(Artwork by Najin Tse)
The commonly used phrases in psychiatry ‘organic psychosis’ and to ‘rule out organic causes’ strike me as very odd. Organic, in the sense of the word as it is used here, means there is a physical cause for the patient’s mental state. In turn, it implies that in other cases there is no physical cause. Not all may interpret it this way, but as far as I know, this is pathognomonic of psychiatry when compared to other fields of medicine.
Pathognomonic is a term that refers to a feature that is exclusive to a particular disease. For example, Murphy’s sign is the term given for pain experienced when taking a deep breath in as the gallbladder is pressed. This is pathognomonic for an inflamed gallbladder, known as cholecystitis. It is in this sense that the use of ‘organic’ is pathognomonic of the diseased state of psychiatry. The most common pathogen causing this disease – the infection – is free will.
Medicine is far from being a complete science – there is a lot of uncertainty. Indeed, it is this uncertainty that makes it exciting for many practitioners, and demands a great degree of humility. Even in something as simple as high blood pressure (known as hypertension), only 5-10% of cases have a known cause – these cases are termed ‘secondary hypertension’. The remaining 90-95% of cases of hypertension have unknown causes. Of course, many risk factors have been identified – male gender, older age, smoking, lack of exercise, and poor diet – but they do not translate to any clear, reliable, causative link. Rather, they each increase your chance of having high blood pressure. So what do doctors call this? ‘Primary hypertension’. Notice it is not known as ‘nonorganic hypertension’. There is no notion – no hint or flavour – that anyone believes there isn’t a cause. Doctors correctly assume there is an explanation, and is most likely the complex interaction of a multitude of determinants – as suggested by the wide range of factors that increase risk of developing hypertension.
Contrast this with schizophrenia, the disease most commonly implicated with psychosis. Schizophrenia, like hypertension, has many known risk factors – family history, early heavy cannabis use, and childhood trauma – yet they too do not map onto any clear pathophysiological mechanism. However, the striking similarities between these two diseases has not been tracked by the attitudes towards them. We still talk in terms of ‘organic’ and ‘nonorganic’ – some cases have causes, others don’t.
Schizophrenia has been left behind, stuck in the mud of centuries-old science and philosophy. To understand this, we will refer back to the esteemed philosopher Rene Descartes. Most famous for his quote “I think, therefore I am”, Descartes was interested in the mind and consciousness. He has also been credited with the philosophical idea now known as Cartesian Dualism;
“When I consider my mind, I cannot distinguish any parts, but apprehend it to be clearly one and entire. The faculties of willing, feeling, conceiving, etc cannot be said to be its parts, for it is one and the same mind which employs itself in willing and in feeling and understanding. But it is quite otherwise with corporeal objects, for there is not one of them imaginable by me which my mind cannot daily divide into parts. This is sufficient to teach me that the mind or soul of man is entirely different from the body.”
There has since been ever-mounting evidence that this is not the case. We know that functions of the mind are correlated with impulses of interconnected neurons, as detected via EEG, fMRI, and using electrodes placed directly on the exposed surface of the brain. We appreciate the specific effects that various psychotropic drugs have on personality and the content of thought. We know that damage to the brain by trauma, surgery and tumours can affect isolated faculties of the mind such as speech, memory, emotion and the ability to recognise faces. And there is every reason to believe that when the brain ceases to function, the person ceases to exist.
Despite the evidence clearly undermining Cartesian (or mind-body) dualism, it seems to have endured as the predominant view to this day; and the belief in free will is playing a major role. Libertarian free will – the idea that that we are the sole authors of our thoughts and actions, that we can create a thought uncaused by anything prior – only makes sense if we invoke at least some metaphysical aspect of the mind. It only makes sense if we relinquish it from the bonds of the physical laws of the universe. It only makes sense if we imagine the mind as somewhat irrespective of the brain.
It is not surprising then that a medicine of the mind is not seen as ‘real medicine’. It is practise of the dark arts, accompanied by mind reading, talking to the dead, and fortune telling. It seems psychiatry deals with metaphysics, and science is not in the game of metaphysics.
This leads to stigmatisation of psychiatry, including from the most disappointing of sources – other doctors. Throughout my medical career, the prevailing impression of psychiatry has been that it is a sub-specialty. No, not in the sense that hand surgery is a sub-specialty of orthopaedics. Rather, that psychiatry is less than a specialty, or not a real specialty. Apart from my term in psychiatry as a medical student, not once was I encouraged to consider the field. Rather, as I was gathering references for my application to the field, I was frequently met with comments such as “No, don’t do it!”
Granted, psychiatry currently lacks the diagnostic blood test, CT scan, or biopsy that can diagnose most illnesses. Much uncertainty remains, but for a very good reason – the brain is a fantastically complex organ. Whilst we have dialysis machines to replace the function of kidneys, and pacemakers to make the heart beat, similar technological feats for the brain are understandably lacking. However, pointing to something other than the brain when considering a person’s mental state and behaviour is not helpful, and will continue to pose a detriment to the field.
So long as we refuse to let go of the idea of free will, we allow the mind to escape the grasps of scientific enquiry. This is a self-inflicted handicap that psychiatry, and the wider society, cannot afford to continue.