As a medical student, a medical practitioner, or even as a trainee psy- chiatrist, this sit uation does seem somewhat at odds with the medical train- ing we receive. Imagine the outcr y if an orthopedic surgeon were to set fractures without \201 rst taking an X-ray, or a c ardiologist diagnosed coronary artery disease without an electrocardiogram (ECG), angiograp hy, or com- puted tomography (CT). Imagine if, based on your description of the prob- lem, a car mechanic replaced the radiator in your car (at great expense to you) without even bot hering to look under the bonnet \201 rst. How can it be that the state of the art in psyc hiatry is not to look at the brain? Looking at this issue another way it is perhaps not surprising. If I were a patient, who pr esented to a psychiatrist with a catalog of recent losses (including both my parents, and a recent redundancy), low mood, sleep problems, loss of appetite, and a feeling of general h opelessness about the future, I would probably be somewhat perturbed if my psychiatrist dec lared that they could not help me until they had taken half an arm- ful of blood, performed a painful lumbar puncture (LP), and arranged a magnetic resonance image (MRI)/single photo n emission computed tom- ography (SPECT) of my brain (which might take a few months). I mig ht be impressed at their thoroughness, but over the following weeks as I fretted even more about the results of my brain scan, I might contemplate the wisdom of approaching someone w ho just seems to have added to my worries. When the \201 nal results came in and the psyc hiatrist declared that I was suffering from depression, I might seriously question their ab ilities, when I could have told them that 3mths ago! In the main, psychiatrists base diagnosis and treatment on symptom clusters, not brain imag ing or other investigations. This is not to say that it is not good clinical practice to pe rform a physical examination and some routine blood tests (or even an electroencephalograph [EEG] or CT/MRI when indicated by the history or clinical signs). Rather, these are genera lly investigations of exclusion (sometimes a negative result can be useful \200\224a point that is often lost on other clinicians when psychiatrists do request investigations which a re reported as \200\230normal \200\231). Psychiatric disorders (with the exception of the organic brain disorders, e.g. dementia) are predomi- nantly disorders of brain function; th ere are rarely observable changes in brain structure which would aid diagnosis. At present there are no gold standard diagnostic tests for psychiatric disorders. This is not to say t hat in the future functional imaging of the brain might not play a role in psychiatric 01_Semple_Chap01.indd 10 12/10/2012 6:23:40 PM WHY DON \200\231T PSYCHIATRISTS LOOK AT THE BRAIN? 11 diagnosis, but at present (and despite the fact that high-resolution SPECT and positron emi ssion tomography [PET] scans of the brain have been available for more than 20yrs) it \200 \231s not yet time to use these imaging tools in routine psychiatric practice. More researc h is needed to determine the speci \201 city and sensitivity of these imaging tools, even though there are hundreds of articles on functional brain imaging in a variety of psychiatr ic disorders (as a Medline search will quickly reveal). Does this relegate psychiatry to the lower divisions of medical special- ties? No. Rather, the doctor practicing in psychiatry needs a \201 rm grounding in general medicine (to rec ognize when a condition may have an organic basis), sharply honed interviewing skills (to e licit important psychiatric symptoms), a \201 rm grasp of psychopharmacology (to differen tiate between symptoms of disease and drug-related problems), and an appreciation of the ps ychosocial problems that may affect an individual in the society in which they live. Psychiatry is not about medicalizing normal experience; it is the ability to recognize symp toms of disease, as they are manifest in abnormalities of emotion, cognition, and behavior. Psychopathology reveals as much to a trained psychiatrist as pathology does to his medical or surgical colleagues. Psychiatrists may not (yet) examine the brain directly, but they a re cer- tainly concerned with the functioning of the brain in health and disease. 