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Biological Psychiatry

Truth in Love 258

The historical narrative of biological psychiatry helps us understand how we got to where we are today.

May 11, 2020

Dale Johnson: May is Mental Health Awareness Month, and we are dedicating our Truth and Love podcast to talking about issues that are very prevalent in our culture. In fact during this time of pandemic the terminology of mental health is actually increasing.

One of the signs we’ve seen that mental health issues are increasing is the 34.1 percent increase in anti-anxiety prescriptions between March and April. We want to talk about a historical narrative for us to understand how we got to where we are today with this terminology of biological psychiatry, which dominates the mental health scene right now.

There is a story. There is a way in which we arrived at a place just like this. In fact, Dr. David Powlison in the Journal of Biblical Counseling in 1999—21 years ago—wrote an article called Biological Psychiatry. The interesting thing is that the narrative has only grown. Dr. Powlison was correct. What we see even further down the road, now 21 years later, is biological psychiatry has increased in its influence and its narrative. It’s important for us to consider why and how this happened.

This week on the podcast I have with me again Dr. Sam Stephens, our Director of Training Center Certification here at ACBC. This is a subject and an area of interest in our studies, and I thought it would be helpful for us to have a conversation about these things to inform you so that this subject becomes less fearful and less ambiguous in our understanding. Dr. Stephens, I think it’s important for us to go back and give a little bit of the history of the Diagnostic and Statistical Manual of Mental Disorders (DSM), as we talked about last week on the podcast. We talked about its structure as an introduction, but now we’re getting a little bit more into the weeds and we’ll talk about the DSM and how it developed over time.

There were some major shifts that happened from its beginnings in the 1950s. While it was constructed in the 1950s, people had been talking about nosology or what’s called “categories” for a century at least, and basically building the ideas of categories of mental disorder. Now we get into the 50s, the DSM is constructed. The DSM-2 was constructed in 1968 and then moved towards a shift to biological psychiatry, away from a Freudian style of psychiatry that was popular early on in the DSM. Something significant happened in the 1980s. Help us to understand a little bit about that shift towards biological psychiatry.

Sam Stephens: In many ways it’s fascinating when you read about the history of psychiatry—it’s always been a field looking for a home. As you move more and more into recent history, especially when you get into the 80s, you see this major shift in the actual construction of the DSM. At the start, the DSM was a fairly small text. The DSM-1 and DSM-2 were not very significant and definitely not written in the same way that the DSM is written today using medical language, constructs, and even categories.

The DSM-3 was a major switch and turnaround to where it was seeking to be established as Allen Frances calls it upon “firmer scientific foundations.” Bob Spitzer, who served as the the task force chairman for that edition of the DSM, was very influential in that switch. I believe you’ve got a quote to help us understand his influence there.

Dale Johnson: Dr. Allen Frances, who was the task force chairman for the DSM-4, was actually a student of Bob Spitzer and he recounts Bob Spitzer’s influence. This began really in the 1970s. Bob had a mission. Dr. Spitzer wanted to see something happen. This is what Allen Frances notes here about Bob Spitzer. He says, “Without Robert Spitzer, psychiatry might have become increasingly irrelevant, drifting back to its pre-war obscurity. It is rare that one man saves a profession, but psychiatry badly needed saving and Bob was a rare man.”

As you mentioned, psychiatry needed to find a home. Their claim was that psychiatry wasn’t just dealing with the immaterial part of a person, they were trying to describe their profession as being a solidified physician dealing with the physical parts of a person. Yet they weren’t finding any science to demonstrate that. So they were finding themselves as people without a home.

In the early years, the DSM not used a whole lot. It wasn’t catching steam as psychiatry had hoped. It was using Freudian language, in terms of psychosis and neurosis to describe the problems of people. For a lot of people that was sort of mystical—they couldn’t wrap themselves around it. That concept could never be proposed as truly scientific. It was seen more as philosophy during those days, but then several major things contributed to what’s called biological psychiatry. Chlorpromazine comes on the scene. This was viewed as the first major contribution of psychiatry to the medical world, but there was a huge difference in something like penicillin, for example, in contrast to chlorpromazine. Edward Shorter, a renowned biological psychiatrist, says, “The introduction of chlorpromazine into asylum medicine in 1955 initiated a revolution in psychiatry comparable to the introduction of penicillin in modern medicine.”

Do you see what he’s doing? He’s conflating the discovery of chlorpromazine to the medical advancement of penicillin. The problem is that penicillin was addressing a known cause—a known pathology. Whereas chlorpromazine was simply treating a symptom and trying to borrow from the advancement of the medical system. Now psychiatry sees an opportunity. Chlorpromazine really didn’t work out. It treated symptoms to a certain degree, but the side effects were potentially fatal. From that, what starts to happen is now you see a flood of research—Joseph Schildkraut probably one of the best known researchers—to build another “pillar” of biological psychiatry in what was known as the monoamine hypothesis. This is the serotonin deficit theory of depression that we have too little serotonin, and that leads to depression from a biological perspective.

