THE%20FUTURE%20OF%20PSYCHIATRY%20IS%20THE%20BIOPSYCHOSOCIAL%20MODEL

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THE FUTURE OF PSYCHIATRY IS THE BIOPSYCHOSOCIAL
MODEL

• D B Double

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My argument

• Psychiatry has always had a biomedical emphasis

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My argument

• Psychiatry has always had a biomedical emphasis
• There has always been a biopsychosocial minority
  view

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My argument

• Psychiatry has always had a biomedical emphasis
• There has always been a biopsychosocial minority
  view
• The future needs to be shifted away from
  biomedical to biopsychosocial

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John Haslam (1764-1844)

• Insanity is "a corporeal disease".

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John Haslam (1764-1844)

• Insanity is "a corporeal disease".
• Mental illness is "the peculiar and exclusive
  province of the medical practitioner" (his
  emphasis)

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John Haslam (1764-1844)

• Insanity is "a corporeal disease".
• Mental illness is "the peculiar and exclusive
  province of the medical practitioner" (his
  emphasis)
• Madness has always been connected with
  diseases of the brain and of its membranes

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John Haslam (1764-1844)

• "The various and discordant opinions, which
  have prevailed in this department of knowledge,
  have led me to disentangle myself as quickly as
  possible from the perplexity of metaphysical
  mazes."

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John Haslam (1764-1844)

• "The various and discordant opinions, which
  have prevailed in this department of knowledge,
  have led me to disentangle myself as quickly as
  possible from the perplexity of metaphysical
  mazes."
• "From the limited nature of my powers, I have
  never been able to conceive . . . a disease of
  the mind." (his emphasis)

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Henry Maudsley (18351918)

• Donated money to found Maudsley hospital - centre
  of treatment and research rather than confinement
  and "asylum".

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Henry Maudsley (18351918)

• Donated money to found Maudsley hospital - centre
  of treatment and research rather than confinement
  and "asylum".
• Expanded scope of Journal of Mental Science to
  include psychology and philosophy

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Henry Maudsley (18351918)

• Donated money to found Maudsley hospital - centre
  of treatment and research rather than confinement
  and "asylum".
• Expanded scope of Journal of Mental Science to
  include psychology and philosophy
• "The explanation, when it comes, will not come
  from the mental, but from the physical side

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Aubrey Lewis (1900-1975)

• Inaugural chair from 1948 of Institute of
  Psychiatry which was Maudsley Hospital Medical
  School

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Aubrey Lewis (1900-1975)

• Inaugural chair from 1948 of Institute of
  Psychiatry which was Maudsley Hospital Medical
  School
• Postgraduate psychiatry for ardent, critical,
  lively, disputatious and reflective, eager
  minds.

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Aubrey Lewis (1900-1975)

• Inaugural chair from 1948 of Institute of
  Psychiatry which was Maudsley Hospital Medical
  School
• Postgraduate psychiatry for ardent, critical,
  lively, disputatious and reflective, eager
  minds.
• Lewiss sceptical approach to psychiatry may not
  be enough

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Wilhelm Griesinger (1817-1868)

• Mental pathology and therapeutics (original
  German edition 1845)

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Wilhelm Griesinger (1817-1868)

• Mental pathology and therapeutics (original
  German edition 1845)
• Mental diseases are brain diseases

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Wilhelm Griesinger (1817-1868)

• Mental pathology and therapeutics (original
  German edition 1845)
• Mental diseases are brain diseases
• "It is only from the neuropathological standpoint
  that one can try to make sense of the
  symptomatology of the insane

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Ernest von Feuchtersleben (1806-1849)

• The principles of medical psychology (originally
  German edition 1845)

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Ernest von Feuchtersleben (1806-1849)

• The principles of medical psychology (originally
  German edition 1845)
• "The notion, mental disease, must be deduced
  neither from the mind nor from the body, but from
  the relation of each to the other."

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Ernest von Feuchtersleben (1806-1849)

• The principles of medical psychology (originally
  German edition 1845)
• "The notion, mental disease, must be deduced
  neither from the mind nor from the body, but from
  the relation of each to the other."
• "Psychopathies have no seat they are combined
  constitutions which appear in the disturbance of
  these functions by which the mind is manifested,
  that is, in the collective personality."

