As you read through PBM, you’re left with the impression that psychiatry consists of extracting a diagnosis from a patient, and based on that diagnosis, psychotropic medications are then prescribed, or if they’re feeling particularly nasty, ECT is delivered. This is the model that is implied through repeated, disparaging use of the phrase “biological psychiatry.”
If you buy this conception of what psychiatrists do, and you believe that mental illness isn’t real, diagnoses are a sham, and psychiatric medications are by definition harmful, it seems pretty obvious that giving psychiatry the boot is a logical and necessary step.
We’ve addressed the latter three issues previously. Let’s consider how accurate “biological psychiatry” and all that it implies actually takes into account theory, training and practice.
The Psychiatric Perspective
One word you will find exactly once in the entirety of PBM is “biopsychosocial.”
It’s an interesting omission, as the biopsychosocial model is the fundamental approach taken in modern psychiatry. It tells us that our health (in this case, mental health) is based on a wide range of different factors that interact in various ways. These factors include biological ones (which includes genetics, other illnesses, nutritional or other deficiencies, and the behaviour of neurotransmitters), psychological ones (broadly speaking, the coping styles you’ve learned to think about and deal with stressors), and social ones (including such things as family issues, community pressures, socioeconomic status).
This sounds like it encompasses a lot more than just diagnosing and prescribing, but what does it all really mean?
It means that when we talk about assigning a diagnosis, it’s rarely about diagnosing one particular disorder, and effectively saying “you patient are XYZ disorder.” That would fit the reductive antipsychiatry narrative of “biological psychiatry” but is inaccurate.
Instead, when asked to assess a patient, a psychiatric diagnosis is more likely to look something like this (until recently; more on that shortly):
Axis I: Major Depressive Disorder, moderate Generalized Anxiety Disorder rule-out Social Anxiety Disorder Axis II: Obsessive-Compulsive Personality Disorder Axis III: iron deficiency Coronary Artery Disease Axis IV: financial strain limited supports Axis V: GAF 60
Each “axis” consists of one or more diagnoses or factors that are impacting the patient’s mental health. Axis I is what we’ll tongue-in-cheek refer to as the “chemical imbalance” disorders. Axis II is the “personality disorders” (more on this shortly). Axis III includes other non-psychiatric medical issues. Axis IV is factors in their social situation affecting their illness. Axis V consists of something called a Global Assessment of Functioning (GAF) which is a rough measure of in general how well a person is doing in their daily life. If there are no relevant problems on a particular axis, it is labelled as “non-contributory,” while if it hasn’t really been examined yet, it is marked as “deferred.” Particular factors to be considered later are noted as “rule-out”.
That is a lot more than just pushing pills. Let’s elaborate further.
What Psychiatrists Actually Do
Let’s start with the biological side of things (Axis I and III).
A big part is certainly what is implied by the term “biological psychiatry.” That is, determining if the patient meets diagnostic criteria for one of the mental illnesses in the DSM where medications can play a role. When it comes to suggesting medications, a psychiatrist is more likely to look at symptoms rather than a particular diagnosis. This is because, as we described earlier, certain symptoms tend to be influenced by certain neurotransmitters.
Psychiatrists also look for a range of physical health problems that can be affecting a patient’s mental health, and have nothing to do with neurotransmitters. The sorts of things that are considered are based on the patient’s physical and family health history as well as mental health symptoms. For example, an iron deficiency can present as poor concentration, low energy, and memory problems. So psychiatrists order and review a wide range of blood tests (e.g. looking at vitamin deficiencies, hormone levels, electrolytes, etc.) as these can all pay a role in mental health.
They may also, again based on physical history and symptoms, order more complex tests like EEG’s (electroencephalograms, which can pick up types of epilepsy) or CT scans (which might pick up a tumour or other brain lesion). It’s not uncommon for behaviour changes to be the first indication of some of these illnesses. Psychiatrists, as medical doctors, are particularly trained at recognizing the signs of different physical health disorders that can appear as mental illnesses. Even if patients intend to seek treatment elsewhere, seeing a psychiatrist to rule-out some of these physical causes can be valuable. Brain tumours and vitamin deficiencies don’t generally respond well to psychotherapy.
So contrary to the reductive suggestions sprinkled throughout PBM, a crucial aspect of psychiatry is being aware of the impact of physical illnesses on mental health.
On the psychological side, psychiatrists are mostly dealing with Axis II, the “personality disorders.” To grossly over-simplify, we all learn to cope with stressors in different ways. An unhealthy coping strategy is one that causes you a lot of difficulties, or doesn’t deal very well with the stress. Someone who feels no control in their life may cope by trying to take strict control of the few things they can control, and spend hours each day devoted to this; this would be an example of Obsessive-Compulsive Personality Disorder. Personality disorders are not about passing judgment on “right” ways to deal with things, but if a coping style is causing significant distress to you, the framework of personality disorders helps to better understand what isn’t working for you.
On the treatment side, addressing personality disorders usually involves psychotherapy of some sort. This is a normal part of psychiatric practice, to varying degrees (some people, usually in private practice, do more). Often psychotherapy is delegated to psychologists or other professionals, but is part of the required skill set of any psychiatrist. When my wife was doing her psychiatry residency, she was required to learn the theory of over a dozen therapeutic modalities, as well as use each one over a number of weeks with a particular patient, while being supervised by someone expert in that modality.
On the social side (Axis IV), psychiatrists are more likely to defer handling of many issues to social workers or other professionals, but issues raised certainly affect treatment decisions. As an obvious example, if they prescribe a particular medication, will the patient be able to afford it?
So, it seems psychiatrists do a bit more than just pushing pills.
A Retreat to Biology?
You may hear various things about the biopsychosocial model no longer being used, or falling out of favour. Does this mean the critics are right, and psychiatry is admitting it is really just about biology (and specifically neurotransmitters)?
Not at all. What’s actually happening is that everyone recognizes that all the different biological, psychological and social factors overlap and interact with other in complicated ways. By separating things out too much (e.g. putting things on a different axis), things felt too compartmentalized and simplistic, and didn’t take into account this complexity.
So the “end” of biopsychosocial is really just the end of assigning each illness to a category and thinking of each category as a separate type of thing, e.g. that an Axis I disorder was very different from an Axis II disorder. In fact, the latest version of the DSM, DSM-5, dispenses with the whole “Axis” form of diagnoses altogether.
Incidentally, that one mention of “biopsychosocial”? It’s used to summarily dismiss it—without evidence, mind you—as “essentially the biological model with add-ons.” The way the text is written also implies that the biopsychosocial model is a component of the Canadian Mental Health Association (CMHA), as opposed to a fundamental part of psychiatry as a whole. For readers not in Canada, the CMHA is a voluntary organization that “promotes the mental health of all and supports the resilience and recovery of people experiencing mental illness.” Or as BB puts it, the CMHA is one of the “seemingly more benign organizations … [that] receive huge funding from the state to do its bidding, and as such, constitute an integral part of the ruling regime.”
For what it’s worth, I was expecting “biopsychosocial” to not appear in PBM at all.