Though psychiatric residency training is a year longer than internal medicine residency training in the United States, psychiatrists in training are expected to master a smaller proportion of the knowledge and skills than their internal medicine colleagues are. Worse still, the fraction of diagnoses that psychiatrists are expected to manage compared to internists include pseudomedical disorders, the status of which is suspect even within the profession.1 Given that psychiatrists are charged with the task of caring for the most vulnerable members of society, the basic level of training should equip psychiatrists to fulfill this task. The knowledge base of neurological, medical and genetic disorders with neuropsychiatric presentations, the insights of psychological and social sciences, evidence-based practice, and the philosophy and ethics of psychiatry must become part of the training of every psychiatrist. Many would claim this is already the case, but what is currently emphasized is tantamount to pseudoscience.
The Medical Basis of Psychiatry
The remedicalization of American Psychiatry was ushered in by the publication of DSM-III in 1980.2 The triumph of DSM-III was to firmly establish the central role of psychiatric diagnosis in the practice of psychiatry. As the DSM-5 debacle has shown, psychiatric diagnoses are not the product of nature but common consensus, a consensus that has been criticized for eroding the range of human behavior seen as normal.3 This emphasis on the DSM has marginalized the contribution of descriptive psychopathology,4 de-emphasized the construction of the medical and neurological differential for the psychiatric patient,5 and led to the uncritical acceptance of psychiatric diagnoses whose validity and reliability are questionable.6
In focusing on teaching psychiatric diagnosis à la DSM, psychiatrists are no longer familiar with the rich descriptions of morbid mental life described by Kraepelin,7 Jaspers,8 Bleuler,9 and Schneider,10 who attempted to feel their way into their patients’ experiences and catalog the heterogeneity of human suffering. In contrast, the DSM teaches psychiatrists there are prescriptive ways to suffer or become mentally ill throughout the globe.11 When the psychiatrist meets a patient who has the audacity to have not read the DSM and not present a constellation of symptoms described therein, the psychiatrist is at a loss, and the patient finds herself ‘not otherwise specified.’
Rather than teaching practices that amount to pseudo-diagnostics, psychiatrists should learn more about the infectious, autoimmune, toxic, nutritional, metabolic, vascular, degenerative, and drug-related causes of disturbed moods, thoughts, behavior and perception that lead to psychiatric consultation. The recent discovery of the N-methyl-D-aspartate receptor autoimmune limbic encephalitis has led to a renewed interest from psychiatrists into other medical causes of neuropsychiatric disturbance.12 Yet most psychiatrists learn little about when to order EEGs, neuroimaging, viral, autoimmune, and paraneoplastic panels, heavy metal screens and other investigations that can help diagnose their patients’ maladies, and how to distinguish between these and primary psychiatric disorders. We must be advocates for patients with neuropsychiatric disturbance whatever the etiology and this begins with diagnosis.
One of the most burgeoning fields of psychiatric research is genetics and psychiatrists in training are expected to learn something of this research.13 The research so far has no clinical relevance to the practice of psychiatry. On the other hand, there are number of well recognized syndromes that are associated with intellectual impairment, emotional, behavioral and perceptual disturbances that lead to psychiatric consultation. The majority of these syndromes presents in childhood or adolescence. Occasionally however, these genetic syndromes can present in adult life. Most psychiatrists are familiar with genetic diseases like Huntington’s disease and Wilson’s disease that lead to psychiatric care, but are totally unfamiliar with the inborn errors of metabolism, chromosomal microdeletions, or mitochondrial diseases that can present with neuropsychiatric disturbance. Conditions such as orthnithine transcarbamylase deficiency,14 velo-cardio facial syndrome,15 or mitochondrial encephalopathy16 are long forgotten from medical school if they were ever learned about at all. Many of these genetic syndromes are rare and it would be a waste of time for psychiatrists to learn the ever-growing list, but knowing when to suspect a certain type of genetic syndrome or when to consult a geneticist should be part of the training of psychiatrists.
