Embracing psychiatric uncertainty

I always get troubled looks from psychiatry residents when I point out that our field is the domain of the uncertain and the not-well-understood - and that it will always remain so. As soon as the cause of a disease is known, it automatically leaves psychiatry for another specialty. General paresis (advanced syphilis), once identified as an infectious disease, became the domain of internists. Senility (dementia), multiple sclerosis, and many other apparently psychiatric conditions went to the neurologists. Thyroid disorders belong to endocrinology. Brain tumors and hemorrhages are surgical conditions. And so forth. I have little doubt that schizophrenia will someday be understood as due to a slow virus, a complex genetic error, or something else. At that point it will no longer be a psychiatric condition. It will join neurology, internal medicine, or some other specialty.

This makes my residents squirm in their seminar chairs, particularly when I point out that the closest analogy to psychiatry's status in medicine is philosophy's status among the humanities. Philosophy consists of questions in the humanities that we don't yet know how to answer. Once we do, that area is no longer considered philosophy. "Natural philosophy" is what we now call science. It isn't considered philosophy anymore. Logic was one of the classic branches of philosophy; now it is better understood as a branch of mathematics. In the same way, psychiatry consists of questions about human thoughts, feelings, and behavior that we don't yet know how to answer, not down to the level of mechanism anyway. Once we do, that area is no longer considered part of psychiatry.

It's no mystery why the residents are uncomfortable. They want and expect certainty. Why did they study all that organic chemistry, memorize all the bones and muscles, spend years learning to diagnose and treat, if in the end they can't make definitive statements about their chosen specialty? Many cling to pseudo-certainties for reassurance. Simple-minded factoids like "alcoholism is a disease" or "depression is due to a chemical imbalance" give them something to hang onto. Unfortunately, we don't really know what causes depression, and alcoholism is disease-like in some respects, but not in others. Most of our field is complicated, messy, and not well understood. Moreover, this need for certainty in an uncertain field leads many psychiatrists, including and perhaps especially those well out of training, to convey unwarranted confidence regarding diagnosis and treatment recommendations. We can come across as smugly self-assured.

Frankly, this very uncertainty - mystery, if you will - is one of the things I like about psychiatry. It isn't a settled area. It is endlessly debatable, much like an undergraduate philosophy course. Yes, there are concepts and terms to learn, principles to refine and employ, scientific studies to evaluate. There is a body of knowledge, a history, practice guidelines to teach and learn. Most of all, there are real patients to help. Yet as in philosophy, experts in psychiatry can and do disagree. Our diagnostic categories are revised periodically. Treatments come and go. Unscientific fads influence the field, as when American psychiatrists used to diagnose schizophrenia more liberally than our British counterparts, when multiple personality disorder suddenly became common in the 1980s and just as suddenly faded away, and in the way ADHD, PTSD, and bipolar diagnoses are so popular now.

Confident pronouncements of certainty have no place in psychiatry. Humility is the only honest attitude to take to this work. At the same time, the questions we face are fascinating, patients are suffering, and neither can wait for definitive knowledge. We must do the best we can with imperfect knowledge, with limited data and educated guesses, with hunches and subtle impressions. As in life generally, we cannot wait for certainty before acting. As in life generally, this makes psychiatry risky, vibrant... alive.

© 2011 Steven P Reidbord MD. All rights reserved.