Monthly Archives: July 2016

Thoughts on Brexit for British psychiatry

On the 23rd of June Britain voted to leave the EU. It will take many years before we ultimately know how things turn out. Here I will only discuss certain possible implications for psychiatry. Whilst issues surrounding funding of British research and collaboration with European research have been discussed in the media, there may also be an impact on the nature of mental illness itself.

The media is often calling Brexit the biggest decision in UK politics in the last fifty years. Philosophers of psychiatry rightly emphasise that people with mental illnesses are social beings living in a social environment. Even if there are set biological or psychological causes of many DSM diagnosis individuals with those diagnosis will still be affected by the social environment they are in. Consequently, different social environments could mean mental illnesses turn out differently. Now, exactly how much this is the case is difficult to judge, it is certainly very easy to focus too heavily on people as just being their abstract diagnosis disembodied from the environment but equally it is easy to just simply see mental illness as a social phenomena. Exactly how much weight we should place on each is difficult to say, and this may vary both for different diagnosis and for individuals with the same diagnosis. However, I do think it is credible to say social factors are important and can with some regularity make mental illness turn out differently. To the degree there are significant social changes then, for symptoms with social causes, there could be differences in which symptoms are expressed or in how they are expressed. For example, if there was an economic downturn then this could reduce the quality of life of many people, pushing many over the threshold for a diagnosis of anxiety or depression. Equally, it might mean people who are currently diagnosed now face new challenge and thus express symptoms in different ways. It may impact comparisons of studies taken from different decades, and impact ongoing longitudinal studies, if there are significant changes in the population of the UK. It could also impact comparisons with studies done in Europe.

It also raises more deeper philosophical questions. If mental illness can be influenced by social factors, should we have classificatory systems like the DSM and ICD which are typically treated as universal? I think this is a question which would need be informed by empirical research, studies of exactly how mental illness manifests in different settings, and even after that the decision would be influenced by difficult practical questions. If universal classificatory systems were rejected, then how broad should they be? Do we want to be part of the American classificatory system, the European one or have a unique British one? Of course, for better or for worse, the American and European systems are very similar, so in that reguard any detachment from Europe does not leave a binary choice between choosing between contrary American and European systems.

Reviewing Philosophical issues in Psychiatry III: Nature and Sources of Historical Changes

This is the third book in the series, started in 2008 and then the second volume in 2012. All three volumes have been edited by Kenneth Kendler and Joseph Parnas, bringing together contributions from psychiatrists, philosophers of psychiatry and historians of psychiatry. Each volume takes the same format, an overall introduction by one of the editors and then individual papers grouped by themes. Each paper is fronted by a brief introductory article by one author, then the main article by another author and then a commentary by a third author. This means each book contains an immense number of articles (43 in the case of this volume) despite only being 380 pages long. The introductions and commentaries are almost always worth reading, often making significant points in their own right which are not present in the main article they are discussing. This makes the book an excellent source for a multiplicity of viewpoints and, since sometimes the introductions and commentaries disagree with the main article, diverging points of view. If you wish to find an academic expressing a philosophical viewpoint on psychiatry, or multiple academics expressing contrary viewpoints, then turning to one of these volumes is a good idea.

Of the three volumes, this one is the most diverse in approach, mainly because it closely integrates philosophy and history. It has three sections. The first discusses ontological, epistemic and methodological issues relating to changes in psychiatry, relating to issues like why does psychiatry keep changing, are these changes for the better, what sort of changes should we aim for, etc. Secondly, what specific broad changes have occurred in psychiatry, such as development and decline of psychoanalysis, operationalism and genetic explanations. Thirdly, philosophically informed histories of specific diagnosis, such as schizophrenia, depression and autism. All three sections are worth reading, though how much you will get out of each section will likely vary considerably on your specific interests. As someone interested in questions of belief in psychiatric classifications, I primarily found the first section useful. I think psychiatric diagnosis can potentially merit belief even if there is not one fixed, eternal true set of psychiatric diagnosis – the causes of mental illness change, mental illnesses manifest differently as social settings change and our values which we use to interpret mental illness change. Though not all articles in this section addressed these specific issues, I found they gave much to think about on such question and offered some novel approaches and novel possible solutions to such issues.

Though I could comment on many articles (and may do so in future blog posts), the one which most interested me is by German Berrios. This articles challenges a long standing approach in philosophy of psychiatry. Generally, most mental illnesses are seen as separate from their environment. Internal biological and psychological causes (potentially set off by environmental causes) produce symptoms which express themselves in a social context. So on this model, the social context is not itself a cause of the symptoms but is a cause of how the symptoms are expressed, i.e. the symptoms interact with a social environment. However, Berrios challenges this, arguing the social context is itself part of the symptom, the social context cannot be separated out as something the symptoms interact with but are themselves part of the causal process. This makes causation in psychiatry much more complicated but I think much more realistic. It makes mental illness less static, less fixed, more embedded within the environment, rather than viewing mental illnesses as fixed and static yet malleable in how they are expressed. At a minimum, it raises important questions about how we should think about causation in psychiatry, where we should put the boundaries between things, their causes, and the environment in which they causally manifest in. At minimum, Berrios shows an alternative way of parsing up that equation and argument is needed to take the symptom manifesting in social context approach as superior to social context as part of symptoms.