By the 1980s, psychiatrists became so enthralled with the new drugs that many were no longer identifying as psychiatrists, but as psychopharmacologists. Yet with these new powerful tools at their disposal came the realization of serious adverse effects. Such is the risk associated with these powerful psychotropic drugs that Peter Gøetzsche, a co-founder of the Cochrane Collaboration, recently argued that they should be withdrawn from the market as physicians cannot be trusted to prescribe them.17 Now that psychopharmacology has eclipsed psychotherapy as the mainstay of psychiatric treatment, it seems unacceptable that the study of toxicology in general and a full survey of the potential risks of psychotropic agents in particular is not part of psychiatric training. A recent study found only 2% of surveyed training programs had psychiatry residents elect formal training in toxicology and only 41% featured any toxicology in their didactic curriculum.18 Little to no training is provided on withdrawing psychiatric drugs. It is unclear how many psychiatrists are familiar with the literature on supersensitivity psychosis,19 antidepressant related tardive dysphoria,20 or antidepressant-associated chronic irritable dysphoria.21
Though psychiatrists routinely prescribe atypical antipsychotics, which cause metabolic syndrome, few psychiatrists are comfortable with treating hypertension, diabetes and dyslipidemia,22 and many of our patients are unable to access primary care. It is a shameful state of affairs that psychiatrists are not being trained to treat the very illnesses they cause in their patients and undermines the very basis of psychiatry as a medical specialty.
The Psychological Basis of Psychiatry
Although psychiatry’s love affair with biology long ago made a cuckold of psychodynamics, dynamic theory and therapy still form the crux of psychological approaches to our psychic woes that American psychiatrists learn. Many psychodynamic concepts are useful. It it is hard to argue with the core principles: our past experiences shape our present experience, our subjective consciousness is unique and should be respected, we are less aware of our motivations for actions than we like to think, our past relationships play out in the clinical arena, and our minds have carefully developed methods to help us ignore or avoid that which we do not wish to acknowledge.23
That aside, psychodynamic theory is not scientific, can lead to blaming patients for the atrocities they suffer (for example the domestic violence victim is a ‘masochistic personality’ who needs to suffer),24 often blames patients for not getting better (failure to recover is a ‘resistance’, the possibility that the therapy is simply ineffective rarely entertained), and can lead to fatuous interpretations which cannot be rejected by the patient who does not agree with the therapist (rejection of the interpretation is again, but a ‘resistance’, to the truth and the therapy). Some formulations are so ridiculous as to serve only perfunctory mental masturbation on the part of the therapist.25
As a result of the psychodynamic hegemony over theoretical thinking in psychiatry, most psychiatrists have little awareness of the psychological theories that do have more robust support from research and help us understand our patient’s suffering. For example, cognitive psychology offers valuable explanatory frameworks that can be helpful in understanding depression,26 PTSD,27 and the formation of delusions and hallucinations.28 The role of self-esteem and self-efficacy,29 theories of why different life events seem to trigger difficulties in different people,30 the development of social cognition in childhood,31 the role of attachment,32 and theories of personality33-35 are given cursory attention if covered at all. Even though the same elements that comprise symbolic healing across cultures and therapies has been demonstrated,36 psychiatrists are still learning the basics of psychodynamic psychotherapy, cognitive behavior therapy, and supportive psychotherapy separately, instead of learning how to maximize the effects of contextual healing.37
The Social Basis of Psychiatry
Despite the rich social science contributions to psychiatry that are extremely relevant to clinical practice, most psychiatrists, especially in the United States, are completely unaware of the classic studies in our field. Social scientists conceived of psychiatric disorders as social constructs38 long before the geneticists realized these categories to be cultural rather than ‘natural kinds.’39 Social scientists highlight the role of social class,40 ethnicity,41 discrimination,42 life events,43 expressed emotion,44 the built environment,45 urbanicity,46 and social capital47 on mental health. Goffman’s insights into the toxic effect of the total institution on psychiatric inmates,48 or the stigma of ‘spoiled identity’49 have passed a generation of psychiatrists by, despite being highly applicable to patient care. The damaging and unintended consequences of psychiatric labeling,50 the concept of mental illness in cross-cultural perspective,51 and the lack of validity of psychiatric diagnoses were highlighted by social scientists,52 and yet these studies are not must-reads for psychiatrists in training. Social science research explored why the prognosis of schizophrenia is better in developing countries,53 and the effects of political economy on mental health,54 and yet most psychiatrists are completely oblivious to the evidence for the causal role of macrosocial factors in major mental illness.
Instead ‘social psychiatry’ curricula consider ethnic and sexual minority groups, homelessness, insurance programs, and the structure of mental health programs. Even then, the causal role that minority status may play in collective and individual suffering is minimized. Many psychiatrists still believe that 1% of the population has schizophrenia, without respect to gender, ethnicity, or geography, despite widespread differences in the incidence of psychosis, even within the same city.55 As Kleinman observed, the rest of medicine began to embrace the social sciences at the same time that psychiatry was turning her back on it.37 Lay opinion holds that psychiatric illnesses are significantly influenced if not entirely caused by social factors.56 Psychiatrists risk being out of touch with the public if they do not have a full appreciation of the effects of social factors on the etiology and course of mental illness.