01_Semple_Chap01.indd 11 12/10/2012 6:23:40 PM CHAPTER 1 Thinking about psychiatry 12 Can psychotherapy change the brain? Descartes \200\231 error is never more apparent than wh en confronted with expla- nations of how exactly the psychotherapies bring about often prof ound changes in a patient \200\231s beliefs, ways of thinking, affective states or behav- i our. If we are ever to bridge the mind \200\223brain divide, then a neurobiological underst anding of the mechanisms by which the psychotherapies exert their actions is vital. This wo uld not only provide a sound theoretical foundation for these treatment approaches, but als o aid the improvement of psycho- therapeutic interventions by opening up the possibility of objectively meas- uring potential bene \201 ts and comparing one approach with another. Psychotherapy has been beset with accusations of being non-scienti \201 c. Even Freud had the good sense to abandon his Project for a Scienti \201 c Psychology which he started in 1895. He just did not have the tools he needed to detect functional changes in the living b rain. However, Freud \200\231s early experiments with cocaine \200\224mainly on himself \200\224convinced him that his putative libido must have a speci \201 c neurochemical foun dation. Now that we do have the ability to reliably detect training- and learning-related c hanges in brain acti- vation patterns using non-invasive functional imaging,1 Freud \200 \231s un \201 nished Project may be \201 nally realizable. Research in this area is neve r likely to attract the funding that major drug companies can invest in neurobiological res earch. Nevertheless, evidence is emerging for alterations in brain metabolism or blood \202 ow that relate to therapeutic effects. A recent review article2 identi- \201 ed a nu mber of studies assessing the effects of cognitive behavioral therapy (CBT) in obsessive \200\223compulsive disorder (OCD) and phobic disorders and of CBT and interpersonal therapy in depression. In OCD, psychological intervention led to reduced metabolism in the caudate and a decreased correlation of right orbitofrontal cortex with ipsi- lateral caudate and thalamus. Interes tingly, similar changes are observed in OCD treatment with \202 uoxetine, suggesting comm on or at least converging mechanisms in the therapeutic bene \201 ts of psycho- and pharma cothera- pies. In phobia, the most consistent effect of CBT was reduced activation in limbi c and paralimbic areas. Reducing amygdala activation appears to be a common \201 nal path way for both psycho- and pharmacotherapy of phobic disorders. Whether different functional networks are responsible for this common end point remains to be determined, although anima l research does suggest this may well be the case. Studies of depression are more dif \201 cult to interpret, showing both increases and decr eases in prefrontal metabolism associated with successful treatment. It does appear that de pression is a much more heterogeneous disorder and the functional networks implicated in th e treatment effects of the different therapies are not as straightforward as for the anxiet y disorders. Future studies need to address issues including larger patient numbers, use of standardized imaging protocols, and utilization of molecular mark- ers. However, it is clear that modul ation of brain activity through psy- chotherapeutic interventions not only occurs, but also may explain the bene \201 ts that patients experience. It may be time to put old prejudic es aside and properly study alternative non-pharmacological interventions. As the neurobiol ogist Jaak Panksepp has said, modern research into the etiology of disorders of emotion and behavior \200\230is not a matter of proving Freud right or wrong, but of \201 nishing t he job \200\231. 01_Semple_Chap01.indd 12 12/10/2012 6:23:40 PM CAN PSYCHOTHERAPY CHANGE THE BRAIN? 13 1 Linden DEJ (2003) Cerebral mechanisms of learning revealed by functional neuroimaging in humans. In R K hn et al. (eds) Adaptivity and learning \200\224an interdisciplinary debate , pp. 49 \200\22357. Heidelberg, Springer. 2 Linden DEJ (2006) How psychotherapy changes th e brain \200\224the contribution of functional imag- ing. Mol Psychiat 11: 528 \200\22338. 01_Semple_Chap01.indd 13 12/10/2012 6:23:40 PM CHAPTER 1 Thinking about psychiatry 14 The power of placebo \200\230the passions of the mind [have a wonderful and powerful in \202 uence] upon the s tate and disorder of the body. \200\231 Haygarth (1801) \200\230Placebo \200\231 from the Latin \200\230placare \200\231, \200\230to please \200 \231, entered the medical lexicon in Hooper \200\231s Medical Dictionary in 1811, as \200 \230an epithet given to any medicine adopted to please rather than bene \201 t the patient \200\231. However, the modern study of the \200\230placebo effect \200\231 began when ane sthetist Henry K. Beecher described patient responses to oral analgesics in 1953 and later discussed \200\230the powerful placebo \200\231 in the often quoted JAMA article of 1955.1 In these largely uncontrolled studies he found that around 30% of the clinical effect coul d be attributed to the effect of placebo. Over 50yrs later, research has generated many the ories of how placebos may exert their effects (see Box 1.3) but it still remains a controve rsial area. For psychiatry, understanding the reality of the placebo effect is critical when it comes t o examining the evidence for (and