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Psychiatry beyond the current paradigm

  • Pat Bracken (a1), Philip Thomas (a2), Sami Timimi (a3), Eia Asen (a4), Graham Behr (a5), Carl Beuster (a6), Seth Bhunnoo (a7), Ivor Browne (a8), Navjyoat Chhina (a9), Duncan Double (a10), Simon Downer (a11), Chris Evans (a12), Suman Fernando (a13), Malcolm R. Garland (a14), William Hopkins (a15), Rhodri Huws (a16), Bob Johnson (a17), Brian Martindale (a18), Hugh Middleton (a19), Daniel Moldavsky (a20), Joanna Moncrieff (a21), Simon Mullins (a22), Julia Nelki (a23), Matteo Pizzo (a24), James Rodger (a25), Marcellino Smyth (a26), Derek Summerfield (a27), Jeremy Wallace (a28) and David Yeomans (a29)...
Summary

A series of editorials in this Journal have argued that psychiatry is in the midst of a crisis. The various solutions proposed would all involve a strengthening of psychiatry's identity as essentially ‘applied neuroscience’. Although not discounting the importance of the brain sciences and psychopharmacology, we argue that psychiatry needs to move beyond the dominance of the current, technological paradigm. This would be more in keeping with the evidence about how positive outcomes are achieved and could also serve to foster more meaningful collaboration with the growing service user movement.

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Corresponding author
Pat Bracken, MD, MRCPsych, PhD, Centre for Mental Health Care and Recovery, Bantry General Hospital, Bantry, Co Cork, Ireland. Email: Pat.Bracken@hse.ie
Footnotes
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See editorial, pp. 421-422, this issue.

Declaration of interest

None.

Footnotes
References
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Psychiatry beyond the current paradigm

  • Pat Bracken (a1), Philip Thomas (a2), Sami Timimi (a3), Eia Asen (a4), Graham Behr (a5), Carl Beuster (a6), Seth Bhunnoo (a7), Ivor Browne (a8), Navjyoat Chhina (a9), Duncan Double (a10), Simon Downer (a11), Chris Evans (a12), Suman Fernando (a13), Malcolm R. Garland (a14), William Hopkins (a15), Rhodri Huws (a16), Bob Johnson (a17), Brian Martindale (a18), Hugh Middleton (a19), Daniel Moldavsky (a20), Joanna Moncrieff (a21), Simon Mullins (a22), Julia Nelki (a23), Matteo Pizzo (a24), James Rodger (a25), Marcellino Smyth (a26), Derek Summerfield (a27), Jeremy Wallace (a28) and David Yeomans (a29)...
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eLetters

Evolutionary psychiatry could be the new paradigm

David Geaney, Formerly Consultant Psychiatrist and Honorary Senior Clinical Lecturer
01 February 2013

The answer to Bracken et al's (1) critical evaluation of contemporarypsychiatry needs to go beyond Holmes' suggestion (2) of an increased focuson developmental psychopathology, important though that is. Fundamental questions remain - "what is the the normal function of the brain/mind?", and "how can you distinguish normal functioning under stress from abnormalfunction?".

The environmental conditions in which we evolved, and to which we areadapted, are very different to those that we face today and so a further worrying question is "are we treating people whose brains/minds are functioning normally in response to stress, whilst overlooking the source of their stress?". Evolutionary psychiatry is clear that dysphoric symptoms are an evolved adaptive response to adversity (3) and the placeboresponse makes sense in this context, as an evolved response to psychosocial support at times of adversity.

An evolutionary perspective recognises the importance not only of ourgenetic heritage but also of our evolved neuroplasticity in response to our social and cultural environment, and so naturally embraces the biological and social sciences (4).

The current debate about psychiatry's future direction has a strikingparallel with the evolution of our asymmetric cerebral hemispheres and their differentiated function. The right hemisphere takes an holistic, global perspective through an active interaction with the environment whereas the left hemisphere takes a detached, analytical view of a specific aspect of the environment, before returning the information to the right hemisphere for reintegration with the whole (5). If the left hemisphere becomes unduly dominant, it fails to recognise the importance of the right hemisphere's global perspective and functions instead in an increasingly detailed but disconnected way.

It is crucial that we reintegrate the functioning of psychiatry's twocerebral hemispheres in a complementary way and it seems to me that evolutionary psychiatry provides the urgently needed paradigm to reconcilemultiple perspectives in a respectful, unifying manner.

Certainly evolutionary psychiatry is in its infancy and will need to develop with care, but in its absence it seems inevitable that our profession will continue to suffer from fundamental divisions and will fail to develop a corpus of broadly accepted knowledge and practice. The time is right for psychiatry to make a decisive move.

