THE FUTURE OF PSYCHIATRY IS THE
BIOPSYCHOSOCIAL MODEL
D B Double
My argument

Psychiatry has always
had a biomedical
emphasis
My argument


Psychiatry has always
had a biomedical
emphasis
There has always been a
biopsychosocial minority
view
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
John Haslam (1764-1844)

Insanity is "a corporeal
disease".
John Haslam (1764-1844)


Insanity is "a corporeal
disease".
Mental illness is "the
peculiar and exclusive
province of the medical
practitioner" (his
emphasis)
John Haslam (1764-1844)



Insanity is "a corporeal
disease".
Mental illness is "the
peculiar and exclusive
province of the medical
practitioner" (his
emphasis)
“[M]adness has always
been connected with
diseases of the brain
and of its membranes”
John Haslam (1764-1844)

"[T]he 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."
John Haslam (1764-1844)


"[T]he 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."
"[F]rom the limited nature of
my powers, I have never been
able to conceive . . . a disease
of the mind." (his emphasis)
Henry Maudsley (1835–1918)

Donated money to found
Maudsley hospital - centre of
treatment and research
rather than confinement and
"asylum".
Henry Maudsley (1835–1918)


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
Henry Maudsley (1835–1918)



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”
Aubrey Lewis (1900-1975)

Inaugural chair from 1948
of Institute of Psychiatry
which was “Maudsley
Hospital Medical School”
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.”
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.”
Lewis’s sceptical approach
to psychiatry may not be
enough
Wilhelm Griesinger (1817-1868)

Mental pathology and
therapeutics (original
German edition 1845)
Wilhelm Griesinger (1817-1868)


Mental pathology and
therapeutics (original
German edition 1845)
“Mental diseases are
brain diseases”
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”
Ernest von Feuchtersleben (1806-1849)

The principles of medical psychology
(originally German edition 1845)
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."
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."
Pluralism in psychiatry (1900-1970)

Psychoanalysis – Freud
first spoke publicly in
USA at Clark University
in 1909
Pluralism in psychiatry (1900-1970)


Psychoanalysis – Freud
first spoke publicly in
USA at Clark University
in 1909
Pragmatic approach of
Adolf Meyer Psychobiology
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
The current scene
1)
Underwhelming evidence of
efficacy of medication
The current scene
1)
2)
Underwhelming evidence of
efficacy of medication
Lack of appreciation of
environmental factors in
psychiatric disorders
The current scene
1)
2)
3)
Underwhelming evidence of
efficacy of medication
Lack of appreciation of
environmental factors in
psychiatric disorders
Non-standardised use of
operational diagnostic
criteria
The current scene
1)
2)
3)
4)
Underwhelming evidence of
efficacy of medication
Lack of appreciation of
environmental factors in
psychiatric disorders
Non-standardised use of
operational diagnostic
criteria
Lack of ability to examine
the structure and function of
the mind directly
1) Underwhelming evidence of efficacy
of medication

About a third of published studies
show no difference between
antidepressants and placebo
1) Underwhelming evidence of efficacy
of medication


About a third of published studies
show no difference between
antidepressants and placebo
Mean drug–placebo difference in
improvement scores is only 1.8
points on the Hamilton Rating
Scale for Depression
1) Underwhelming evidence of efficacy
of medication



About a third of published studies
show no difference between
antidepressants and placebo
Mean drug–placebo 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
2) Lack of appreciation of
environmental factors

Work of the geneticists has been replete
with uncritical dogmatic statements and
lack of scientific rigour
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
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
3) Non-standardised use of operational
diagnostic criteria

Diagnostic criteria do not
solve the dilemma
surrounding psychiatric
classification
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
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
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.
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
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
Conclusion - Biomedical psychiatry as
the Emperor’s new clothes

“Biomedical psychiatry is
naked," the child said.
Conclusion - Biomedical psychiatry as
the Emperor’s 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
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
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
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