D. B. Double

The limits of psychiatry.

Much of the expansion of psychiatry in the past few decades has been based on a biomedical model that encourages drug treatment to be seen as a panacea for multiple problems. Psychiatrist Duncan Double is sceptical of this approach and suggests that psychiatry should temper and complement a biological view with psychological and social understanding, thus recognising the uncertainties of clinical practice The increasing accountability of doctors following the deaths of children in the Bristol Royal Infirmarys paediatric cardiac surgical unit has focused attention on the foundations of medical practice. Ian Kennedy, who chaired the Bristol inquiry,1 provides a direct link with earlier cultural critics of medicine—such as Ivan Illich—in his Reith lectures in 1980 about “unmasking” medicine.2 Illich made specific comments about psychiatry in his critique of medicalisation and the limits to medicine.3 He attended the 1977 world federation for mental health conference in Vancouver, Canada, where he debated the issue of whether mental health professionals are necessary.4 He maintained that “do it yourself” care was preferable. The central concern of Illichs work was the legitimacy of professional power, whether in health systems or in other systems, such as education. There is no direct equivalent in general medicine of the “anti-psychiatry” movement, commonly seen as a passing phase in psychiatry and associated with the names of R D Laing and Thomas Szasz.5 Illich came from outside medicine, whereas the proponents of anti-psychiatry came from within psychiatry, even if their influence was subsequently marginalised by mainstream psychiatrists. The cultural role of psychiatry is more obviously open to criticism than is the case in the rest of medicine. This is because of its direct relation to social control through mental health legislation. Although diagnosis of mental illness should not be predicated on social conformity, in practice …

The factor structure of manic rating scales

Separate factor analyses were performed on interview and ward behaviour ratings of 81 manically disturbed patients. The principal components analyses produced a dimensions of manic disturbance separating elation from aggressiveness. For the interview scale the rotated factors were (a) thought disturbance, (b) overactive and aggressive behaviour and (c) elevated mood and vegetative symptoms. For the ward behaviour scale the rotated factors were (a) motor and speech disturbance, (b) aggressiveness and (c) unrealistic expansiveness of mood.

Efficacy of maintenance use of anticholinergic agents

Twenty‐seven long‐term psychiatric inpatients maintained on neuroleptics with concomitant antiparkinsonian medication were entered into a study in which anticholinergic medication was gradually withdrawn in a randomized double‐blind within‐subjects design. The extrapyramidal symptoms of each patient were compared when taking their usual anticholinergic medication, when taking placebo and when taking no antiparkinsonian drug. The relapse rate on no medication was 14%, and if patients relapsed on no medication they also relapsed on placebo. The relapse rate was not significantly different on active medication. Nor were there significant differences in ratings of parkinsonism or dyskinesia. The lack of difference between double‐blind and overt withdrawal does not mean that studies that find a much higher relapse rate are necessarily unaffected by nonspecific factors, as significant unblinding may occur in clinical trials.

Adolf Meyer's Psychobiology and the Challenge for Biomedicine

George Engel’s biopsychosocial model was associated with the critique of biomedical dogmatism and acknowledged the historical precedence of the work of Adolf Meyer. However, the importance of Meyer’s psychobiology is not always recognized. One of the reasons may be because of his tendency to compromise with biomedical attitudes. This paper restates the Meyerian perspective, explicitly acknowledging the split between biomedical and biopsychological approaches in the origin of modern psychiatry. Our present-day understanding of this conflict is confounded by reactions to ‘anti-psychiatry.’ Neo-Meyerian principles can only be reestablished by a challenge to biomedicine that accepts, as did Meyer, the inherent uncertainty of medicine and psychiatry.

A cluster analysis of manic states

A cluster analysis was performed on 81 manically disturbed patients assessed at interview on items of manic symptomatology and general psychopathology. Four groups were obtained: (1) a mildly excited group, (2) a group characterized by elation and speech disturbance, (3) a small severely disturbed excited group, more schizophrenic than manic, and (4) a group characterized by aggressive overactivity.

