Fads and Fallacies in PsychiatryRichard Balon, MD
Wayne State University, Detroit, Michigan, USA
By Joel Paris; The Royal College of Psychiatrists; London, United Kingdom; 2013; ISBN 978-1909726062; pp 124; $30 (paperback).
Psychiatry has been going through a serious period of reevaluation and rethinking—from doubts about our diagnostic systems, through the perpetual debate about the brain and mind schism, to questions about the efficacy and even usefulness of its treatments. We do not have answers to most, if not all, of the questions about mental illness and, as Joel Paris perhaps optimistically points out in the introduction to his book, it will probably require another century of research to answer them.
One of the problems of medicine and psychiatry is, as Paris writes, “progress is not linear. Impeded by false beliefs, medical science sometimes goes off on serious tangents” (p 1). When explaining that the title of his book is based on a title of a classic volume, Fads and Fallacies in the Name of Science1 he adds that “Fads are temporary bursts of enthusiasm, based on fallacies that reflect cognitive errors or wishful thinking…But fads in psychiatry have occurred not only on the fringe, but in the mainstream of theory and practice” (p 1). (He still gives psychiatrists some credit as he admits that we do at least as well as physicians in other specialties in helping our patients.) It seems that at the time of “The current rage to reduce everything in psychiatry to a neuronal level” (p 2) it may be good to look critically at the fads and fallacies of psychiatry, and that is what this book fairly aptly attempts to do.
The slim volume consists of an Introduction and 3 parts: I. Origins; II. Effects; and III. Antidotes. In the Introduction, Paris not only explains what fads and fallacies mean and why he has written this book but also summarizes the psychiatric fads of then and now, and points out the 3 problematic areas his books focuses on: the diagnostic system; the current trend (as he states) in the United States for an almost exclusive reliance on drugs, which is putatively based on the application of the neuroscience model to practice; and the concern that “those who only prescribe may forget how to listen” (p 6) and thus psychiatry going from brainless to being mindless.
In Part I (2 chapters), the “Medicine” chapter is a general one; reviewing fads, fallacies, and cognitive errors; establishing cause and effect; fads and good intentions; medical fads in historical context; diagnostic fads in medicine; surgical fads; the challenge of chronicity; and the way the pharmaceutical industry promotes fads. Paris points out that “science moves slowly and caution makes progress more certain. Yet, since they can appear new and attractive, fads initially earn great attention. Most end by disappearing from view, sometimes with barely a trace” (p 11). An important discussion of cognitive errors (one of the sources of fads) notes that they derive from preconceived beliefs. Interestingly, scientists sometimes do the same thing as fanatical followers of a fallen prophet. Once committed to a point of view, it is hard for them to admit being wrong or foolish and they hold on to their original opinions more strongly than ever. They (and clinicians and others) may use confirmation bias—new information is interpreted in the light of preconceived ideas. Among many interesting ideas, Paris also writes that although peer review is a necessary part of science, it can be used by experts who do not want data contradictory to their own views to appear in print (p 13). I loved 2 great comments here: first that “many a beautiful theory is killed by an ugly fact” (attributed to Thomas Huxley) and “theories only change when old scientists die” (p 13). In the part on establishing the cause and effect, Paris points out the frequent reductionism forced by our wish to treat every malady, “if all you have is a hammer, everything else looks like a nail” (p 14). As this chapter is really filled with a lot of food for thought, I mention just a few more thoughtprovoking ideas: “Most research articles published in medical journals are never replicated” (J. Ioannidis), “The consensus of experts has been a traditional source of all the errors that have been established throughout medical history” (A. Feinstein), or “the internet (and other forms of publicity) allow uninformed groups of consumers and patients with a strong agenda to ‘flood’ search engines with dubious ideas, sometimes supported by instant ‘experts’ (some of whom are celebrities rather than experts” (p 22). Finally, while criticizing the pharmaceutical industry about all its problematic practices, Paris cautions us that medicine is practiced in a climate inevitably promoting fads for what we cannot blame the industry—“It is the result of our own unjustified enthusiasm” (p 23).
In the “Psychiatry” chapter, Paris first writes, for comparison, about psychiatry 100 years ago. He then delves into 2 illustrative examples of psychiatry’s fads: psychoanalysis and psychosurgery. He reminds us that “Psychoanalysis was an archetypal treatment fad” (p 27) that has been criticized by many leading psychiatrists throughout the last century (eg, Emil Kraepelin). Putting the birth and growth of psychoanalysis into historical context, Paris writes that “Finally, psychoanalysis, like Marxism, offered a comprehensive world view that addressed modern alienation. This was a time when organized religion had fallen into decline” (p 28). He also brings to our attention that one of the most faddish aspects of psychoanalysis is its way of explaining its failure—unsuccessful therapy is attributed to resistance and/or not carrying out treatment properly or not long enough, but never admitting that it simply does not work. At times, Paris makes conclusions without data (eg, claiming that classical psychoanalysis is surviving only as a remnant in Tavistock [London] and Menninger [Houston] clinics). I am not sure Manhattanites and many others around the world would agree! The psychosurgery fad discusses the well-known example of frontal lobotomy.