against) interventions. A good example is the recent cont roversy that \200\230Antidepressants are no better than a sugar pill \200\231. This statem ent conceals an assumption that giving placebo ( \200\230sugar pills \200\231) is the same as no treatment at all. This could not be further from the truth, and in mild to moderate d epression placebo exerts a powerful effect. Nobody is likely to run the headline \200\230P sychiatrists agree antidepressants should not be \201 rst-line treatment for mild to mode rate depression \200\231. In fact, clear separation of antidepressant medication bene \201 t from placebo is only seen for moderately severe depression as de \201 ned by the Hamilt on Depression Rating Scale (i.e. scores of 25+).2 Another telling illustration of the power of placebo in psychiatry is Johnstone et al. \200 \231s3 ECT trial comparing sham-ECT (anesthesia plus paral- ysis) to active treatment. It i s no surprise that placebo treatment with sham-ECT was very effective, reducing Hamilton De pression scores by around 50%. The real result was that ECT was superior to sham-ECT but on ly for psychotic depression (i.e. clinically much more severe). Should we be surprised that placebos can exert such powerful effects? Research on pain4 (se e Box 1.3) suggests that humans and other animals have neurobiological systems that evolved to utilize activation through cognitive mechanisms, including expectation, preconditioning , and con- textual-related assessment, that are capable of inducing physiological change. ( Just imagine the physical effects of exam nerves.) This certainly presents a challenge when designing RCTs and interpreting ef \201 cacy of active treatments but it also offers the potential of invoking these resil- iency mechanisms to effectively aid in the recovery of a n organism from injury, infection, distress, and functional impairment. The potency of such techniques has been well known to practitioners of traditional medicine for millennia. This is not to suggest we should pipe in soothing music, don Mesmeresque pu rple robes, and mutter incantations in Latin. Rather, we ought to be circumspect in how we interpret and present the evidence for the treatments we recommend to our patients. We also ought to be aware that our attitude towards the patient and the setting in which they are seen will affect the real bene \201 ts of any intervention. 01_Semple_Chap01.indd 14 12/10/2012 6:23:40 PM THE POWER OF PLACEBO 15 Box 1.3 Proposed mechanisms for the placebo effect \200 Natural remission to the nature of the condition. Regression to the mean parameters, later testing is more likely to be closer to the mean than to be more extreme. Anxiety reduction encounter leads to diminution of symptoms, particularly when they are painful or emotionall y distressing. Expectations (of the intervention, practitioner, setting), experience of oth ers \200\231 accounts, media in \202 uences, and cultural factors; and current in \202 ue nces: logic, verbal information, non-verbal cues, attitude (towards the intervention, pract itioner, setting), perception of the practitioner (attitude, personality, temperament, expe rience), and knowledge. Transference Psychoanalytical theory would suggest placebo works du e to the unconscious projection of feelings, attitudes and wishes, initially formed towards a signi \201 cant \201 gure early in development, onto another person, such as the doct or. e.g. the patient \200\231s response may be a simulacrum of the child \200\231s need to please the parent. Meaning effects accessible, sometimes the meaning or context of an inter action may be more complex and not directly expressible. Researchers separate microcontext (setting or physical environment) from macrocontext (wider culture pertaining to the practi tioner, patient, and setting). Conditioning learned response mechanisms when followed by pl acebo. Conditioning processes help explain \200\230expectations \200\231 and \200\230mean ing effects \200\231 but there are also circumstances when conditioning operates on physiol ogical responses (e.g. heart rate, blood pressure, hormone excretion, immune response) with out explicit expectation or even conscious awareness of the response occurring. Neurobiolog y a distributed network (anterior cingulate, periaqueductal gray, DLPFC, orbitofrontal cort ex, insula, nucleus accumbens, amygdala, and medial thalamus) modulated by both opioid and dopamine neurotransmission in various elements of the placebo effect: e.g. its subjective v alue, expectations over time, affective state, and subjective qualities of pain. Improvement would have occurred anyway due If a measurement is outwith normal Alleviation of anxiety following a therapeutic Cognitive factors \200\224past in \202 uences: direct experience Whereas \200\230expectations \200\231 are generally explicit and Previous exposure to active treatment engages Functional brain imaging studies of pain implicate 1 Beecher HK (1955) The powerful placebo. JAMA 159: 1602 \200\2236 M http://www.ncbi.nlm.ni h.gov/ pubmed/13271123 2 Fournier JC, DeRubeis RJ, Hollon SD, et al. (2010) Antidepressant drug effects and depression severity: a patient meta-level analysis. JAMA 303: 47 \200\2235 3 M http://jama.ama-assn.org/cgi/content/ full/303/1/47 3 Johnstone EC, Deakin JF, Lawler P , et al. (1980) The Northwick park electroconvulsive therapy trial. Lancet 2: 1317 \200\223 20. 