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From Biological Psychiatry to Ap...

Posted Sep 28 2008 6:11pm

From Biological Psychiatry to Aplysia californica. Recently read Charles Barber’s Comfortably Numb: How Psychiatry is Medicating a Nation, a book noted elsewhere on this blog. It’s a compelling read that covers a lot of ground — the rise of Big Pharma and what he calls “The Triumph of Biological Psychiatry” (a history of how psychiatry shifted from a focus on Freudianism to a focus on medication), a section on psychotherapy that leans pretty heavily in favor of cognitive-behavioral therapy, and a curious chapter on the work of Eric Kandel, winner of the 2000 Nobel Prize in physiology or medicine.

Big Pharma. Barber manages to trot out numerous horror stories about the behavior of Big Pharma — the weakness of the FDA, the number of articles ghostwritten for American medical journals by writers hired by Big Pharma, that one in five visits to a psychiatrist leads to the prescription of an antipsychotic (New York Times, June 6, 2006) and plenty more. The chapter entitled “The Commerce of Mood” is particularly enlightening about the power of the pharmaceutical industry.

A history of psychiatry. Barber covers a jolting swing of the pendulum in psychiatry, from an almost complete embrace of Freudianism to an equally complete embrace of the use psychotropic medication. Freud’s ideas flourished after the Second World War. Barber asserts that it was the discovery of Thorazine in 1952, followed by that of Valium in the 1960s that signaled the death of psychotherapeutic psychiatry. (He provides an amusing Freudian conception of what today we’d call Post-traumatic Stress Disorder (PTSD). “…the conditions of war caused soldiers to regress to an infantile condition, whereby commanding officers became father or older brother figures” [p. 71]). Thorazine literally transformed asylums within days, a shift from mayhem, to something a more manageable. And Valium came at just the right time, social pressures on happiness were increasing, and here was a drug that eased anxiety. Here was perhaps the beginning of what Barber terms “emotional entitlement”.

American unhappiness. Barber also shifts into a sociological mode, comparing SUVs and SSRIs as emblematic of their times, both examples of overkill, one provides the ability to drive up the Himalayas, while the other provides an opportunity for “cosmetic pharmacology”, the use of medication for those who are not ill, but rather are facing some difficulty in their lives. The author decries:

…the tremendous bias in academic psychiatry against psychological and social forms of inquiry. The psychosocial realm is tolerated but often barely so — viewed as well-intentioned and sort of cute, but ultimately and soundly relegated by the margins, literally and figuratively.

Psychiatry as science? The means by which psychiatry stakes this claim on reality is in the guise of science. The author makes a number of interesting points on this score. Psychiatry as a:

bona fide science built on white-coated certitude… that all our behavior finally comes down to molecules and transmissions between those molecules and that psychiatry in some profound way is starting to unlock those mysteries. It is the all too hasty belief that biological psychiatry has emerged into something akin to physics or chemistry, reassuring in its rules and clarity.

Neuroscience has made many impressive accomplishments, but psychiatry is not neuroscience. When it makes an appeal to neuroscience that is a weak appeal. Barber talks with a “leading neuroscientist”, Elliott Valenstein and speaks to him about “why all psychiatric drugs address only a small proportion of all the neurotransmitters that are thought to exist”. There are thought to be over 100 neurotransmitters and psychotropics address four of those neurotransmitters. Why those four? Arbitrary accidental discoveries. The point is, many of those other neurotransmitters may have “some vital impact on psychiatric syndromes, yet to be explored”. By extension, any claim to scientific certitude on the part of psychiatry is weak at best, ludicrous at worst.

And another thing. Anyone that has seen psychotropic meds prescribed on an in-patient basis, knows that it is more art than science, that it depends upon a good deal of trial and error, not to mention a great deal of patience on the part of the patient. The “science” of studies are based on generalities, not individuals, and it often takes quite some time to find a medication that suits the particular individual seeking help.

Kandel and the sea slug. Barber’s own appeal to science is a chapter based loosely around the work of Eric Kandel. Kandel’s study of a sea slug has provided important insights into the workings of the nervous system. The key finding was that the experience of the slug changed its brain, its nervous system, its synaptic connections. (The slug has so few cells that this is not difficult to observe.) Barber also quotes some of Kandel’s observations on genetic functioning:

Kandel writes: The regulation of gene expression by social factors makes all bodily functions, including all functions of the brain, susceptible to social influences…

Barber also goes on to quote some of the scientific literature which supports the idea that brain imaging has demonstrated that psychotherapy can make physiological changes to brain structures. The critical point is that experience alters the brain. Presumably some alterations in the brain may lead to a decrease in psychological suffering. Certainly, that’s the premise of biological psychiatry. That experience alters the brain opens the door to the idea that all kinds of environmental, social, interpersonal, and psychotherapeutic may alter the brain. Therefore, there is no reason to conclude that psychotropic medications are the sole route to easing psychological suffering.

Cogito, Ergo Sum. This is the title of the chapter largely about cognitive-behavioral therapy. It was effusive in places and inaccurate in others. I thought it was the weakest part of the book. But to take the chapter apart would take far too much space here, and detract from the most important message of the book. That there is still a place for the human touch in helping those with mental illness.

It’s an important point, worth repeating. Barber’s book is well worth reading. Another review of the book, at the New York Review of Books, is here.

Kalea Chapman, Psy.D.

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