1. Bracken P, Thomas P, Timimi S et al. Psychiatry beyond the currentparadigm. Br J Psychiatry 2012;201:430-42. Holmes JA. New paradigm: developmental psychopathology. Br J Psychiatry2012;http://bjp.rcpsych.org/letters/201/4303. Nesse RM. Evolutionary explanations of emotions. Human Nature 1990;1:261-894. Nettle D. Beyond nature versus culture: cultural variation as an evolved characteristic. J Royal Anthropological Institute 2009;15:223-405. McGilchrist I. The Master and his Emissary: the divided brain and the making of the Western world. Yale University Press, 2009

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Conflict of interest: None declared

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Brain Mind Interface

Mario F. Juruena, Professor Doctor/Honorary Senior Lecturer
09 January 2013

Dear Editor

I commend Bracken and colleagues for their interesting and timely article Psychiatry beyond the current paradigm. The authors highlight an important issue: "Psychiatry is not neurology; it is not a medicine of thebrain. Although mental health problems undoubtedly have a biological dimension..."The presence of merely a few number of well-validated biomarkers and the early stage in which our understanding of neurobiology and genetics finds itself have obstructed the integration of neuroscience into psychiatric diagnosis to date (1).Integrative approaches to understanding complex mental health issues can transcend disciplinary and knowledge boundaries and provide opportunities to view phenomena from diverse perspectives. The potential of an integrative approach to contribute to improvements in human health and well-being are more important than historical biases (2). This approach states that the causes, development and outcomes of disorders are determined by the relationship of psychological, social and cultural factors with biochemistry and physiology. Biochemistry and physiology are not disconnected and different from the rest of our experiences and life events. This system is based on current studies that reported that the brain and its cognitive processes show a fantastic synchronisation. Consequently, accepting the brain-body-mind complex is possible only when the three systems - nervous, endocrine and immune - can receive information from each of the other systems (3). The fourth system, the mind (our thoughts, our feelings, our beliefs and our hopes), is part of the functioning of the brain integrating the paradigm. The interaction of the mind, an explicit functioning of the brain, with other body systems iscritical for the maintenance of homeostasis and well-being (4). The relationship between stress and illness is a strong example that can be more fully understood from an integrative perspective. It is now broadly accepted that psychological stress may change the internal homeostatical state of an individual. Whenever there is an acute interruption of this balance, illness may result. The social and physical environments have an enormous impact on our physiology and behaviour, and they influence the process of adaptation. It is correct to state that at the same time that our experiences change our brain and thoughts, namely, changing our mind, we are changing our neurobiology Genes, early life stress, adult experiences, life style, and stressful life experiences all add to the way the body adapts to a changing environment; and all these factors help to determine the cost to the body or the "allostatic load" (5). Of special interest are the psychological stress (stress in the mind)and the interactions of the nervous, endocrine and immune systems. The lack of correlations between clinical and biological data continues to be,according to several authors, one of the great unsolved problems of psychiatry today and could be solved by recovering the value of traditional psychopathological analysis based on fundamental and thorough clinical assessment, which should support aetiological research and treatment decisions. Therefore, only the adoption of a multidisciplinary approach that will bring together the knowledge and the technology of physics, physiology, psychology and philosophy, we can integrate the whole system, but they areimperfect without the contribution from other fields such as cultural anthropology, economics, epidemiology, political science, and sociology.Yours sincerely,

Prof. Dr. Mario F. Juruena

References:1.Hyman SE. Can neuroscience be integrated into the DSM-V? Nat Rev Neurosci 2007;8:725-732. 2.King SL, Hegadoren KM. An integrative science approach: value added in stress research. Nurs Health Sci. 2006;8(2):114-9. 3.Basar E, Karakas S. Neuroscience is awaiting for a breakthrough: an essay bridging the concepts of Descartes, Einstein, Heisenberg, Hebb and Hayek with the explanatory formulations in this special issue. Int J Psychophysiol 2006; 60:194-201. 4.Ray O. The revolutionary health science of psychoendoneuroimmunology:a new paradigm for understanding health and treating illness. Ann N Y Acad Sci 2004;1032:35-51. 5.McEwen BS. From molecules to mind. Stress, individual differences, and the social environment. Ann N Y Acad Sci. 2001;935:42-9

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Conflict of interest: None declared

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What are the 'non technical' aspects of Psychiatry

Prasanna N. de Silva, Consultant Psychiatrist
08 January 2013

As a non-academic with a predominant neuroscience orientation, I welcome the contribution by Bracken and colleagues (1). This article is timely for the following reasons.