4 Zubieta JK & Stohler CS (2009) Neurobiological mechanisms of placebo responses. Ann N Y Acad Sci 1156: 198 \200\223210. 01_Semple_Chap01.indd 15 12/10/2012 6:23:40 PM CHAPTER 1 Thinking about psychiatry 16 Treating patients against their will Psychiatric patients may have treatment, hospitalizati on, and other meas- ures imposed on them against their wishes. The power to impose such mea sures does not sit comfortably with the usual doctor \200\223patient relation- ship, and ps ychiatrists may \201 nd \200\230sectioning \200\231 patients unpleasant. The exist- ence of these powers means that under some circumstances psychiatrists will be damned if they d o (criticized for being agents of social control, disregarding a person \200\231s autonomy, and being heavy handed) and damned if they don \200\231t (neglecting their duties, not giv ing patients the necessary care, and putting the public at risk). Although it may not seem so, sectioning a patient may, in fact, be a very caring thing to do: akin to lifting and ho lding a two-year-old having a tantrum and at risk of hurting themselves and then soothing t hem. Such a (literally) paternalistic view may appall some people, but historically, patern alism has had a major in \202 uence in this area. When we consider why it is that we have such powers, we might argue that because psychiatri c illness may affect insight and judgment (i.e. a per- son \200\231s capacity) sometimes pa tients might not be capable of making appro- priate decisions about their care and treatmen t. Although to modern ears this may sound ethically sensible, we have had mental health leg islation for over 200yrs, and it is only recently that explicit consideration of such matte rs has in \202 uenced mental health legislation. Mental health legislation has its origins in eighteenth-century laws allow- ing for the con \201 nement of \200\230lunatics \200\231 and the regulation of private mad- houses. The main concerns at that time were the proper care of lunatics, fear of lunatics wandering fre e, and paternalistic sentiments that lunatics as a group did not know what was best for the m and so others should determine this. Large county asylums were built in the nineteenth ce n- tury and became the old mental hospitals of the twentieth. Until 1930, all patients were detained; there was no such thing as a voluntary or informal patient. If you were insane y our relatives (if you were rich) or the poor law receiving of \201 cer (if you were poor) would apply to a justice of the peace with the necessary medical certi \201 cation and you would be con \201 ned to an asylum \200\224because this was deemed to be the best place f or you. Our current legislation has its ancestral roots in such procedures \200\224reform h as rarely led to redrafting from scratch; vestiges of old laws are passed on through the ce nturies. Another question often raised is why should we deal with psychiatric illnesses any differen tly from physical illnesses? After all, physicians cannot detain their patients in order to manage their medical problems, can they? Interestingly, in certain circumstances, they can . Although it is unusual, under Sections 37 and 38 of the Public Health Act, the compulsory deten- tion of patients with infectious tuberculosis of the respiratory tract is allowed \200\224however, the patient cannot be treated against their wishes. Patients with physical illness can only be treated against their wishes if they lack capacity (which may be due t o psychiatric disorder). Is it right that psychiatric patients can be treated against their wishes even when they ha ve capacity to make such decisions? In the twenty- \201 rst century paternalism is dead an d autonomy rules. A patient with motor neuron disease is allowed to have their life support machine turned off, 01_Semple_Chap01.indd 16 12/10/2012 6:23:40 PM TREATING PATIENTS AGAINST THEIR WILL 17 despite the wishes of their doctors \200\224why not the same right for psychi- atric patien ts? This does seem to raise interesting ethical questions about whether interventions can ever be justi \201 ed by principles of paternalism or public protection, when a mentally disord ered person has capacity. A pertinent example is that of a currently well patient with a di agnosis of bipolar dis- order, who wishes to stop their mood stabilizer, despite