the best approximation of reality. That is, until a better one comes along.