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Pluralism in psychiatry (1900-1970)

• Psychoanalysis Freud first spoke publicly in
  USA at Clark University in 1909

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Pluralism in psychiatry (1900-1970)

• Psychoanalysis Freud first spoke publicly in
  USA at Clark University in 1909
• Pragmatic approach of Adolf Meyer - Psychobiology

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Pluralism in psychiatry (1900-1970)

• Psychoanalysis Freud first spoke publicly in
  USA at Clark University in 1909
• Pragmatic approach of Adolf Meyer - Psychobiology
• Focus on the person

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The current scene

• Underwhelming evidence of efficacy of medication

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The current scene

• Underwhelming evidence of efficacy of medication
• Lack of appreciation of environmental factors in
  psychiatric disorders

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The current scene

• Underwhelming evidence of efficacy of medication
• Lack of appreciation of environmental factors in
  psychiatric disorders
• Non-standardised use of operational diagnostic
  criteria

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The current scene

1. Underwhelming evidence of efficacy of medication
2. Lack of appreciation of environmental factors in
   psychiatric disorders
3. Non-standardised use of operational diagnostic
   criteria
4. Lack of ability to examine the structure and
   function of the mind directly

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1) Underwhelming evidence of efficacy of
medication

• About a third of published studies show no
  difference between antidepressants and placebo

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1) Underwhelming evidence of efficacy of
medication

• About a third of published studies show no
  difference between antidepressants and placebo
• Mean drugplacebo difference in improvement
  scores is only 1.8 points on the Hamilton Rating
  Scale for Depression

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1) Underwhelming evidence of efficacy of
medication

• About a third of published studies show no
  difference between antidepressants and placebo
• Mean drugplacebo difference in improvement
  scores is only 1.8 points on the Hamilton Rating
  Scale for Depression
• Raters' expectations and patients' suggestibility
  could entirely explain the small effect size

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2) Lack of appreciation of environmental factors

• Work of the geneticists has been replete with
  uncritical dogmatic statements and lack of
  scientific rigour

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2) Lack of appreciation of environmental factors

• Work of the geneticists has been replete with
  uncritical dogmatic statements and lack of
  scientific rigour
• Despite the hype, genetics of psychiatric
  disorders so complex that accurate prediction may
  not be possible

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2) Lack of appreciation of environmental factors

• Work of the geneticists has been replete with
  uncritical dogmatic statements and lack of
  scientific rigour
• Despite the hype, genetics of psychiatric
  disorders so complex that accurate prediction may
  not be possible
• Genes only set the boundaries of the possible
  environments define the actual

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3) Non-standardised use of operational diagnostic
criteria

• Diagnostic criteria do not solve the dilemma
  surrounding psychiatric classification

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3) Non-standardised use of operational diagnostic
criteria

• Diagnostic criteria do not solve the dilemma
  surrounding psychiatric classification
• The basic issue is about the meaning of
  psychiatric diagnosis

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3) Non-standardised use of operational diagnostic
criteria

• Diagnostic criteria do not solve the dilemma
  surrounding psychiatric classification
• The basic issue is about the meaning of
  psychiatric diagnosis
• Too easily assume a diagnosis is an entity of
  some kind

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4) Lack of ability to examine structure and
function of the mind directly

• Structural and functional cerebral abnormalities
  are at best subtle rather than gross.

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4) Lack of ability to examine structure and
function of the mind directly

• Structural and functional cerebral abnormalities
  are at best subtle rather than gross.
• Brain cytoarchitecture itself is fashioned by
  input from the social environment

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4) Lack of ability to examine structure and
function of the mind directly

• Structural and functional cerebral abnormalities
  are at best subtle rather than gross.
• Brain cytoarchitecture itself is fashioned by
  input from the social environment
• Even psychosis should be understood in
  psychosocial terms, rather than reduced to brain
  abnormalities

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Conclusion - Biomedical psychiatry as the
Emperors new clothes

• Biomedical psychiatry is naked," the child said.

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Conclusion - Biomedical psychiatry as the
Emperors new clothes

• Biomedical psychiatry is naked," the child said.
• Biomedical psychiatry could not admit to that. It
  thought it better to continue the procession
  under the illusion that anyone who couldn't see
  its clothes was either stupid or incompetent

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Birth pang of a new age?

• Questioning the biological basis of mental
  disorder does not necessarily amount to denial of
  the reality of mental illness or invalidation of
  the practice of psychiatry

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Birth pang of a new age?

• Questioning the biological basis of mental
  disorder does not necessarily amount to denial of
  the reality of mental illness or invalidation of
  the practice of psychiatry
• Avoid the need to objectify those identified as
  mentally ill

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Birth pang of a new age?

• Questioning the biological basis of mental
  disorder does not necessarily amount to denial of
  the reality of mental illness or invalidation of
  the practice of psychiatry
• Avoid the need to objectify those identified as
  mentally ill
• Recognise the inherent uncertainty in psychiatry
  and medicine