Psychiatry is more than a science.

Some loosely framed hypotheses may be stated. (a) Psychiatry depends on science and considerably more besides. (b) Consideration of the clinical methods of psychiatry enables us to characterise six axioms of fundamental importance to the subject which are primary features of human experience, not derived from any theory, ethically neutral and in principle independent of culture. (c) These axioms do not belong to the world of science, in that they are unlikely ever to be fully comprehended by scientific methods. Although they can to a limited extent be studied scientifically, in essence they belong to that part of the world of human experience which is not amenable to scientific study. They are of critical importance to psychiatry, and may be of relevance to all clinical specialties. (d) Psychoanalytic theory and its derivatives contain much that has a bearing on these axioms. Insofar as there is a connection, the theory derives from the axioms rather than vice versa. (e) In their concern with the uniqueness of the individual, his/her inner feelings and thoughts, consciousness of self, empathy and transactions with others, the axioms have common ground with the group of disciplines known as the humanities. (f) Their relationship with the humanities is not such that one can at present identify specific advantages to the psychiatrist (or to the mentally ill person) that might accrue from studying particular topics in literature, art and music. (g) Among the humanities, the one subject that may prove to have relevance to appropriate theory and competent practice is philosophy.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnoses are not diseases.

The psychiatric community seems determined to ground its medical legitimacy on principles that confuse diagnoses with disease. If mental illnesses are diseases of the CNS, they are diseases of the brain, not the mind. If mental illnesses are the names of (mis)behaviour, they are forms of behaviour, not diseases. Psychiatric metaphors have the same role in medicine as religious metaphors have in theology. Religion is, among other things, the institutionalised denial of a finite life. Psychiatry is, among other things, the institutionalised denial of the tragic nature of life: individuals who want to reject the reality of free will and responsibility can medicalise life, and entrust its management to health professionals. Psychiatrists have succeeded in persuading the scientific community, the courts, the media, and the general public that the conditions they call mental disorders are diseases, that is, phenomena independent of motivation or will. The more firmly psychiatrically based ideas take hold of the collective American mind, the more foolishness and injustice they generate. Long ago, the law makers agreed to let psychiatrists literalise the metaphor of mental illnesses. Thus, the Americans With Disabilities Act (AWDA), scheduled to be fully implemented by July 1992, covers claustrophobia, personality problems, and mental retardation, though unlike DSM-III-R it excludes kleptomania, pyromania, compulsive gambling, and transvestism. The literal language of psychiatry allows motivated actions to be called 'disease'. Other examples of behaviour for which psychiatrists have disease names, and which AWDA implicitly accepts as genuine diseases, include dysmorphophobia, multiple personality disorder, frotteurism, hypoactive sexual desire disorder, and fractitious disorder with physical symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Psychodynamics and psychotherapy on an acute psychiatric ward. The story of an experimental unit.

The treatment of severely disturbed patients is strengthened in an important way by listening closely to them and by attempting to understand their experience in the depth that is made possible by the use of psychoanalytic concepts. It follows that the practice of clinical psychiatry in the UK would be greatly improved by the introduction of a psychoanalytic and psychotherapeutic perspective into the acute ward. This paper reviews the work done on a ward at the Maudsley Hospital in which this approach was the practice.

Educating the psychiatrist of the 21st century.

Psychiatry is under threat from developments within mental health care. In educating future psychiatrists, more emphasis should be placed upon: collaborative research; integrated teamwork, without interprofessional rivalry; work in primary care; the non-scientific components of psychiatry, centred upon relationships with patients; less dogmatic attitudes for or against psychoanalysis: psychiatry as a branch of medicine; and modern management and audit methods. Younger psychiatrists should be encouraged to take responsibility for shaping the future of the profession.

Psychogenic facial pain: presentation and treatment.

Ninety three patients took part in a two centre double blind controlled clinical trial designed to assess the efficacy of dothiepin (Prothiaden) as compared with placebo and a soft biteguard in the treatment of psychogenic facial pain. The results showed the superiority of dothiepin over placebo in achieving pain relief; 71% of patients were pain free in the dothiepin group at nine weeks compared with 47% in the placebo group. The biteguard conferred no benefit and compliance in its use was poor. Out of 84 patients followed up for 12 months, 68 (81%) became pain free. An adverse life event before development of pain, minimal previous surgical treatment, and freedom from pain at nine weeks were strong prognostic indicators for successful treatment. These results are clear evidence of the efficacy of dothiepin in psychogenic facial pain, though the drug may be needed for up to a year.

Unexplained breathlessness and psychiatric morbidity in patients with normal and abnormal coronary arteries.

Of 99 patients with chest pain undergoing coronary arteriography, 31 had normal coronary arteries, 15 slight disease, and 53 significant coronary obstruction. 28 (61%) of the 46 with haemodynamically insignificant disease and 12 (23%) of the 53 with significant obstruction had psychiatric morbidity, assessed by standard interview. 37 patients had several respiratory symptoms and signs not attributable to organic disease, designated unexplained breathing disorder (UBD). UBD was found in 65% of the patients without and 13% of those with significant coronary disease; it was associated with psychiatric morbidity in the former but not in the latter group. Spirographic measurements of tidal volume and frequency were not helpful in detecting UBD but an end-tidal pCO2 below 30 mm Hg was highly suggestive. In the absence of significant coronary disease the associations of chest pain with psychiatric morbidity and UBD are striking. However, coronary disease and UBD are not mutually exclusive, and diagnostic difficulties can occur when they coexist.

Distress or illness? A study of psychological symptoms after myocardial infarction.

Three groups of patients were identified during a study of men who had recently suffered an acute myocardial infarction: those with psychiatric morbidity antedating the infarction and those with no significant psychopathology. Compared to the other two groups, patients with psychiatric morbidity before the infarction were more likely to be unmarried, unemployed and to have received previous psychiatric treatment. They also obtained higher scores for neuroticism and psychoticism on personality assessment. Patients whose symptoms have been precipitated by the infarction resembled the psychologically healthy group with regard to their demographic characteristics and personality. Their symptoms tended to be transient, improving without special psychiatric treatment.