Defense and Illustration of Psychiatry*

I wish to express my deepest thanks to Doctor María Elena Medina-Mora for the honor of inviting me to give the Ramón de la Fuente Speech for the 26th Annual Research Meeting. It is an honor which also implies great responsibility, as our founder holds, as has been shown on numerous occasions, a very important place within Mexican medicine, and his work continues to be of relevance in the field of Psychiatry. During the 34 years that I worked with him in several different areas (the Organizational Committee of the 5th Global Psychiatry Summit, the UNAM, the FCE, and at this Institute), I had the privilege of talking and debating with him, through highly stimulating dialogue, above all on topics of divinity and humanity. Some of the central topics that earned his interest and concern are those I will be discussing today. You might say that today I keep my promise. The spiritual survival of those who create ideas allows us to enjoy fruitful dialogue across time and space. Today, I summon him once more, here. In February 2010 a controversial article by Professor Heinz Katschnig of the Medical University of Vienna appeared in the journal World Psychiatry, an official publication of the World Psychiatric Association, titled «Are psychiatrists an endangered species? Observations on the internal and external challenges faced by psychiatry.»1 After a long professional career of four decades and with the support of 114 recent references from Anglophone literature, the author summarizes in six pages a stark and brave vision of what he considers, together with no small number of other authors, a current crisis in our field. Among internal challenges he identifies the decrease in confidence based on knowledge (diagnosis, classification, therapeutic interventions) and the lack of a coherent theoretical base. The external challenges include the dissatisfaction of patients, competition with other professions and the negative image of our field in society and among doctors from other disciplines. The Austrian author lists a series of peculiar pieces of information: the confused situation of two different diagnostic systems used internationally for some 60 years, a parallelism that is possibly due to the specific nature of the definitions of nearly all psychiatric diagnoses; combinations of phenomenological criteria, such as signs and symptoms, and their development over time, prepared by expert committees in variable ways to integrate categories of psychiatric disorders that have been defined and redefined over and over again during the past half century. The better part of these diagnostic categories is not validated by biological criteria as nearly all medical illnesses are. However, although they are called «disorders,» they have the appearance of medical diagnoses and seek to represent medical diseases which are entwined with hierarchical classifications comparable to the botanical taxonomies of the 17th and 18th centuries. The approach of the DSM in creating «operational definitions» has certainly made the process of diagnosis more reliable, but as Katschnig points out, this is different from validity. Psychopathological phenomena most surely exist, and can be observed and experienced as such. However, psychiatric diagnoses are defined in an arbitrary way, and do not exist in the same way as psychopathological phenomena. For the author, in addition to criticism of the diagnostic classification systems and the definitions of diseases, which began several decades before coming from outside the field of psychiatry, other more recent criticisms have been proposed from within. Thus he recalls the «genetic deconstruction of the psychosis» suggested by certain colleagues and the complaints of psychiatric geneticists that seek to use «Star Wars technology for bow-and-arrow diagnosis.» And it goes beyond just this: «The basic reasoning of these debates is that if our diagnostic categories have not been valid until now, then research of any kind (epidemiologic, etiologic, pathogenic, therapeutic, biological, psychological or social) if conducted with these diagnoses as inclusion criteria, is thus also invalid.» The other area of conflict indicated by Katschnig relates to the decreasing confidence in therapeutic interventions, not only because studies with positive findings are published more often and more quickly than those with negative findings, but also because the issue of conflicts of interest has emerged based on the relationship established