past episo des of dangerous driving when unwell. Let \200\231s return to the public health argument of public protection. Infectious patient s with tuberculosis may pose a risk to others, and some psychiatric patients may also pose a risk to others. However, most people with men- tal disorder (even severe cases) are never violent; violence is dif \201 cult to predict, and many other people who pose a public ri sk (those who drink heavily or drive fast) are not subject to such special measures. Potent ially dangerous behavior is not in itself a justi \201 cation for the existence of men- ta l health legislation, but instead provides one criterion for the use of such measures when a person meets other criteria (namely having a mental disorder) and needs care and treatmen t. We need to be very wary of how our special powers to detain and treat patients against thei r wishes might be extended and misused. It is not the role of psychiatric services (includi ng forensic psychiatric services) to detain dangerous violent offenders and sex offenders j ust to prevent them from re-offending. That is not to argue that psychiatrists should not h ave a role in the assessment and management of such individuals; just that we should not ha ve primary responsibility for their care. In the twenty- \201 rst century we should be clear of our role: to care for individuals wi th psychiatric illnesses, without necessarily being paternal- istic. We should treat our pa tients in such a way as to prevent harm to them and to others, but this should not be our r aison d \200\231 tre. The primary justi \201 cation for the existence of mental health le gislation should be to ensure the provision of care and treatment for people who, because o f mental disorder, have impaired ability to make appropriate decisions for themselves. We s hould not be able to forcibly intervene unless this is the case and, when we do, our interv entions should be for their bene \201 t. 01_Semple_Chap01.indd 17 12/10/2012 6:23:40 PM CHAPTER 1 Thinking about psychiatry 18 Perceptions of psychiatry Since the beginning of recorded history, the public imagination h as been fascinated and provoked by the mentally af \202 icted. Of equal interest have been the social and political responses to mental illness and the mecha- nisms that have emerge d to manage and control the \200\230mad \200\231 among us. In general, public perceptions have tended towards polar extremes: on the one hand fear, ignorance, ridicule, and revulsio n; on the other, idealization, romanticism, and a voyeuristic curiosity. The social constru ctions of mad- ness throughout history have colored both lay and professional notions of me ntal illness and its treatment in the present age. These varying per- ceptions are represen ted in the arts, the media, and the political discourse of our societies. from the Gods. Nebuchadnezzar \200\231s delusions, the senseless violence of Homer \200\231 s Ajax, and the suicidal depression of Saul were the result of angry or meddling deities an d \200\230furies \200\231. In Deuteronomy (vi: 5) it is written \200\230The Lord will smi te thee with madness. \200\231 The \201 rst to situate mental suffering within the brain were the sages of the classic world: Hippocrates, Aristotle, and Galen. However, the dark a ge of medieval Europe saw a return to magical and spiritual interpretations of mental distu rbance \200\224madness was the work of demonic forces and witchcraft. Thus, Joan of Arc and countless others were burnt at the stake or drowned for their sins. With the dawn of the E nlightenment, Cartesian notions of rationality and a mind that resided separate from the bo dy displaced the supernatural and laid a foundation for modern concepts of mental illness. Insanity represented \200\230the \202 ight of reason \200\231 and religious moralism gav e way to scienti \201 c moralism \200\224instead of being one possessed the unfortunate su fferer was now a \200\230degenerate \200\231. The Romantic era provided a foil to the empi ricist veneration of reason. Byron, Blake, Rousseau, Shelley \200\224these were the \201 gures that epitomized in the public mind the archetypal union of madness and genius. \200 \230Great wits are sure to madness near allied;/And thin partitions do their bounds divide \200\231 wrote Dryden, while in a 17th-century etching, Melancolicus proclaims \200\230the price of wisdom is melancholy \200\231. The age of asylums and shackles (por- trayed by Ho garth in his series depicting \200\230The Rake \200\231s Progress \200\231 through Bedlam and condemned by Foucault as \200\230the great con \201 nement \200\231) came to an end w hen, in the spirit of the French Revolution, Pinel struck off the chains from his charges. In the ancient world, mental illness came The beginning of the twentieth century witnessed Freud \200\231s description of the unconsc ious and