These things began to build—that was in 1965, Schildkraut presented a paper to the APA. It’s no wonder now in the 1980s Bob Spitzer takes some of that movement, some of that momentum, and seeks to make psychiatry a significant discipline. It had been waning, but now they see daylight with opportunities. We begin to see the conflation of medical advancement into this pseudo-scientific approach from psychiatry because they find things that treat symptoms. They don’t find pathology. This is what we’re left with in the development of biological psychiatry, which influenced this transition in 1980 where Bob Spitzer intentionally changes the landscape of psychiatry with what he called criteria-based diagnoses.

This was a shift to describing man and his problems from a philosophical narrative—that we are who we are, and we do what we do, because of our biology. Click To Tweet

He’s trying to shape the DSM into biological language. This was a shift to describing man and his problems from a philosophical narrative—that we are who we are, and we do what we do, because of our biology. The language of Darwinian biology flooded this narrative that Bob Spitzer was trying to build.

Sam Stephens: You see a lot of papers on this from researchers in the field. In fact, we have an article that was just published this year in BJPsych Bulletin where David Kingdon discusses this very thing—rather than neuroscience research underpinning some of these theories, really it’s been serendipity that has furthered the key advances in psychotropic drug discovery, for example.

Joanna Moncrieff has discussed this at length in many of her books. Irving Kirsch does the same thing. These researchers communicate that these drugs were not born out of scientific study and research that demonstrated very clear causation and what the the drug actually did in the body to address that causation, but it’s been a lot of trial and error. That still continues at large, and I don’t think it’s a coincidence that you see the massive growth of the use of psychotropic medications and Big Pharma, along with the expansive growth of the DSM and its diagnostic categories. I think in many ways the DSM is all form and no substance. With the DSM-3, you have these categories built, scientific language used, but there’s a clear admittance from those within the field that there really is no objective science to support that form.

In some ways, the idea of a biological psychiatry is kind of a misnomer. Allen Frances mentions this in his book. I think this is very eye-opening. He says, “We still do not have a single laboratory test in psychiatry.” If you can stop right there for a moment, that’s a very condemning statement for an entire field that sees itself as a medical practice and a scientific field—as a hard science or a physical science. He goes on to say, “Because there’s always more variability in the results within the mental disorder category than between it and normal or other mental disorders, none of the promising biological findings has ever qualified as a diagnostic test.” These categories are subjective. They’re voted on by committee. Even the number of items that someone has to meet in order to be diagnosed with a mental disorder according to the DSM is quite arbitrary. Four vs. five, seven vs. nine. There is no rhyme or reason behind those numbers.

I think something else to mention, as we think about the contradiction in this attempt to be purely biological in psychiatry, is what Joanna Moncrief talks about regarding the difference between the physical sciences and the behavioral sciences. She says, “The methods that we use to investigate the natural world in a scientific manner are fundamentally different from the ways in which it is appropriate and meaningful to understand human behavior and the mental attributes that that manifests.” So we think about the subject matter first—dealing with people and all the different variants that involves is quite different from what we would do in the hard or physical sciences. She goes on to say this, “Unlike the subject matter of the physical sciences, people have motives, interests and purposes, they make choices and do things for reasons. Although human actions are, of course, influenced and constrained by various factors, including human biology and the current and past circumstances of each individual’s life, they are not determined. They cannot simply be understood as the inevitable product of a given set of conditions.”

There is a logical difference between these two sciences. But what you continue to see—even in the university model today—is that the behavioral sciences are in the same school as the hard sciences, but the subject matter is different. The means are different, the approach is different. That’s largely what psychiatry as we understand it today has been built off of.

What it means to be human is to be a holism of body and soul put together. Click To Tweet

Dale Johnson: The difficulty here is many people would say, “Well, in biblical counseling, you don’t even acknowledge the biological.” I would pause on that and I would say, the Bible makes it very clear that we are both body and soul. If the Bible stakes that claim, it’s not staking that claim as if to say that we are one part body, one part soul. What it means to be human is to be a holism of body and soul put together.

What’s happening in psychiatry—and this is the fault where we drive the car into one ditch, unfortunately—biological psychiatry is simply a way to reduce man to biological-only perspective. That’s what we begin to see happen in our philosophical approach to these problems of man, as we try to explain it from one narrow hallway of our biology. That’s built on a philosophical disposition that we are who we are because of our biology. We evolved into this type of creature, so this is what we get when our instincts or our environment dominates who we are and what we think. Or when our brain is broken in a certain direction. When we try to describe this only from a biological perspective, it leads to a narrow view of man.