The Clinical Epidemiological Basis of Psychiatry
Evidence based care is supposed to drive up standards, ensure uniformity, establish best practice, guide clinicians and protect patients. This should be celebrated. Instead, evidence-based mental health is openly disparaged,57 and when psychiatrists don’t get the results they want, they ignore them, suppress them, or denounce them. The suggestion that antipsychotics could worsen the course of psychosis19 was such an important one that you would think it would deserve considerable study, yet it has been largely forgotten. The finding that antipsychotics cause significant cerebral volume loss, rather than immediately being published,58 was analyzed again and again, until the reality of this finding could no longer be denied.59 When randomized controlled trials, the gold-standard investigation, showed that SSRIs were associated with suicidal ideation,60 the results were denounced invoking correlational studies showing a inverse relationship between adolescent suicides with SSRI prescriptions,61 despite these studies being methodologically inferior. These attitudes have repercussions on the training of psychiatrists.
All of this is damning enough without calling into question the veracity of the evidence base which influences patient care. The deceptive influence of the pharmaceutical industry, the ghostwriting of journal articles, and selective publication bias, are well known to the public. Yet these concerns sit at the periphery of psychiatric training instead of the core.
The Philosophical and Ethical Basis of Psychiatry
The concept and nature of mental disorder
Most psychiatry residency training programs claim to teach a ‘biopsychosocial’ approach to psychiatric illness, though this approach has been deconstructed and derided as meaningless,62 anarchic,63 and a myth.64 Although most psychiatrists also claim to use a biopsychosocial approach, a number of studies show that psychiatrists have different explanatory frameworks for different patients.65-67 Assumptions about the nature of mental disorder go unexamined. These assumptions filter into the psychiatrist’s approach to the patient. Given that values, meanings and assumptions about the concept and nature of mental disorder, whether acknowledged or not, are at the very heart of psychiatric practice, they should also be at the heart of psychiatric training.
The Mind-Brain Problem
The central debate of the philosophy of mind is the mind-brain problem. Although psychiatrists may wish to remove themselves from the fray, and pretend it has little to do with psychiatric training or practice, it confronts us at every turn.68 Psychiatrists often make contradictory statements about the relationship of mind and brain without a second thought. Whether one invokes substance dualism, property dualism, materialism, explanatory dualism, functionalism, or eliminativism, far from being irrelevant, shapes our approach to patient care and how we frame research questions. Training psychiatrists in the philosophy of mind is neither practical nor useful, but psychiatrists should have an awareness of the different approaches they reflexively use and the implications on their work.
The Ethics of Psychiatry
Psychiatric ethics tends to focus on individual interactions between clinicians and patients, and psychiatrists consider issues of boundary violations, capacity, consent and coercion as part of their training. Given that the ethical basis of psychiatry as a profession is so often challenged, psychiatrists should learn not just psychiatric ethics, but the ethics of psychiatry. The ethics of psychiatry concerns itself with rights: the right to autonomy and self-determination, the right to happiness, the right to (refuse) treatment, and even the right to commit suicide. The ethics of psychiatry can thus be considered from the perspectives of utilitarianism, liberalism, libertarianism, Rawlsian ethics, and communitarianism.69 Again, I am not suggesting psychiatrists be quasi-ethicists or philosophers, only that these aspects so implicit and entwined in psychiatric work be subject to critical examination that must begin with the training of psychiatrists.
The suggestions outlined above are not my own but have been developed from listening to what the public, patients and their families, and psychiatric survivors say they want. Those who don’t call for the outright dissolution of the specialty want psychiatrists to be able to know when a serious medical or neurological illness is responsible for their problems, to not have normal human suffering medicalized, and to avoid applying those pejorative labels that have no scientific basis. They want psychiatrists who not only can start medications but also safely withdraw them, be judicious with their use, be familiar with the inherent risks and respond appropriately to them; who can think psychologically about their problems; who understand what healing looks like; who can see as clearly as they can how powerful social forces and life events can affect mental health; whose practice is based on the evidence as it is and not how they wish it to be; who examine the assumptions and values that underlie their practice; and whose practice is ethically defensible. Current psychiatric training does not adequately meet these needs, and if not remedied, will lead to the continuing criticism and marginalization of psychiatry in medicine.
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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.