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but fail to eliminate most stereotypical beliefs, except for the myth about the mentally ill being dangerous. Bojan Zalar, Ph.D. Mateja Strbad, M.D. ˇvab, M.D., Ph.D. Vesna S University Psychiatric Hospital Ljubljana, Clinical Department, Ljubljana, Slovenia

References 1. Sartorius N: One of the last obstacles to better mental health care: the stigma of mental illness, in The Image of Madness. Edited by Guimon J, Fischer W, Sartorius N, et al. Basel, Switzerland, Karger, 1999, pp 96–104 2. Feifel D, Moutier CY, Swerdlow NR: Attitudes toward psychiatry as a prospective career among students entering medical school. Am J Psychiatry 1999; 156:1397–1402 3. Mas A, Hatim A: Stigma in mental illness: attitudes of medical students towards mental illness. Med J Malaysia 2002; 57:433– 444 4. Baxter H, Singh SP, Standen P, et al: The attitudes of tomorrow’s doctors towards mental illness and psychiatry: changes during the final undergraduate year. Med Educ 2001; 35:381– 383 5. Creed F, Goldberg D: Students’ attitudes towards psychiatry. Med Educ 1987; 21:227–234 6. Chung KF, Chen EY, Liu CS: University students’ attitudes towards mental patients and psychiatric treatment. Int J Soc Psychiatry 2001; 47:63–72 7. Sartorius N, Schulze H: Reducing the stigma of mental illness: a report from a Global Programme of the World Psychiatric Association. Cambridge, Mass, Cambridge University Press, 2005 8. Schulze B, Richter-Werling M, Matschinger H, et al: Crazy? so what! effects of a school project on students’ attitudes towards people with schizophrenia. Acta Psychiatr Scand 2003; 107:142–150 9. Christison GW, Haviland MG, Riggs ML: The medical condition regard scale: measuring reactions to diagnoses. Acad Med 2002; 77:257–262 10. Chung KF: Changing the attitudes of Hong Kong medical students toward people with mental illness. J Nerv Ment Dis 2005; 193:766–768 11. Corrigan PW, Edwards AB, Green A, et al: Prejudice, social distance, and familiarity with mental illness. Schizophr Bull 2001; 27:219–225

Should We Be Teaching Philosophy to Psychiatrists-in-Training? In order to answer the question in the title, two further questions need to be addressed. First, what is the primary job of a psychiatrist, and second, how can philosophy aid 246

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psychiatry? Not only do I believe that psychiatry can benefit from philosophy, but it can be easily introduced into a residency program’s curriculum. For these reasons I argue that some general philosophical principles ought to be considered by psychiatrists-in-training. Paul McHugh explains in The Perspectives of Psychiatry that the psychiatrist studies “a natural biosystem called the mind” (1). Although neuroscience is progressing rapidly, we still rely on ardent observation by skilled clinicians. Because we use mental processes in order to study the mind itself, we must be attuned to any limitations that this may place on our knowledge of the mind. This is precisely where philosophy would be useful. Many medical specialties have expertise in related fields. For example, neurologists-in-training will frequently study radiology and pathology. These other areas serve to help the neurologist care for his or her patient. Modern technology has enabled us to examine the mind through neuroscience. However, it is also important to include other fields that examine the mind. Philosophy has long been concerned with the workings of the mind, and its branch, psychology, has made great progress. Some of the greatest psychiatrists were also philosophers, such as Karl Jaspers and Sigmund Freud. Because there is such a large body of knowledge preceding biomedical science, namely in the form of philosophy, I believe that it should at least be addressed. There are three components of philosophy that can aid psychiatry: metaphysics, epistemology, and ethics. Metaphysics is concerned with the nature of being. Epistemology, on the other hand, is the analysis of how we obtain knowledge, and ethics is the study of what is morally right or wrong. In many ways, the focus of psychiatry begs to be fundamentally philosophical. Other specialties have distinct entities to study, such as the heart, lungs, or gastrointestional tract. In addition to studying the brain, psychiatry also examines incorporeal substances, such as thoughts and feelings. By examining the field from a metaphysical standpoint, one can get a better grasp on what psychopathology is and where it comes from. Most people would agree that the mind is a product of the brain, and functional imaging studies have even been able to detect differences between various mental states. The fact that medicines successfully treat mental illness also points to a biological basis for mental phenomena. However, we still cannot study particular thoughts or feelings by neuroimaging. Functional imaging and medications are more likely glimpses of the actual structure of what we term the “mind.” Academic Psychiatry, 31:3, May-June 2007

