Psychiatry: a controversial practice

  Psychiatric practice will probably always be risky and controversial. Many psychiatrists argue for a more limited approach, restricting it to clearly identifiable and agreed mental illnesses: ‘We should stick to treating diagnosed illnesses, schizophrenia, anorexia nervosa, depression and accept that there are many other causes of human distress beyond mental illness.’ ‘We should leave the social policy and ethics to the politicians and philosophers.’ This is an attractive argument. The history of psychiatry is full of examples of overstepping the mark. But as we have seen in this chapter it is not simply up to the psychiatrists – there are other stakeholders and powerful forces at play with broad ethical issues and significant potential benefits in the balance.

  Scientific developments are expanding what we can do; families and patients have steadily rising expectations from us; governments and the pharmaceutical industry challenge us with new demands, inducements, and opportunities. We could only possibly avoid controversy and the risk of potential mistakes if we turned our back on progress and innovation. But that means not fulfilling either psychiatry’s promise or its obligations. Straddling hard science and the field of human behaviour and ambitions, it is simply impossible for psychiatry to be uncontroversial. It comes with the territory and, as we are about to explore in Chapter 7, may be getting worse.

 

Chapter 7 Into the 21st century New technologies and old dilemmas

  It doesn’t matter what he does, he’ll never amount to anything.

  (Albert Einstein’s teacher, 1895)

Computers in future may weigh no more than 1.5 tons.

  (Popular Mechanics, 1949)

We don’t like their sound, and guitar music is on the way out.

  (Decca Records on the Beatles, 1962)

It is risky to make predictions. Psychiatry at the beginning of the 21st century is very different to that of just a few decades ago. Who could have imagined that we would be able to visualize not only the living brain’s structure in minute detail but even watch as different regions light up with specific emotions or during hallucinations? Could we have foreseen diagnoses derived by computers or psychotherapies on the web with neither psychiatrist nor psychologist involved? Psychiatry is changing and the rate of change intensifies the dilemmas raised in Chapter 6. Optimists believe these will fade away as the scientific base of psychiatry becomes firmer, but there is little evidence for this yet. The areas of concern may shift but they seem, if anything, as pressing.

Improvements in brain science

  We will continue to experience an acceleration in our understanding of brain functioning. Neurosciences have become the ‘hot topic’ in biomedical research, driven by increasingly powerful tools for visualizing and measuring brain functioning. For so long it has been a mysterious, apparently inert organ with no moving parts. Modern imaging techniques reveal the brain’s dynamism, allowing us to observe activity spread through it with individual areas activating sequentially in response to stimulation. And not just responding to external stimuli, but solving mathematical problems or even discriminating between pictures of people we like or don’t like.

  The big leap forward came with imaging. The structure of the brain has been studied in great detail by anatomists for over a century. They identified the function of areas by examining the brains of people who had had strokes and lost different functions. Shrinkage or damage to the brain could be demonstrated in post-mortems and by x-ray techniques. These later involved either injecting dye into the bloodstream or air into the ventricles (fluid-filled cavities that exist normally in the brain). Visualization of the body’s structures took a great leap forward with CAT scanning and then MRI scanning. These use magnetic fields to produce amazingly detailed images of ‘slices’ through any part of the body (including the brain) that can be used to construct 3D pictures. While these techniques were useful in diagnosing brain tumours and demonstrating dementia they were of little help in most psychiatric disorders. Indeed, the term ‘functional disorder’ has long been used as shorthand for psychiatric illnesses precisely because no structural abnormalities could be shown.

  Functional imaging has been a further advance for psychiatry. There are already three different types – measuring increased blood flow, measuring cell metabolism with the use of marked chemicals, and now even directly measuring the electric activity of nerve cells. We can now show that thinking and feeling are reflected in activities in different parts of the brain and that the same parts of the brain are active when patients hallucinate as when we hear real voices. Functional imaging has confirmed the complexity and interconnectedness of brain activity.