PROBLEMS IN

PSYCHIATRY

Dr.K.Nagi Reddy
MD (AIIMS New Delhi)
Hard problems
in Psychiatry
Joining psychiatry !!!!
Experience as private
practitioner
Psychiatrist dilemma - am I a
real doctor???
If somebody speaks ill about
psychiatry.. it hurts
The persons who really
understand about the real
problem are patients , care
givers and of course
psychiatrists
Hard problems
in Psychiatry
Defining mind
Diagnostic dilemma
Why Antipsychiatry
Preventive Psychiatry
Future of Psychiatry
MindWhere
are you???
Before defining metal illness we
need to define mind
Mind is a real thing
Mind and body are profoundly
different?
Concept of Psychiatry in
medieval ages
Rene Descartes (1596-1650)
Mind and body are different
substances
Mind is immaterial and
ontologically different from
material external world
Mind cant be explained by
natural sciences
Mind body
dualism
But there is a big problem.
Mind influences the body
and body influences mind
How something immaterial
influences material without
violating physical laws
Deep problem not solved
until today completely
Monistic view of mind body
problem is brain interacts
with environment and
produces mind
Difficulties with monistic view of
Mind Body problems

Mind appears to be exclusively private access to ones

own conscious states
If we open skull we can see only brain not immaterial
mind
Even we experience mind is immaterial, it is strictly
bound to physiological process of nervous system
If we block the physiological process of brain , mind is
totally gone
Three classical approaches of
Mind Body problem

Psychoanalytic reduction of mind body problem

Ignore the body
Freud
Behaviorist resolution
Ignores the mind
Pavolov,Watson,Skinnar,Eysenk
Biological resolution of Mind Body problem
Eliminate the problem by conflating the mind and
brain ( using technology of modern biology to investigate
mind )
How does Water turn into Wine
Brain generates Mind

Human brain is the most complex thing in

the known universe
Human brain contains 86billion neurons
(worm only 300)
Each neuron is having 10,000 connections
Estimated 100-500 trillion synapses
At each synapse specific chemicals are
released that opens or closes an electric
circuit in adjacent neurons
Brain
generates
Mind
Brain
neurotransmitters
Excitatory
glutamate
Inhibitory GABA
Dopamine
Acetylcholine
Serotonin
Brain generates Mind

Neuroscience can explain under which condition

brain generates mind without violating the physical
laws
But we experience mind as completely different from
our brain?
The system talks to mostly itself and many times
immune to outside world
Based on immense intracortical connectivity
compared to input and output (1,00,000:1)
So the inaccessibility of consciousness from outside is
easily understood if we understand the ratio
The evolution of PFC
PFC IS PFC mediates those parts of cognition that
are uniquely human
UNIQUELY Symbolic thought

HUMAN Conceptualizing
Planning
Making rules
Creating abstractions
Controlling our physiological drives
Imposing meaning on things
Conceiving past and future
To see self and others as independent
agencies
 Humans are unique in having
dual form of consciousness
Conceptual
consciousness Reason
(PFC mediated) Abstraction
Will power
Transcedence
Animate
consciousness
(common to all Primary
emotions
mammals) Instincts
Sexual drives
The rise of conceptual consciousness
over animate consciousness
PFC coup

Conceptual
consciousness

Animated
consciousness
Classification dilemma
Manuals Vs Minds

How many of us following the

bible of psychiatry?
Many times psychiatry
diagnosis are difficult to fit
into neat boxes
Paper pen diagnostic
methods in modern scientific
era..???
However we need
diagnostic criteria for
research, reasonable
diagnosis, treatment plans
and communication
Diagnostic dilemma
Over inflation of
mental disorders

In 1960,there were 10
diseasesnow it is > 300
Influence of pharma and
insurance companies
Effect of super specialist
researches
Problem with over inflation
Allen J Francis
chair,DSM-IV task force
Why dont
psychiatrists look
at the brain
The exception of academic
researchers psychiatrists rarely
examine the organ they treat
At present there are no gold
standard neuroimaging tests
for psychiatric disorders
Spectacular research is going
on psychiatric disorders with
PET and SPECT scans
In future functional imaging of
the brain may play key role in
psychiatric diagnosis
However at present we have
to be cautious but not
suspicious
 Anti oncology