the birth of medical psychiatry. It was to be a century of controversy and intense soul-searching as psychiatry became equated in the public imagination with \200\230shock therapy \200\231, lobotomies, and the politi- cal abuses of Nazi and Soviet regimes. This p rovided fodder for Laing and Cooper and the anti-psychiatry movement (pp. 24 \200\2235), wh ile skirmishes continue to this day between psychoanalytic and biological paradigms. Finall y, in the age of mass media, the actions of a handful of mentally ill stalkers and assassin s such as Hinckley (who shot President Reagan), Mark David Chapman (who killed John Lennon) , and Tsafendas (who killed Verwoerd, the architect of apartheid) have kindled the public \200\231s image of the crazed killer into a blaze of prejudice and stigma. 01_Semple_Chap01.indd 18 12/10/2012 6:23:40 PM PERCEPTIONS OF PSYCHIATRY 19 In the second decade of the third millennium we are the inheritors of these historical cons tructs of mental illness. Our individual notions of madness and perceptions of psychiatry a re derived in part from this varied bequest. Supernatural, romantic, biological, and psycho logical notions of madness abound, while the historic tensions between the belief that psy- chiatry is fundamentally benevolent and the conviction that it is inherently repressive co ntinue into the present. The public mind is exposed to por- trayals of madness and psychiat ry in art, literature, \201 lm, and the media, and these are powerful in \202 uences in shaping individual and collective percep- tions. There are many examples of our contrasting notions within popular art. For example, The Crucible illustrates the mentally af \202 ic ted as cursed and invokes witchcraft as the agent of causation. By comparison, Quills and T he Madness of George III portray the sick as mentally impaired, disor- dered, degenerate (w ith differing degrees of historical accuracy). Similarly, in literature, Don Quixote and Ki ng Lear depict the anti-hero as simple or incomplete. The neurologist Oliver Sacks has done much to counter this stereotype with his sympathetic portrayal of neuropsychiatric conun- drums, for example in Awakenings. The mad genius archetype appears in A Beautiful Mind, The Hours, and Shine, while Joyce \200\231s \200\230Nighttown \200\231 chapter of Ulysses and Nietzsche \200\231s Thus Spake Zarathustra celebrate the gift of unfettered thought. Nietz sche de \201 nes madness as the \200\230eruption of arbi- trariness in feeling, seeing an d hearing, the enjoyment of the mind \200\231s lack of discipline, the joy in human unreaso n \200\231.1 In Hannibal Lecter (Silence of the Lambs), Raskolnikov (Crime and Punishment), and the villainous Hyde of Dr Jekyll and Mr Hyde, we see the stereotype of the crazed and dangerous killer. Finally, artistic critiques of psychiatry abound, but the champions surel y include One Flew Over the Cuckoo \200\231s Nest, The Snake Pit, and Sylvia Plath \200\231 s The Bell Jar. The challenge for us in this postmodern era is to consider our own constructs of what menta l suffering means and to re \202 ect upon how we should portray our psychiatric profession in society. In doing so, it is worth remembering the ideas we have inherited from our ance stors and how these ideas pervade current discourse. In sifting the grain from the chaff we would do well to proceed cautiously: most ideas contain at least some grains of wisdom. 1 Nietzsche F (1974) The gay science. Trans W, Kaufman. New York, Vintage. 01_Semple_Chap01.indd 19 12/10/2012 6:23:41 PM CHAPTER 1 Thinking about psychiatry 20 Psychomythology \200\230Science must begin with myths and with the criticism of myths. \200\231 Sir Karl Popper (1963) Myths matter. Throughout history myths have served the central func- tion of explaining the inexplicable: creating the illusion of understanding. Human nature seems to defy explanati on and yet we constantly make value judgements of people and ourselves \200\223 inferring motivation and cau- sation on relatively little evidence \200\223 in an attempt to make se nse of the world. Most of the time erroneous beliefs matter little and may even be comforti ng, but some of the time they can make us prejudicial or lead us to act unwisely. Whilst it may be acceptable in our private lives to be more liberal with the truth, in our professio nal lives we are afforded the bene \201 ts of authority based upon our expertise. This is why there are professional examinations and quali \201 cations. We must guard against misi nformation and protect ourselves and our patients from treatments and explanatory models fo r which evidence is decidedly lacking. Pseudoscience Fortunately we have the scienti \201 c method to help us sift the evidence ( see EBM b pp. 107 \200\22327) and the testable biopsychosocial model of the etiology of psy chiatric illness (b p. 245). Nevertheless we can