Axioms of psychiatry

I want to write a few posts about psychiatric care. As I wrote in a recent post I’ve come to realize that psychiatric care is inadequate in many ways in the western world.

I believe that I need to declare a fundamental set of “axioms” (beliefs, assumptions) to be able to discuss many of the more practical problems in psychiatry later. Many decisions and treatments in psychiatry depend on such things as whether human beings have “free will”, what responsibility an individual has for his or her actions, and what the difference is between a mental illness and a person’s character. In this post I will try to summarize my personal assumptions as a basis for subsequent posts. I realize that this attempt might be seen as presumptuous by some experts and I may want to revise this post as I learn more but writing promotes further learning so I will boldly go forth.

I Googled for “axioms of psychiatry” and the first hit was this:

These axioms do not belong to the world of science, in that they are unlikely ever to be fully comprehended by scientific methods. Although they can to a limited extent be studied scientifically, in essence they belong to that part of the world of human experience which is not amenable to scientific study. [1]

I’m an engineer and don’t subscribe to that kind of cop out mentality. We are starting to understand the wiring of the brain with a number of new modalities and methods such as fMRI, DWI, and MAPseq. Several big science project aim at mapping and understanding the brain. The new advances in artificial intelligence will also likely increase our understanding of the function of the brain.

Here is my first take on assumptions important for discussing psychiatry and for designing interventions:

Assumption #1: The brain is a very powerful control system, nothing more, nothing less. The brain has evolved to take input from our senses, perform computations based on that input with the help of inherited and learned algorithms and memories, and to take appropriate (and sometimes not so appropriate as it happens) action to reach the goals set by our genes. It is still hard for some to accept that we’re just clever animals “doing our thing” (see e.g. this post).

Assumption #2: There is as little “free will” in the brain as in a PID controller. I have written about this earlier here, here, here, here, and here (ok, that starts to look like an obsession). We react to external events perceived through our senses filtered by the brain’s internal state. Sorry guys, that’s all there is to it as far as we can see now. No mechanism for “free will” has been discovered. This is not surprising since nobody has even been able to give a reasonable definition for the term. (The same goes for “consciousness” but I’ll leave that for now.)

Assumption #3: Since there is no free will, there is no guilt or shame. A patient can not and should not be blamed for his or her condition, whether drug addiction, poor impulse control, lack of motivation (to get into treatment) or poor self-discipline. To help a person, health care must establish the true status of the person without judgement and take the, in a mathematical sense, optimal action to ultimately help the person to get healthy. Many times that action is to motivate the person to access care in the first place.

Assumption #4: We have an obligation to help every person that has a reasonable chance of getting well regardless of their current mental or physical state. Illness can lead to hopelessness which can lead to a lack of motivation to even try to get better. Some schools of thought say that if a person isn’t motivated for therapy, then they should be excluded from therapy. That is a little bit like locating the care unit for leg amputees on the 13:th floor without an elevator. Some may be able to crawl up the stairs but some will not be “motivated” enough.

Assumption #5: The physical structure and the “programming” of the brain can be affected through our senses. Several studies show how both the structure and the activity of the brain changes when learning the street map of London, after talk therapy, when becoming good at playing an instrument, learning a second language, playing video games and many other activities [2 – 6]. Our senses provide ample access to the brain so therapeutic interventions through our senses is a good place to start (before say electroconvulsive therapy or inserting electrodes into the brain).

Assumption #6: The goal for psychiatric interventions is to help people to become and remain productive members of the society they live in. This is not equal to removing symptoms of mental illness. Neither is it equal to making people perpetually happy. When people injure their backs they may first undergo surgery and then a long rehabilitation learning how to manage in their daily lives and their job with any remaining handicaps. Psychiatry should likewise whenever possible reach outside the clinic. A reasonable job, a decent place to live and some relationships are crucial components in the rehabilitation of the mentally ill. So is a useful lifestyle including planning skills, good sleeping habits, and regular physical activity.

Links

[1] Psychiatry is more than a science. Cawley RH.

[2] Neuroplasticity in response to cognitive behavior therapy for social anxiety disorder. K N T Månsson et.al

[3] Navigation-related structural change in the hippocampi of taxi drivers. Eleanor A. Maguire et.al

[4] Mental maps: route learning changes brain tissue, Carnegie Mellon University News. October 27, 2015

[5] The Brain of Musicians: A Model for Functional and Structural Adaptation. Gottfried Schlaug

[6] Playing Super Mario induces structural brain plasticity: Grey matter changes resulting from training with a commercial video game. Simone Kühn et. al

[7] Motivation and Autonomy in Counseling, Psychotherapy, and Behavior Change: A Look at Theory and Practice. Richard M. Ryan, Martin F. Lynch, Maarten Vansteenkiste, and Edward L. Deci

[8] OECD, Making Mental Health Count, 2014

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