Conceptual structure

Conceptual structure, information, and application, in that order, are at the heart of our teaching at Johns Hopkins—structure first and foremost because we believe that a lack of understanding about the relationship of observations to explanations impedes much of the general discourse, including the teaching, of psychiatry. In fact, at Johns Hopkins we concluded that until we made explicit the conceptual structure of psychiatry implicit within the discipline, we would not progress in our teaching skills, nor for that matter in our clinical services or research.

In this century, physicians and surgeons have evolved in their practices as they came to see the disorders and treatments of their patients more coherently based on advancing knowledge of biology and biological responses to injury. Diseases came to be seen not so much as dehumanizing distinctions or harbingers of mortality but as aspects of life under altered circumstances.

Psychiatrists cannot depend upon a direct translation of information from brain mechanisms into explanations for disorders of mental life. The link between brain and mind is the least comprehended connection in the natural sciences. Psychiatrists, members of a 'top-down' discipline, recognize signs and symptoms of mental disruption but must seek their explanations either through their correlations with brain states or as meaningful reactions to life experiences. From correlation and interpretation can come 'armchair' theorizing productive of outrageous speculations and practices. These have emerged in psychiatry from time to time, have been embedded in some educational programmes, and have proved difficult to challenge and eliminate.

Before their appreciation of bodily disorders as examples of life under altered circumstances, internists and surgeons also had problems with theory gone awry. They learned to avoid these pitfalls by committing their discipline to scientifically sound reasoning and research, derived in part from laboratory investigations of bodily structure and function. Psychiatrists, because they currently lack such laboratory means for confirming or rejecting an opinion, must fight against a tendency to blur distinctions between health and disorder. They must be committed to learning a methodologically coherent structured approach to practice, one that can promote progress and eliminate error. Their education must rest upon just such an approach, their teachers exemplifying and discussing it in the process of patient care and research.

Psychiatrists have attempted to bring coherence to the amorphous character of their discipline. In the United States efforts have been made over the last two decades to bring reliability, if not validity, to psychiatric diagnoses. These efforts culminated in the third and successive editions of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III, DSM-IIIR, and DSM-IV).(1) Although these classificatory manuals encourage empirical research by establishing a common nomenclature and an operationalized approach to diagnosis, they are, like their predecessors, only catalogues. They do not offer an explanatory structure for psychiatry that derives from any conception of the basic natures of the disorders they list. Indeed, the authors of dSm-IV deliberately reject an explanation-based approach to their classificatory system, opting for 'a descriptive approach that attempted to be neutral with respect to theories of etiology.' (DSM-IV, p. xviii).

When DSM-III emerged in 1980, George Engel(2) offered an encompassing theoretical approach (the 'biopsychosocial' concept) to explain the psychiatric disorders listed in that catalogue. The biopsychosocial idea, however, is so broad in its scope and so non-specific in its relation to particular mental disorders that it has proved heuristically sterile. It does not provide a foundation for teaching in that, although identifying the ingredients for explanation of mental derangements, it offers no specific recipes to validate or explain the DSM disorders. American psychiatry is committed to using DSM terminology, but it has not agreed upon a conceptual structure from which to derive its opinions, practices, and teaching.

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