Historical Perspectives on Anti-psychiatry

The origin of the modern use of the term anti-psychiatry was in a book by David Cooper (1967) entitled Psychiatry and anti-psychiatry. In the preface, he talked about anti-psychiatry being at a germinal stage. He suggested that what he called the ‘in-stitutionalising processes’ and ‘day-to-day indoctrination’ of work in the psychiatric field were starting to produce answers antithetical to conventional solutions.

Placebo mania. Placebo controlled trials are needed to provide data on effectiveness of active treatment.

EDITOR,—Kenneth J Rothman questions whether there is any point in using a placebo group if blind assessment can be achieved in a comparative trial of two active treatments.1 He minimises both the practical advantages of placebo controlled trials and their advantages for hypothesis testing. The limitations of statistical hypothesis testing mean that the probability of an inferential error is known if one is rejecting the null hypothesis but not if one is accepting it.2 The probability of a type II error in equivalence …

Can a Biomedical Approach to Psychiatric Practice Be Justified

The modern explicit and intentional concern with psychiatric diagnosis contrasts with earlier views de-emphasising diagnosis in favor of understanding the life story of the individual patient. Psychiatric diagnosis became increasingly codified following the original paper by Feighner et al. (1972) and the introduction of the Research Diagnostic Criteria (Spitzer, Endicott, & Robins, 1975), through editions of DSM-III, DSM-IIIR and DSM-IV (American Psychiatric Association, 1994). Symptom checklists and formal decision-making rules for diagnoses were produced. This operationalization of diagnostic criteria was developed specifically to respond to criticisms of the basis of psychiatric classification. These criticisms included contentions that psychiatric diagnosis was unreliable, involved labelling of patients and was associated with the biomedical model of mental illness (Blashfield, 1984). The attempt to make psychiatric diagnosis more reliable, combined with a return to a biomedical model of mental illness, has been called the “neoKraepelinian” approach (Klerman, 1978). This perspective promotes many of the ideas associated with the views of Emil Kraepelin, often considered to be the founder of modern psychiatry. It regards psychiatry as a scientific, medical speciality that clearly demarcates mentally ill patients, who require treatment, from normal people. The focus is on biological aspects of mental illness and an intentional concern with diagnosis and classification. Belittling of the value of psychiatric diagnosis is discouraged. The view that mental illness is a myth is emphatically opposed.

The history of anti-psychiatry: an essay review

Sufficient time has elapsed to reflect on the history of ’anti-psychiatry’. One prevailing version of that history is that it was a passing phase (Tantam, 1991). Another view places anti-psychiatry in its broader cultural context and sees it in terms of its continuities. The book Cultures of Psychiatry and Mental Health Care takes the latter refreshing approach. It is one of a productive series in the History of Medicine from the Wellcome Institute (series editors W. F. Bynum and Roy Porter). The contents of this book emerged from a workshop held in June 1997 in Amsterdam, organized by the Wellcome Institute for the History of Medicine (London) and the Dutch Huizinga Institute for Cultural History. Cross-national comparisons are made between post-war Britain and the Netherlands, exploring how these similar but contrasting national cultures have had an impact on the presence of critical psychiatry. Fourteen papers are presented (in English) by British and Dutch historians and social scientists, mostly matched in pairs on particular aspects of the respective histories of mental health care. There are

The Biopsychological Approach in Psychiatry: The Meyerian Legacy

When giving notice of a memorial service for the eminent psychiatrist Theodore Lidz, the Yale Bulletin and Calendar (2001) observed that Lidz had expressed regret in his last years that he did not write just one more book to show that biology-based lines of research and training in current psychiatry are ‘barking up the wrong tree’. Lidz was professor and chief of clinical services in psychiatry at Yale, having taken his residency in psychiatry at Johns Hopkins University, where he studied with Adolf Meyer. There is no question about his distinguished standing within mainstream psychiatry. Although he was critical of the biomedical model of mental illness, this did not mean that his views were labelled and dismissed as ‘anti-psychiatry’.