This shifting understanding of anthropology is contrary to what the Bible describes as true about human beings. What this often leads to is faulty science. When you think about biological psychiatry, if you buy into the idea that God is not real, then biological psychiatry starts to make sense. Biological psychiatry really begins to build into a narrative that is maybe a best explanation that we have for why we struggle with the things that we struggle with.

But unfortunately, this has led us into areas of faulty science. Here again, we are saturated with this narrative that this discipline is scientific and we feel pressure between science and faith. But the reality is, what’s being presented is not actually seen as true science, as you referenced with Dr. Frances’ comment: There’s not one biological marker that we can go to and look at from a perspective of cause or pathology to demonstrate these issues that we see floating around all the time.

Sam Stephens: If I could say anything I would want to urge our listeners to be very discerning regarding popular articles that come out in magazines that claim that neuroscience, which is the hot topic right now, has all the answers. Yet, if you read the actual studies, the terms they use are very important. They’ll say things like, “It seems to be,” “It implies,” or “It suggests”—that language is there on purpose, because they don’t have a verifiable link between causation and what they’re claiming is the problem.

Again in that David Kingdon article published this year, he says very clearly that it is still not possible to cite a single neuroscience or genetic finding that has been of use to the practicing psychiatrist. This is in secular research. Yet, you’ll see so many different articles or blogs posts that claim that there’s a connection, when there’s not.

Dale Johnson: This has been an ongoing idea. In the beginning in 1965, the idea of the “chemical imbalance theory” was a hypothesis. I would say at that time, it was a decent hypothesis in the way people viewed human beings, but the science has not demonstrated that the chemical imbalance theory is true.

I know when I say that, for many people you’re absolutely shocked, thinking, “How can you be saying something like this?” But the literature demonstrates that it is not true. Most of us believe very clearly that depression is a biological issue. I take a medication and it cures, repairs, or fixes what’s broken in my brain. Yet, in 1984—I was five when this came out—the National Institute of Mental Health said this, “Elevations or decrement in the functioning of serotonergic systems [that’s your serotonin, the neurotransmitter serotonin systems], per se, are not likely to be associated with depression.”

Stephen Stall in Essential Psychopharmacology in 2000 said this, “There is no clear and convincing evidence that monoamine deficiency [that means the theory about depression] accounts for depression. That is, there is no real monoamine deficit.” We could go on. Steven Hyman in Molecular Psychiatry in 2002 says, “There’s no compelling evidence that a lesion in the dopamine system is a primary cause of schizophrenia.”

We just have to be cautious. We’re not saying one way or the other—something may be discovered in the future. But what we’re saying is that what is described and touted as science now is not as demonstrable as what the the common man typically believes.

Ronald Pies, who was the Editor-in-Chief of the Psychiatric Times for years and years, and is professor emeritus at Tufts University in Boston, said in the Psychiatric Times on July 11, 2011, “In truth, the ‘chemical imbalance’ notion was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.”

That leads us to deduce a couple of things. The biological narrative is distinct and philosophical. People are trying to prove something based on a philosophical reality and it determines the way they see data. What does that do for us? A couple of things—it frees us from feeling like there’s tension between what we believe the Bible describes about the causes, reasons, and defects of our human existence because of sin and all the emotions that are flooded with it. It’s not a denial that those emotions and behaviors aren’t true. It’s just a different explanation as to why it helps us to have confidence in the Scriptures and not follow those vain philosophies and empty deceptions that the biological psychiatric narrative is pushing.

Sam Stephens: The assumption that psychiatry has the answers is a faulty assumption. It’s definitely something that they want to push and market—there’s financial gain in it, there’s prestige in it, there’s cultural relevancy in all of it. In the midst of this pandemic, there’s been hundreds of articles coming out on mental health and mental illness, but no one can really tell you what it means.

I would just urge our pastors and urge those of you listening to really deeply consider what’s been said and what’s continuing to be said by many people about the very purposeful, and I’d say anti-biblical, framework and pillars of psychiatry as we consider engaging with it.

Dale Johnson: This has been a fun discussion. What I want to do next week on the podcast is discuss the idea of mental disorder and mental illness from the DSM. That is a huge category for most people. It’s a phrase that has a lot of meaning for a lot of people, and so I want to discuss that next week on the podcast. We hope that you’ll stay with us. We can’t deal with everything in one podcast comprehensively. We’re trying to help you to understand a case as we work through it. So stick with us and we’ll see you next week.

Recommended Resources

Bibliography of Critical Psychology
Biological Psychiatry by David Powlison
The Bible of Psychiatry in ACBC’s Mental Health Month Podcast Series