Firstly, on Revalidation (and avoidance of 'remediation'); the new format of annual appraisal appears to be slanted towards the so called 'technical competences' - involving psychopharmacology, specific psychotherapies (such as CBT) and, more generally, evidence of compliance with national and trust guidelines on disease management care pathways. The ability to work collaboratively with patients, carers and other professional colleagues to maintain engagement and adherence is tacitly recognized, but still considered secondary to demonstrating 'hard' (i.e. measurable) competences.

Therefore, practitioners who consider 'non technical' practices as their main purpose do so at their own risk. Furthermore, the problem of measuring non technical aspects of our work remains, despite the availability of the 'tick box' patient feedback via the 360 degree appraisals.

A key 'non technical' aspect of our work is service redesign, usuallyunder the banner of 'new ways of working'. However, we do not have sufficient outcome research nationally to base our local efforts. For example, we are unclear if the split between community and in-patient Consultant activity is more effective than different Consultants working into Psychoses and Affective disorder teams in both wards and in the community (the so called 'functional modal'). Similarly, we don't know if Consultant led triage is better than the now traditional 'single point of access' to Community teams (CMHTs) and crisis teams (gatekeepers to wards).

Service redesign projects carry major costs (including Consultant time) and therefore demands more professionalism to avoid wasting valuableresources. Surely it is time that the College Research Unit looked in to outcomes of service redesign projects across the UK in terms of readmissions, turnover, untoward events and poly pharmacy rates.

Finally - perhaps of most relevance to users and carers - is the issue of compassionate care (2, 3). In old age services, this area is highly topical with increasing involvement of politicians and the media. In my opinion, compassion should not only be directed at patients and carers, but also be a central component of relationships between front line caring staff when collaborating in patient care. Furthermore, of late, compassion has often been lacking in the relationships between caring staff and their managers. Perhaps medical managers should take a lead in developing this culture, which no doubt will assist further service development and productivity (not to mention staff retention).

Compassion is not emotional over involvement or maintenance of dependency; it can involve 'tough love' on occasion. In my opinion, it is a core aspect of recovery, the 'glue' holding the patient, carer and professionals in the joint enterprise of healing. It does not exclude robust physical and psychological therapies. It might well involve recognition of spiritual values and needs involved in the process of recovery. Perhaps psychiatrists (and their trainees) need to have a working knowledge of the major religions as well as some lesser known forms of faith (such as spiritualism), in order to understand their patients presentations and motivations.

References 1. Bracken, P., Thomas, P., Timimi S. et.al. Psychiatry beyond the current paradigm The British journal of psychiatry (2012) vol 201, pp 430-434 2. Gilbert, P. Introducing compassion focussed therapy Advances in psychiatric treatment (2009) vol 15, pp 199-208 3. Boyce, N. Alys Cole-King; a pioneer of suicide mitigation in the UK. The Lancet (2011) vol 375, issue 9791, p 561

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Conflict of interest: The opinions expressed are not those of my employer

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Academia versus the Masses

Saad F. Ghalib, consultant old age psychiatrist
02 January 2013

The article by Bracken,et al(BJP 2012;201) has raised some fairly warranted concerns. I am afraid the situation is more serious than one is prepared to contemplate. It goes deep into our understanding of what mental illness is. For example, any serious attempt to set precise phenomenological limits on what a delusion is will soon run into difficulties! Should some cultural, political or religious beliefs be considered delusional? Conversely, a good number of people who do not suffer from mental illness do occasionally experience psychotic symptoms (1)! Or probably we should ask different cultures as to their understanding of depressed mood as a symptom of depression? We would most certainly get several different interpretations ranging from the cognitiveto the somatic as well as the spectrum in between. It's about time that the prescriptive nature of current classification systems is called into question; for example, the ICD-10 choice of' loss of interest' as a'' core'' feature of depressive episodes, whereas' reduced self-esteem' is relegated to secondary symptoms! No wonder why talk of biological reductionism should probably be taken with a big pinch of salt. Talk of top-down or bottom-up approach of psychiatric disorders is unrealistic andcan be outright damaging. Extensive research has thus far yielded no precise causal factors for most psychiatric disorders. Indeed, there are potential risks, ranging from the psychological to the biological and the social. However, none of these potential risks is either necessary or sufficient for the development of mental illness. Let's be clear, selling the biological model to the public is about ''choosing'' (driven by academia) one school of thought over another, rather than being ''true'' natural reductionism. A mental health symptom can potentially have a range of meanings to different individuals, depending on its place within a particular individual's narrative. The said individual narrative is influenced by a host of variables. Therefore, it would make sense to rid the upcoming classification systems of as many labels as possible, but also to attempt a tentative approach towards some basic definitions of common symptoms within the context of the patient's life narrative. Symptoms related to mental health (contrary to physical disorders) should be set locally, within the context of patients' culture, semantics and life story, ratherthan ''dictated'' from without. Failing to do so will render psychiatric signs and symptoms completely meaningless. Notwithstanding this, it should be emphasized that the identification of psychiatric signs and symptoms is by no means a grantee that the end result is a valid disorder.It is just possible that, none of our current diagnostic labels can claim a true existence in nature!Response to placebo can indeed be highly effective. However, if patients' improvement is in part due to some placebo response, let's make sure that their expectations are grounded in reality rather than being shaped by pharmaceutical marketing or some vague biological reasoning in situations where it is not applicable.Reference; Kelleher I, Jenner J A, Cannon M. Psychotic symptoms in the general population-an evolutionary perspective. BJP 2010; 197; 167-169.

