精神病学的局限性IndianJPsycholMed3016-1133595_030855

6 Indian Journal of Psychological Medicine LIMITS TO PSYCHIATRY AND LIMITATIIONS OF PSYCHIATRISTS Dr. K. Chandra Sekhar Psychiatry as a clinical discipline has made rapid strides during the last three to four decades. Advances in the field of psychoparmacology, and genetics have contributed to better treatment options and enhanced the quality of life for the mentally ill. However, simultaneously, there is a perception that psychiatry needs to do a lot more to the suffering population at large. At times, it is believed that a psychiatrist has the capacity to give panacea for the innumerable problems that exist in the society. Not a day passes without some “EMMINENT PSYCHIATRIST” giving his ”VALUABLE OPINION”, “PSYCHOLOGICAL EXPLANATION” and advice for a whole range of problems in society including terrorism, kidnappings, murders, earthquakes, tsunamis and what not, in the electronic and print media. I think the time has come when we should ask ourselves in the words of late Dr. Ravinder Lal Kapur “Are we overdoing psychiatry?” Let us remind ourselves that a psychiatrist is not an expert in the whole conduct of life. Unless we understand the “LIMITS OF PSYCHIATRY” and “THE LIMITATIONS OF THE PSYCHIATRIST” in the current scenario, the day will not be far off when a lay person thinks that we talk too much and deliver too little. SCOPE OF PSYCHIATRY “Psychiatry is that medical specialty which deals with behavioral changes arising out of pathology either in the brain or other systems in the body”. This is too simplistic a way of defining and it does not include the various other behavioral maladaptations occurring due to psychosocial factors. It is a known fact that mental disorders are more diverse than bodily disorders in their presentation. When we look at the various psychiatric diagnoses, dementias, organic psychoses, schizophrenia, bipolar disorders, paranoid psychoses, obsessive compulsive disorder, anxiety states, depression and addictions can be termed as disorders and given a disease status while one tends to see more variability and conceptual confusion when the labels Hysteria, Stress reactions, Adjustment disorders, Conduct disorders and Psychopathy as disease, as they appear to be more of problems of routine daily living. Psychiatry is about managing mental illnesses and not human suffering of any cause. As Pridmore points out, “Psychiatrists are now expected to assist (up to and including hospitalization) when individuals have social difficulties and are distressed following relationship breakdowns”. Do Psychiatry or, for that matter psychiatrists have any tools to address or remedy the social causes? Psychiatry can manage “difficult” individuals when the difficulty is because of a mental illness. The general public, unfortunately, including other specialists have a poor understanding of psychiatry and hence try sending all their “difficult” people to the door of a psychiatrist. By magnanimously accepting these challenges, are we diluting our own role as medical specialists? When such “difficult” people creep into diagnostic classifications and get a label attached to them, there is bound to be a vast difference in the perception of psychiatry by the Lay public, Governments and Judiciary, and Human Rights activists etc. It is but natural that this type of overinclusiveness can lead to defective planning and policies and improper NOTE : PRESIDENTIAL ADDRESS delivered at the 40th Annual Conference of Indian Psychiatric Society, Southern Zonal Branch – 2007 at Hyderabad, India. [Downloaded free from http://www.ijpm.info on Saturday, September 05, 2009] Indian Journal of Psychological Medicine 7 priorities in the delivery of mental health care. The tardy and ineffective implementation of MHA in India and almost total non-implementation of the National Mental Health Program born 25 years ago are examples of defective planning and implementation. We do not have a proper program or funding for the mentally ill and allocate precious budget for areas remotely related to psychiatry. Some argue that there is no future for psychiatry. The reductionists’ point of view is that psychiatric disorders can be reduced to either neurological dysfunctions or psychosocial problems of living. While the former can be taken care of by neurologists, the latter are the concern of social scientists. However, there is need to be emphasize that psychiatry is a frontier discipline and psychiatric disorders typically involve the psychobiological interface that defines man. Psychiatry could provide biological sophistication in our understanding of adaptive failures. It could build multidimensional conceptual bridges between human neurobiology and problems of living. MAKING OF A PSYCHIATRIST A Psychiatrist needs a basic medical qualification. For the rational practice of psychiatry there is need to have knowledge of Neurosciences, Psychology, Sociology and Social Anthropology. Also needed, are knowledge of General Medicine, Neurology and Endocrinology. During the tenure of training in psychiatry most of us get to know only very few basic elements of behavioral sciences, which was never taught during undergraduate training. Thus, a psychiatrist starts studying abnormal persons before having full knowledge of normal psychology. It has to be remembered that we cannot extrapolate from the abnormal to the normal; they are unlikely to be on a continuum, but rather are qualitatively different (Andrew Sims). Because of his detailed knowledge of abnormal psychic processes and symptoms and their management, the psychiatrist is not necessarily also an expert on bringing up children or provid- ing a recipe for a tranquil mind. Dangerous generalizations can be made when the psychiatrist often against his will, is thrust into the position of being the expert on whole conduct of life (Andrew Sims). It is unclear how