LETTERS

The interesting challenge that arises from philosophy of mind theories is the mind/brain problem. The mind’s derivation from the brain is a question that has many implications for the fields of neurology and psychiatry. By studying mental states, should we not also be interested in the manner of their formation? The next question concerns epistemology: “How do we know what we know?” Epistemological inquiry is much easier in cardiology, where a heart murmur found on a physical exam is confirmed by the presence of a prolapsed valve on an echocardiogram. In psychiatry, diagnostic certainty is achieved by comparing one’s observation to a consensus of observations. We are left with studying the phenomenology of mental life as Karl Jaspers so avidly championed (2). As technology advances, psychiatry will undoubtedly advance in its manner of examination, and even has so already with the advent of functional magnetic resonance and positron emission tomography imaging. However, as long as the mind/brain problem persists, so, too, will the problem of epistemology within psychiatry. By definition, those fields with a shaky metaphysics also have an unsteady epistemology. Psychiatry’s metaphysics is taking form yet is still questionable. This leaves us with the question of how we can know the specifics of something without being able to fully define it. Finally, psychiatry engages the patient in a very personal and intimate way. By dealing with thoughts, feelings, and wishes, psychiatry is arguably the most humanistic field within medicine. Determining competency and wielding the power to involuntarily commit someone cause psychiatrists to be aware of what it means to practice in an ethical manner. Ethics have been rightfully taught to psychiatry residents for decades and this practice should continue. This letter is not meant to be a mandate to teach philosophy to psychiatrists-in-training. Rather, it is intended to arouse discussion. Psychiatry does not have a clear metaphysics yet, which leaves it open to many different models. By discussing the metaphysical problems with psychiatry residents, they will be more able to think critically about their field. I am only suggesting that these types of arguments occur at opportune times. Additionally, some programs may elect to incorporate one or two lectures on the interesting mind/brain problem. I do not think that extensive philosophical studies should be conducted, but rather discrete practical bits of discussion should be fostered in the proper setting. In summary, psychiatry’s concern with the mind places it in a unique position within the realm of medicine. The mind/brain problem is central in the study of psychiatry. Furthermore, our ontological immaturity leads to quesAcademic Psychiatry, 31:3, May-June 2007

tions about how we obtain our knowledge. Finally, interacting with patients at the most basic human level compels us to act ethically. By studying and discussing these three main tenets of philosophy, psychiatry will be more informed and will continue to progress. After all, the critical examination of one’s field ensures its proper study. Brian S. Appleby, M.D. Department of Psychiatry, Johns Hopkins University, Baltimore, Md.

References 1. McHugh P, Slavney P: The Perspectives of Psychiatry. Baltimore, Johns Hopkins University Press, 1983 2. Jaspers K: General Psychopathology. Translated by Hoenig J, Hamilton M. Baltimore, Johns Hopkins University Press, 1997

Ligers Lived Thank you for Levin and Schlozman’s excellent piece on “Napoleon Dynamite” (1). As a one-time resident of small-town Idaho, I feel compelled to offer an elucidation of Napoleon’s cultural background. The culture of smalltown Mormon Idaho is very different from other places. Here, terms such as “frick,” “dang,” “heck yes,” and “gosh”—not to mention “gall dang” and “oh my heck”— are ubiquitous substitutions for unacceptable swear words. And this homogeneous, superficially all-American but, in fact, idiosyncratically mystical culture breeds a substratum of magical thinkers. There is an epidemic of trinket shops stocked almost entirely with tchotchkes of the crystal-bearing wizard type and a remarkable number of after-school groups devoted to activities such as shape changing, with a preference for unicorns. The fantasy animals that interest Napoleon surround him, in the culture and in the hills. Unicorns can be found next to the wizards, and Ligers briefly populated the outskirts of Lava Hot Springs, Idaho (Google “Ligertown” for proof). So Napoleon is not quite as odd as he might seem to outsiders. What we are seeing in the character of Napoleon Dynamite, at least partly, is an interesting product of an even weirder and more interesting culture, one that is depicted with striking accuracy in this film. Alexander Westphal, M.D. Yale Child Study Center, New Haven, Conn.

Reference 1. Levin HW, Schlozman S: Napoleon Dynamite: Asperger’s disorder or geek NOS? Acad Psychiatry 2006; 30:430–435

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