be fooled when a set of ideas is presented in a scienti \201 c way, even though it does not bear scrutiny. These pseudoscienti \201 c theories may be based upon author- ity rather than empirical observation (e.g. old-schoo l psychoanalysis, New Age psychotherapies, Thought Field Therapy), concern the unobservable (e.g. orgone energy, chi), confuse metaphysical with empirical claims (e.g. acupuncture, c ellular memory, reiki, therapeutic touch, Ayurvedic medi- cine), or even maintain views tha t contradict known scienti \201 c laws (e.g. homeopathy). Some theories are even maintaine d by adherents despite empirical testing clearly showing them to be false (e.g. astrology, bio- rhythms, ESP). Others cannot even be tested. As Carl Sagan pointed out in his excellen t book \200\230The Demon Haunted World: Science as a Candle in the Dark \200\231 (1995): a ny hypotheses should, at least in principle, be falsi \201 able. In fact the scienti \201 c method has this at its heart: the rejection of the null hypothesis. More worrying perhap s is the unthinking promotion of some of these methods by physicians who really should know better. Chi imbal- ance is not the same as serotonin dysregulation (no, really it isn \200 \231t). \200\230Men are from Mars, Women are from Venus \200\2311 Our culture is infused with popu lar myths about psychology and psychia- try. From personality pro \201 ling to violence an d mental illness, there is no end to confusion. The media lap up the newest theory, treatme nt or drug even when the scienti \201 c evidence is shaky. Emotive anecdotes and stirring personal accounts lodge themselves into the public imagination. Modern Barnums promote thei r wares in bookshops, on the Internet, and TV. Autism is on the rise, they say; hospital ad missions go up during a full moon; people are more depressed at Christmas; antidepressants cause 01_Semple_Chap01.indd 20 12/10/2012 6:23:41 PM PSYCHOMYTHOLOGY 21 suicide; I can make you do X,Y and Z; this is what your dreams really mean. There are many reasons why myths persist (see Box 1.4) and they are very dif \201 cult to challenge once they are established. This is one reason why psy- choeducation is a vital component of most psychological therapies. Most people \201 nd that the antidote to the in \202 uence of pseudoscience on them is knowledge of real science. The twist in all of this is that unders tanding the truth of how the brain functions in health and disease is more remarkable, more amazing, and more life-changing than any \201 ction could ever be. Box 1.4 Mythbusting The 10 sources of error:2 \200 Word of mouth begin to believe it is true. Desire for easy answers and the quick \201 x g ood to be true, it probably is. We all suffer from na ve realism Selective perception an d memory and believe that how we see the world is exactly how it is. We also have a tendenc y to remember hits and forget misses which leads to illusionary correlation: the mistaken p erception that two statistically unrelated event are actually related. Inferring causation from correlation For example, although it may be true that a history of CSA is highly corre lated with schizophrenia it does not necessarily follow that schizophrenia is caused by CSA . Post hoc, ergo propter hoc reasoning because of this \200\231) Just because someone appea rs to get better after receiving a homeopathic remedy does not necessarily mean the remedy was effective. Exposure to a biased sample resistant patients and may assume treatment is l ess effective than it actually is for the majority of patients. Reasoning by representative ness similar does not make them the same. Misleading \201 lm and media portrayals recover ed from One Flew Over the Cuckoo \200\231s Nest. Exaggeration of a kernel of truth Terminol ogy confusion can lead to confusion with most people believing it means patients have multi ple personalities. If we hear something repeated enough times, we If something sounds too ( \200\230after this, therefore Psychiatrists usually see treatment- Just because two things appear ECT perceptions have never \200 The etymology of words like \200\230schizophrenia \200\231 1 \200\230 and most popular psychology is from Uranus. \200\231 When John Gray, autho r of \200\230Men are from Mars, Women are from Venus \200\231 appeared on Season 2, Episod e 3 of Penn & Teller \200\231s Bullshit! Penn quipped \200\230I guess the title \200\234W e \200\231re all people and should be treated with love and respect \200\235 just wouldn \200\231t \201 t on the book spine \200\231. 2 Adapted from the Introduction of So, Lynn SJ, Ruscio J, Beverstein BL (2010) Lilienfeld 50 Great myths of popular psychology. Oxford: Wiley-Blackwell. 