psychiatric training as it exists today can claim to address distress in society, which is purely because of social reasons. There are others who can play a better role in imparting communication skills, personality development courses, and tips for social, moral, and spiritual well- being. While well-being sounds like a worthwhile goal, it would appear an ambitious target for psychiatrists who are trained for, and would be well advised to limit their attention to the alleviation of psychiatric disorders. This is not to under estimate the ability of any single psychiatrist who also wants to take on the role of “messiah” for alleviating the distress in society, but to make it an integral part of psychiatry and as a policy, making psychiatry address social issues is a grave error. On the contrary, it would be a great service if psychiatrists can protect those who are mentally ill from being exploited or misled by other agencies. PSYCHIATRIC DIAGNOSIS Our existing diagnostic systems do not define mental disorder adequately. “Distress” can be because of a pathological state or non-pathological state. Behavioral distress often gets classified into a psychiatric disorder without adequate reasons. Nancy Aderasen, a psychiatry professor with a deep devotion to literature too, in her book “The Broken Brain”, observed that the question “What is mental illness” is difficult to answer. When the question is reframed as “What are the common mental illness”, there is astonishing agreement. The Indian Mental Health Act also gives a definition for a mentally ill person, but astoundingly, not mental disorder. When there are no adequate definitions for “mental illness” and “mental health”, there is every possibility that “problems of living” get a “disease label” thereby diluting the very concept of psychiatric disorder. The process of medicalization (ie. Defining non-medical problems in medical terms with an implication that medical intervention or [Downloaded free from http://www.ijpm.info on Saturday, September 05, 2009] 8 Indian Journal of Psychological Medicine treatment is appropriate) forces psychiatry to accept responsibility for situations and problems over which it can exert no real or at best an insignificant influence. When one looks at certain diagnostic categories, in DSM IV or ICD-10, there are certain potentially normal behaviors, which can be called as a mental disorder. Let us look at some examples: Shyness (social anxiety disorder), violence (intermittent explosive disorder), and worry (anxiety disorder). Similarly, the symptoms of depression often get categorized as a disorder even in the absence of other clinical features of depression. Posttraumatic Stress Disorder is often over diagnosed because of similar reasons. Suicide by itself is not a psychiatric diagnosis, but is medicalized and psychiatricized by many commentators. Eg: The suicides by farmers and weavers in Andhra Pradesh and elsewhere in the country reflected more of improper policies by the Government, economic reasons, and other social factors prevailing at that point in time. Psychologization of this social tragedy in fact angered many people. No doubt, there is an emotional and psychological undertone for every human suffering, but it does not mean that the psychiatrist has a role to play in all such situations. A temptation that psychiatrists often succumb to is otherwise label every deviant behavior as a psychiatric disorder. This outlook often lands psychiatry and psychiatrists in trouble. It is not rare to find public, judiciary, and human rights activists blaming psychiatrists for labeling and at the same time telling psychiatrists that they should take care of disturbed individuals, though the disturbance does not fall into the category of a disorder. Thus, the greatest limitation of the psychiatrist starts with the process of diagnosis itself. The uncertainties in diagnosis emanate from criterion variants for the illness, inappropriate use of inferential criteria rather than direct observation, over diagnosis on minimal criteria for fear of missing a serious disorder in the early stages and uncertainty stemming from complexities of psychobiological interface. To a certain extent, the above problems can be addressed by the systemic use of explicit and operationally defined criteria, training in phenomenology and methodology, and research into the biological bases of diseases. In the process of diagnosis, phenomenology and descriptive psychopathology, are the tools, which no psychiatrist can afford to ignore. If these skills are not properly acquired and utilized, it puts a big limitation on the psychiatrists. Psychiatrists should acquire skills in recognizing and understanding psychopathology and also be sensitive to the cultural factors, which can influence the psychopathology. Being medical professionals and trained to practice the “medical model”, it is but natural that we classify illnesses into physical and mental, or psychological. But we do realize that psychological processes influence physical illnesses and vice versa. The whole discipline of psychiatry tacitly accepts a dualistic background for its very existence, although it resents this and tries hard to teach medicine of the whole person. Our language continually brings us back to dualistic words and expressions and we are constantly in the danger of either a “mindless” psychiatry or a “brainless” psychiatry (Eisenberg 19986, 2000). The precision with which psychiatric diagnosis is made always depends upon descriptive psychopathology, which avoids theoretical explanations for psychological events. Phenomenology studies these events and avoids coloring them with explanations of cause or function. In this process there are bound to be errors. Often, these errors are magnified and the diagnosis in psychiatry itself is questioned. The “sting operation” by Rosenbaum in yesteryears is a