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Conflict of interest: None declared

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Territorial disputes

Peter Kinderman, Director
19 December 2012

Dear Sir or Madam:

Territorial disputes are a zero sum game: if one side gains ground itcan only be at the expense of the other. As clinical psychologists, it wastherefore with a wry smile that we read the recent paper by Bracken and colleagues (1), which calls for psychiatry "to move beyond the dominance of the current, technological paradigm" and towards an understanding of mental health problems not as diseases of the brain, but as involving "social, cultural and psychological dimensions".

We agreed with much of the paper's substance, yet found ourselves concerned by the implied route to implementation. Given their audience, Bracken and colleagues can be forgiven for failing to acknowledge the existence of clinical psychology; yet their arguments owe a great deal to advances, both theoretical and empirical, made in this field. By calling for psychiatry to shift its epistemology and praxis, it might seem not only that that they want to adopt an alternative philosophy, but quietly to move their tanks onto the lawns of fellow professionals.

One could follow their argument to a different conclusion. If the goal is a mental health care system in which problems are seen principallyas "social, cultural, and psychological" in origin rather than biomedical,then the case for having medically trained professionals in positions of seniority is substantially weakened. Rather, clinical leadership would need to be provided by people who have received a comparably extensive training in psychological, social and cultural causes of distress.

Reforming the whole of psychiatry from the inside out can hardly be the most practical means of realising this vision. Instead, consider that there are some 10,000 clinical psychologists in the UK, the majority of whom work in the NHS. A substantial number of psychiatric posts go unfilled,(2) while clinical psychologist posts are being cut and downgraded across the country despite training places being vastly oversubscribed. We could begin by imposing a moratorium on filling psychiatric posts and use the money saved (in the order of ?100 million pounds, at a conservative estimate) to reverse the process of downgrading,increase the number clinical psychologists at higher leadership grades andexpand the number of training places. That - at zero net cost to the NHS -could help move us toward Bracken and colleagues' vision.

To be clear, this is not an "antipsychiatry" argument. We do not dispute psychiatric expertise in several technical areas, principally psychopharmacology. Whilst the benefits of neuroleptic medication have often been gravely overstated (3) and the utility of diagnostic categoriesis a source of constant dispute,(4) we would not be amongst those who denythat pharmacological interventions are ever a useful part of the treatmentarmoury, nor would we join the ranks of those criticising the profession of psychiatry. But if we want mental health services to be structured around the epistemological and theoretical assumptions outlined by Brackenand colleagues, psychiatry should not aspire to colonise the territory of social, cultural, and psychological disciplines, but instead adopt a more genuinely equitable stance.

Yours sincerely

Professor Peter Kinderman Director, Institute for Psychology, Health and Society University of Liverpool Brownlow Street Liverpool L69 3GL +44-151-794-5533

Dr Sam Thompson Trainee Clinical Psychologist University of East London Stratford Campus Water Lane London E15 4LZ

References

(1) Bracken P et al. Psychiatry beyond the current paradigm. The British Journal of Psychiatry 2012; 201: 430-434. (2) http://www.rcpsych.ac.uk/pdf/2009%20Census.pdf (3) Whitaker R. The case against antipsychotic drugs: a 50-year record of doing more harm than good. Medical Hypotheses 2004; 62: 5-13. (4) Kinderman P, Read J, MoncriefJ, Bentall R. Drop the language of disorder. Evidence-Based Mental Health (2012); Online First, 10.1136/eb- 2012-100987.

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Conflict of interest: None declared

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