In Part II (6 chapters), the “Aetiology” chapter reminds us of biological reductionism and the key problem of reductionism that “complex structures have emergent properties that cannot be explained by their components” (p 38). Other areas discussed include the fallacies in research on neurotransmitters; fallacies in research on psychiatric genetics, which is quite unimpressive; fallacies of childhood adversity (here we need to distinguish between a risk factor and the cause of a disorder); fallacies of child abuse; and fallacies of social risk (Paris mentions the folly of primary prevention being based on hope, not science, and that “Nobody has ever shown that major mental disorders can be prevented” [p 43]). In the discussion of the fallacies of diagnosis and diagnostic systems, Paris notes that DSM diagnoses are based solely on clinical observations, are frequently overlapping, and that DSM has never produced a definition of mental disorder that can distinguish psychopathology from normality. Nevertheless, as others, Paris recommends following the classification as written in the manuals, as clinicians need a common language (and I add: we have nothing better).
The “Epidemiology” chapter points out the numerous methodological problems of epidemiology, such as almost complete reliance on self-report, the use of cross-sectional assessment without follow up, and the use of partially trained research assistants, before getting into inflated prevalence of mental illness. Paris also views the tendency to see all psychopathology as lying on a continuum being the source of all trouble, as there is no boundary between normality and pathology (p 61). This problem is reflected especially in the estimates of prevalence of major depression. The “Psychopharmacology” chapter mentions the triumph and tragedy of psychopharmacology and reviews the limits of antidepressant therapy, the power of placebo, the practices of the pharmaceutical industry, antipsychotic fads, antidepressant fads (used during life adversities), mood stabilizer fads (eg, the use of mood stabilizers for the environmentally responsive mood swings in borderline personality disorder), the constant need to adjust medication (eg, in response to life events; Paris writes about a new breed of psychiatrists—specialists knowledgeable in psychopharmacology, but at a loss when asked to talk to people about their lives), and the tendency to prescribe without end. The “Psychotherapy” chapter is similarly critical, pointing out that psychotherapy is not always effective, can be sometimes harmful, is farmed out to other professionals, requires expensive human resources, often has unclear goals, goes too long at times, and is sometimes interminable. Psychotherapy research has been behind, nevertheless, it shows that most psychotherapies work in much the same way and produce similar results—an argument against the proliferation of numerous psychotherapies (rather a “marketing phenomenon”). I liked the notion that psychotherapy should be held to the same standards as drug therapy and needs to be regulated the same way drugs are (p 80). Paris evokes some benign psychotherapy fads (eye movement desensitization) and malignant ones (recovered memory therapy), and the self-esteem fad. The final notion of this chapter contemplates whether psychotherapy is a treatment or cultural phenomenon. Paris also writes that “psychotherapy has come to constitute a secular religion, and patients may embark on it as a spiritual journey” (p 86). Finally, the chapter on “Prevention” repeats that “primary prevention lacks a strong evidence base” (p 89) and that what we do not understand cannot be prevented. Paris also writes that “social change cannot be medicalized, and that psychiatry has its hands full looking after people with severe mental illness” (p 89). In dismantling the notion of secondary prevention (even in case of attenuated psychosis), Paris argues “there is no consistent evidence that early diagnosis makes a difference in outcome, or that interventions are more effective when instituted early” (p 90). In the discussion of suicide prevention, Paris notes that when a rare phenomenon cannot be predicted, then it cannot be prevented.
The 2 chapters in Part III (“Evidence-based psychiatry” and “Overview”) extol the virtues of evidence-based psychiatry as the antidote and remedy for fads and fallacies of psychiatry. Paris notes that most psychiatrists spend little time reading journals or books and few read clinical guidelines (p 106), yet they are influenced by colleagues and expert opinions instead of forming their own opinions. At the end, Paris provides general principles to avoid making mistakes of fallacious and faddish thinking.
As much as I liked the book, I was surprised by a couple of things. First, I found the frequent criticism of American psychiatry (or rather psychiatry practiced in the United States)—no matter how correct—unnecessary and uncalled for, as there was no criticism of any other nation’s psychiatry (this is probably partially because Joel Paris is Canadian and the book was published in the United Kingdom). Second, some of the criticism of fads and fallacies would be more understandable when viewed more carefully from a historical perspective, in the eyes of their contemporaries. And last, I found it interesting that an author so interested and devoted to evidence in general, talks so much about his personal experiences and views in particular. Nevertheless, the book is easy to read, full of interesting comments, citations, facts, and is an interesting reading for all psychiatrists, clinicians, academicians, researchers. We should all read it, pause and think about all those fads and fallacies and what we can do to avoid them and better the care of our patients.
- Gardner M. Fads and fallacies in the name of science. 2nd ed. Mineola, New York: Dover Publications, Inc.; 1957.
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