fine example, which questions the validity of diagnosis of schizophrenia. If only psychiatry/psychiatrists can limit diagnosis and treatment to only those disorders listed in standard classificatory systems (which need to be refined periodically) and refrain from involving all problems of human suffering, only then a clear identity for the discipline can emerge without role confusion. From the scientific point of view, disciplines probably achieve their success partly through [Downloaded free from http://www.ijpm.info on Saturday, September 05, 2009] Indian Journal of Psychological Medicine 9 restricting their objectives. Psychiatrists are in particular danger if confusion through failure to delineate the area in which their concepts and theories can be validly applied. However, this is not to underestimate the usefulness of knowledge in arts, literature, spirituality, and other cultural issues. Knowledge in these can make an individual psychiatrist a better person who can probably utilize these skills in appropriate situations during his clinical practice, but saying that they are absolutely necessary for practice of clinical psychiatry, is far from the truth. POSITIVE MENTAL HEALTH Like mental illness, mental health also remains undefined, but slogans are coined, policies are announced, promises are made to improve the “mental health” of the individual and society. Slogans such as “No health without mental health”, though catchy, are equally amusing. What constitutes adequate mental health is debatable. Does awareness about mental illnesses bring about adequate mental health? Definitely not! The glaring example is the conduct of mental health professionals in their behavior in non-professional matters. Does stress tolerance indicate adequate mental health? Again, the concept of stress is nebulous. In the whole process of our reactions to the stress in the individuals, we do not take into account the concept of resilience adequately. Are psychiatrists in any way better qualified to address the social causes of stress? Probably, we can treat those who become vulnerable to the effects of stress and have no tools to address the causes of stress. We talk of “psychological checkup” (akin to physical checkup) without really having any operational definitions or criteria for normal psychological states. We do not have any mechanism even to check the aptitude of those taking up psychiatry or mental health as a profession and even if some claim it exists, it is never used. Robert Cloninger opines that psychiatry failed to improve the well being of the general population as a result of excessive focus on stigmatizing aspects of mental disorders and neglect of methods to enhance positive emotions, character development, life satisfaction, and spirituality. I think psychiatry should never profess that it can take this sort of a role. No doubt, mental disorders carry a stigma. We should adequately address this issue rather than expanding into areas just to gain some public acceptance. Stigma of mental illness persisted for a long time and similarly the stigma of consulting a psychiatrist. It cannot be wiped out by catchy slogans. Unlike physical illness, suffering from a mental illness is not merely the advent and advance of symptoms, but a unique “experience” for the sufferer and his family. This experience involves the negative emotions of guilt, embarrassment, and shame due to the behavior engaged while being mentally ill. To get over such feelings, different individuals take different paths. The psychiatrist’s role is to encourage the individual to come to terms with reality. Stigma gradually disappears when society perceives these behaviors as temporary states of mind caused by an “outside agency” and the individual is not responsible for it. This could be one of the reasons why culturally often, mental illness is seen as a possession by evil spirit - the society accepts the individual with much more ease and lesser stigma. Apart from the role of increased public awareness utilizing cultural beliefs in a positive way can help reduce the stigma. CONCLUSION To make psychiatry as a frontier discipline in medicine, one way is to limit it to those conditions for which it has something to offer; while society can focus (with the help of relevant experts) on the underlying causes of human suffering like poverty, illiteracy, unemployment, human rights issues, etc. It is necessary to have clearcut boundaries for the discipline of psychiatry. The psychiatrist’s role with reference to sociocultural stressors should be limited to ruling out a mental disorder and leave the management of sociocultural issues to the appropriate agencies. Psychiatric diagnosis should be a positive diagnosis and not an exclusion diagnosis. If there are no set boundaries for the [Downloaded free from http://www.ijpm.info on Saturday, September 05, 2009] 10 Indian Journal of Psychological Medicine discipline, budgetary resources in mental health may be diverted to unproductive and poor priority areas and core areas of psychiatry get neglected. REFERRENCES: • Andrew Sims. Symptoms in the Mind. An Introduction to Descriptive Psychopathology, 3rd edition ELSEVIER 2003. • Eisenberg L (1986). Mindlessness and Brainlessness in Psychiatry. British Journal of Psychiatry 148, 497-508. • Eisenberg L. (2000). Is Psychiatry More Mindful or Brainier Than It Was a Decade Ago? British Journal of Psychiatry 176, 1-5. • Pridmore S. Download of Psychiatry, (Chapter 32), University of Tasmania, ISBN 2006. Address for correspondence : Dr. K. Chandrasekhar President, Indian Psychiatric Society, South Zone & Director, Asha Hospital, Banjara Hills, Hyderabad. Ph : 040-66752222 • Robert Cloninger C. The Science of Well-Being; An Integrated Approach to Mental Health and Its Disorders. World Psychiatry 5:2-June 2006. [Downloaded free from http://www.ijpm.info on Saturday, September 05, 2009]