Anti dermatology

Anti plastic surgery

Anti cardiology
Why Antipsychiatry???
19th century medical revolution
Psychoanalytic view
domination
Cold war era
Negative effects of mental
institutions
Labelling and stigma
Psychiatry survivors
Scientologists
Crying minority Vs silent majority
Anti psychiatrists are few
persons with half baked
theories ,deeply held overrated
incompatible beliefs depends
upon few case reports
Celebrity scientologist
Central Antipsychiatry
beliefs
The mind is not bodily organ so cant be diseased
No objective evidence
Mental disorders can be explained by social,
ethical and political factors a romantic view
Labeling of individual as mentally ill is only an
artificial device in society to maintain stability in
phase of challenges revolutionists views
Medication and hospitalization are harmful
psychiatry is industry of death
Szas,Schefe,Goffman,Laing,Cooper,Busalgia,Ber
ging
 Imagine there was no
stigma to mental illness.
A billion people worldwide are suffering with
some kind of mental illness
Everyone should know someone who is suffering
with mental illness
We face stigma everyday being psychiatrists
from our colleagues, intellectuals , press and
general public
Imagine a post partum psychosis patient having
some idea about mental illness
Imagine there was no
stigma to mental illness
Imagine relatives of the patient having some
understanding about mental illness
Imagine a general practitioner or gynecologist
having total knowledge of postpartum psychosis
Imagine a faith healer having knowledge about
real nature of illness
We can easily save mother child and the burden
of whole family
Preventive
psychiatry
Diagnosing
problem earlier
Providing
interventions earlier
Aim is reducing the
burden of illness
Once the brain
gets particular
psychopathology
the brain ingrains it
Preventive psychiatry

Good intentions but not with desirable results

Our well meaning intentions could cause some serious
problems
You can diagnose only one or two in ten cases
Safety and effectiveness of treatment is questionable
Preventive psychiatry

By combining neuroimagery with genetic studies

Genetic testing of high risk group
Neuroimaging if high risk group may reveal
whether the disorder has already set in or not
But it entirely depends on future technologies
Future of
psychiatry
Predicting future is a
dangerous business
Deficiencies in
current psychiatric
practice which is
frustrating
No knowledge of
etiology and
pathogenesis
No objective or
prognostic tests
Our treatments are
partially effective
Future of psychiatry

Are we going to have whole

new psychiatry down the road?
The present way of psychiatry
classification disorders may
become obsolete in future
We may have all kind of
neuroimaging and genetic
testing like other medical
branches
We may know how the
neuronal circuits are disrupted
in various psychiatric disorders
Future of psychiatry

There is widespread concern among

psychiatrists
The profession is in crisis and facing many
challenges.
But there is hope..
1.Early diagnosis and intervention
2.A tsunami of genetic discoveries
3.Neuroplasticity as treatment target
4.Neurostimulation for brain repair
5.Pharmacogenomics in clinical practice
Not quiet there yetbut
they are coming.
Computerized eye movement tracking techniques
useful in schizophrenia and autism
Predict suicidal ideation by immune and inflammatory
markers
Analyzing speech patterns with computers
Antipsychotics with built-in sensor
Virtual reality
Tele psychiatry
Implantables
Brain networks connected between the people
collectively solve problem and can overcome
cognitive and emotional problems
Where to go
from here.
Science shouldnt be
immune to criticism
Brain is not going to reveal its
mind easily
Neurobiological aggression is
to be avoided
Complex problems may
need unconventional
solutions
May take some more time to
decode genetic secrets
Where to go from here

We like it to happen in our

lifetime but our lifetime is too
short compared to
cosmological timelines.
So, don't worry..
We can still diagnose many
psychiatric illness without any
tests and can effectively treat
many cases with currently
available treatment methods
THANK YOU