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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)

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 ‘diseases'. 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 factitious disorder with physical symptoms. However, it remains an open question whether premenstrual syndrome will achieve similar recognition in DSM–IV. Diseases occur naturally, whereas diagnoses are artefacts; why do psychiatrists make diagnoses?

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.

SummaryThree 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, those with psychiatric morbidity immediately following 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.

SUMMARY Using a standardized interview, psychiatric morbidity was diagnosed in 35 out of 100 consecutive male patients one week after admission to hospital following a first acute myocardial infarction. Sixteen of these patients had been psychiatrically ill before the infarction and their psychiatric symptoms and social difficulties persisted throughout the 12 month period of observation. In contrast, patients whose psychiatric morbidity had been precipitated by the infarction tended to have transient symptoms and fewer problems of social adjustment. Measures of psychiatric morbidity one week after the attack did not predict subsequent mortality or difficulty in returning to work. Only a history of heavy smoking was significantly associated with mortality during the ensuing 12 months. Patients who regarded their illness as a loss or a threat had greater psychiatric morbidity than those who regarded it as an insignificant event.

One week after a first myocardial infarction 35 out of 100 consecutive men patients aged under 65 were found by standardised clinical interview to have psychiatric morbidity. In 16 the morbidity had been evident before the infarct, and these patients showed a wider range of psychopathology than those whose symptoms had been precipitated by the infarct. The results suggest that psychiatric morbidity in patients with heart disease is not necessarily a result of the disease process. Thus characterising psychiatric morbidity and identifying the patients' individual needs are important if rehabilitation is to be effective.