David Healy: Shipwreck of the singular

Edward Shorter’s comment


 In psychiatric writing, David Healy offers a distinctive combination of puckish wit and powerful insight.  Many of the ideas in this essay are new and represent adumbrations of themes that hopefully will guide his future writing.  One theme, in particular, is of extraordinary interest, and that is the apparent failure of both of Psychiatry's conventional "models": the biopsychosocial model and the medical model.  

Healy traces the origins of each, locating today the failure of each in a specific locus: the randomly controlled clinical trials (RCTs) and the hunger for data from epidemiological studies and from rating scales.  Healy speaks eloquently of the dangers of Big Risk and its insertion in the doctor-patient relationship; he describes the dehumanizing impact of seeing the patient as a sack of risk, rather than as a sack of enzymes (in the biological model) or an accumulation of "risk factors," as in the biopsychosocial model.  This is a perfectly valid, and highly original, analysis that will dismay a wide spectrum of readers, from Departments of Social Medicine to the advocates of brain imaging.

\But there is a second road that Healy might have taken but didn't.  Putting the accent on pharmaceutical risk, slides by another huge issue in Psychiatry caused by rating scales and RCTs:  the disappearance of psychopathology from the discipline's armamentarium of tools.   Scales and the general diagnostic categories of RCTs ignore the fine differentiations that are required to: (a) figure out exactly what is wrong with a patient; and (b) devise means in the laboratory of conferring a benefit.   (Since we don't know exactly what he's got, we're unable to specify how we might remedy it, and oh please, don't tell us that the problem is "depression.")

Our psychopathology today has been reduced to the gross absurdities of the DSM that do not just kick the proverbial lost keys out of the range of the streetlight, they extinguish the streetlight itself.  It is a manual filled with non-disease and falsely wrought aggregations.  The important diseases of DSM are "major depression," "schizophrenia," and "autism."  Really?  These are all highly heterogeneous clinical populations, none of which will respond in a uniform way to any imaginable agent, just as lung cancer and tuberculosis would not respond to the same agent, though their presentations are vaguely similar.  The brilliance of Healy's formulation "A biobabble replaced a psychobabble" reminds us of the inadequacy of both the biological and sociological approaches to psychiatric disease.  But what we have lost is the Scandinavian and German-speaking traditions of studying the individual patient closely, rather than measuring large and disparate clinical populations in our search for knowledge.

We study the patient closely, not solely to make him or her better, but to gain clues about the conformation of illness patterns as Nature has devised them and society has contoured them.  Healy is quite right in condemning current measurement strategies, but has shied back from saying that several things are going on here, not just Big Risk, and one of those things is the lacking study of psychopathology.


Edward Shorter

May 5, 2016