01_Semple_Chap01.indd 21 12/10/2012 6:23:41 PM CHAPTER 1 Thinking about psychiatry 22 Stigma Stigma is a Greek word meaning \200\230mark \200\231 and originally referred to a s ign branded onto criminals or traitors in order to identify them publicly. The plural, stig mata, when used in medical settings, means the collection of symptoms and signs by which a particular disorder may be identi \201 ed. In its wider, modern sense, stigma refers to th e sense of collective disapproval and group of negative perceptions attached to a particula r people, trait, condition, or lifestyle. Stigmatization describes the process by which the characteristics of the group in question are identi \201 ed and discriminated against. Stigmatization can be thought of as a three-stage process: \201 rst, the indi- vidual is marked out as different by his actions or appearance; secondly, society develops a series o f beliefs about the affected individual; \201 nally, society changes its behavior towards these individuals in a way consistent with those beliefs, often to the detriment of the st igmatized individuals. Stigma can become self-reinforcing as it can be associated with avoi dance of the stigmatized individuals, leaving no opportunity for society to con- front and change its beliefs. Fear of the unknown, fear of contamination, and fear of death or the sight of death have le d to diseases of all kinds being stigmatized through- out history. This is particularly tru e of infectious diseases, diseases caus- ing dis \201 gurement, and mental disorders. As t he infectious and dis \201 guring diseases have become both more treatable and better unde rstood, suf- ferers from mental disorders have remained uniquely vulnerable to stigmatizati on. One marker of this has been the ease with which originally neutral, descriptive terms for m ental disorders have taken on a pejorative and disparaging meaning: cretin, maniac, spastic , imbecile. All have been aban- doned in an attempt to free affected individuals from the a pprobation the name had acquired. Unfortunately, stigmatization involves fundamental and wi dely held beliefs and is not usually amenable to simple cures such as changes of name of co nditions or organizations. For the person affected by mental illness, the name of the condition and their abnormalitie s of experience and behavior will mark them out as different, and are the root cause of the ir distress. However, the wider societal beliefs, expressed as stigmatization, will add to the burden of morbidity, and may in themselves prolong the condition. For example, the beli ef that depression is \200\230all in the mind \200\231 and could be resolved if the affect ed individual would only \200\230pull themselves together \200\231 may cause people to beh ave less sympathetically towards the sufferer, but it may also hinder the sufferer from see king appropriate help. There is no simple answer to the problem of stigma. We can certainly learn from the increas ingly successful approach to the problem of the stigmatization which initially attached to those individuals suffering from HIV infection. Increased public awareness of the cause of the disease, its method of transmission, the plight of its sufferers, and its means of trea tment appear to be associated with less, not more stigmatization. The Royal College of Psyc hiatrists, with its \200\230Defeat Depression \200\231 campaign, has been active in this r egard. 01_Semple_Chap01.indd 22 12/10/2012 6:23:41 PM STIGMA 23 On an individual basis we can: \200 Challenge our own prejudices connection with patients with personality disorder and patient s with substance misuse problems. Avoid stigmatizing language There is no place for forced political correctness in medicine, but we should consider whether calling an individual \200\230a schizophrenic \200\231 describes them as a single, unfavorable characteristic, ra ther than as a person with an illness. Challenge lack of knowledge within the profession la ck of knowledge of mental disorders is often seen in our colleagues in other specialties. T his may be expressed in, for example, a lower aspiration for treatment in individuals with mental handicap or chronic psychotic illness. Be advocates for political change not halt us from being at the forefront of moves to improve the autonomy of patients, their involvemen t in society, and their legal protection. These may exist, particularly in A surprising Professional conservatism should 01_Semple_Chap01.indd 23 12/10/2012 6:23:41 PM CHAPTER 1 Thinking about psychiatry 24 Anti-psychiatry One view of medicine is that it is an applied science whose object of sci- enti \201 c curiosity is the understanding of the causes and processes of human illness an d the study of methods of preventing or ameliorating them. In the scienti \201 c method th ere are no absolute truths, only theories which \201 t the observed facts as they are cur rently known. All scientists must be open to the challenging of \201 rmly established the ories as new observations are made and new experiments reported.