Are “Psychiatric Disorders” Brain Diseases?

Steven Reidbord MD is a board-certified psychiatrist who practices in San Francisco.  He writes a blog called Reidbord’s Reflections.  On December 12, 2015, he posted an article titled Are psychiatric disorders brain diseases?  It’s an interesting and thought-provoking piece, with many twists and turns.

Here are some quotes, interspersed with my comments and reflections.

“Of the conditions deemed inherently psychiatric, some seem rooted in biological brain dysfunction.  Schizophrenia, autism, bipolar disorder, and severe forms of obsessive compulsive disorder and melancholic depression are often cited.  It’s important to note that their apparently biological nature derives from natural history and clinical presentation, not from diagnostic tests, and not because we know their root causes.  Schizophrenia, for example, runs in families, usually appears at a characteristic age, severely affects a diverse array of mental functions, looks very similar across cultures, and brings with it reliable if non-specific neuroanatomical changes.  Even though schizophrenia cannot be diagnosed under the microscope or on brain imaging, it is plausible that a biological mechanism eventually will be found.  (The same type of reasoning applied to AIDS before the discovery of HIV, and to many other medical diseases.)  A similar argument can be made for other putatively biological psychiatric disorders.”

This is a complex paragraph.  Dr. Reidbord names five psychiatric “diagnoses” and expresses the belief that they seem “rooted in biological brain dysfunction.”  He stresses that their apparently biological nature derives from their appearance (natural history and clinical presentation), and not from diagnostic tests or a knowledge of any pathology involved.

As an example of this, he states that “schizophrenia”

• runs in families
• usually appears at a characteristic age
• severely affects a diverse array of mental functions
• looks very similar across cultures, and
• is associated with reliable, though non-specific, neuroanatomical changes

And, it has to be acknowledged, that, at first look, these five factors, if present, might constitute grounds to suspect brain dysfunction. But let’s take a closer look.

RUNS IN FAMILIES

A “diagnosis of schizophrenia” is based on the presence of two or more of the following:

1. delusions
2. hallucinations
3. disorganized speech
4. disorganized behavior
5. apathy or avolition

It seems obvious to me that each of these behaviors (or lack of behaviors, in number 5) can be passed on from generation to generation through normal social learning, without any assumption of a genetically-mediated pathology.  If I, for instance, believe that airplane contrails contain toxic substances that are being spread by the government as part of a sinister plan to render the citizens docile and debilitated, and if I had communicated these concerns to my children during their formative years, there is a good chance that one or more of them would have accepted these assertions at face value, and might even pass them along to their children in turn.

Similarly if my growing children had witnessed me responding to stimuli that were clearly internal rather than external, or speaking in a markedly disorganized way, there would be, I think a reasonable expectation that one or more of them might also acquire these habits through social learning.

And so on for the other three “symptoms.”  There is no need to assume genetic transmission in these behaviors.  Indeed, an assumption of genetic transmission of any behavior is always doubtful.  Genes transmit biological structure.  Structure has an impact on behavior, obviously, but there are always multiple intervening factors.

APPEARS AT A CHARACTERISTIC AGE

I have addressed this issue at some length in earlier posts (here, here, and here).  But for the present purposes, it is perhaps sufficient to note that the “characteristic age” for the “onset of schizophrenia” is during the transition from late adolescence to adulthood (i.e. about 17 to 25).  For a majority of the population, this is probably the most difficult period of life, especially because it comes at a time when we are particularly inexperienced in dealing with complex challenges.   It is a period during which many people experience a good deal of failure, disappointment, embarrassment, and discouragement.  All of which can push an individual towards a negative perspective, and in severe cases to a state of belief that would qualify as “delusional,” without any assumption of a “biological brain dysfunction.”

DIVERSE ARRAY OF MENTAL FUNCTIONS

These are not so diverse really.  The APA criteria essentially identify:  false/mistaken beliefs; responding to internal stimuli; lack of organization in speech and behavior; and apathy/joylessness.  But only two of these need to be present in any given individual.

LOOKS SIMILAR ACROSS CULTURES

This issue has become almost impossible to address in any methodical way, because western influences (including the influence of the DSM) have reached virtually every corner of the globe.  The DSM has become the distorting lens through which all problematic behavior is viewed and assessed, and there are enormous formal and informal incentives for psychiatrists everywhere to find “diagnoses.”

But in 1963, these influences were considerably weaker and less widespread.  In that year, Henry Murphy, MD, et al sent questionnaires about “schizophrenia symptoms” to psychiatric centers in various parts of the world, and received responses from 27 countries.  Here’s how they summarized their results:

“The main significance of our findings at this stage is that doubt has been thrown on the picture which Euro-American psychiatry has built up of the schizophrenic process.  For instance, considering the high percentages of the simplex and catatonic sub-types of schizophrenia reported for certain Asian samples (in some instances our respondents kindly sent actual figures) and the low percentages of the paranoid sub-type, it might be questioned whether the delusional systems which are the most familiar feature of chronic schizophrenia in Euro-American hospitals are an essential part of the disease process.  Might they not be culturally conditioned attempts by the personality to ‘make sense’ of that process, attempts which Eastern cultures inspire to a much lesser degree?” (pp. 248-249 Murphy HBM et al, A cross-cultural survey of schizophrenic symptomatology, International Journal of Social Psychiatry, 1963, 9: 237-249)

Dr. Murphy et al are obviously committed to the disease concept, but their finding of such cultural diversity casts doubt on the universality of “schizophrenia.”

And in 1973, E. Fuller Torrey, MD, prior to his conversion to biological reductionism, reviewed the evidence on the universality of schizophrenia, and summarized the matter:

“In fact, however, there is no evidence upon which to base a belief in the universality of schizophrenia.  The studies which have been used to support this belief are found, on careful examination, not necessarily to point in this direction at all.  If anything, they may lead to the opposite conclusions:  Schizophrenia may not be a universal disorder.” (p. 53 Is schizophrenia universal? An open question, Schizophrenia Bulletin, 1973, 7: 53-59)

and

“‘Once an idea becomes part of a textbook, it develops a life of its own and is seldom questioned.  This is what has occurred with the idea that schizophrenia is universal.'” (ibid, p 56)

and

“Finally, within the past few years some preliminary data on schizophrenia in New Guinea have become available. Burton-Bradley, a psychiatrist who has been there for a decade and a half, reported 343 cases of schizophrenia among the first 1,000 cases of mental disease which he examined. Virtually every one of the cases, however, occurred among individuals who had been living in the larger towns (‘the person of limited cultural contact, the so-called bush individual, very rarely presents with the symptoms of schizophrenia [Burton-Bradley 1969]’) or who had just migrated from rural areas to the towns (‘Not uncommon is the acute schizophrenia of sudden onset coming on usually within three months of  the patient’s leaving the village and working for the first time in a large town. Such patients readily recover and are returned to their village, at which level they can function without disturbance [Burton-Bradley 1963]’)” (ibid p 57.  The Burton-Bradley reference is:  Burton-Bradley, B.G. Culture and mental disorder.  Medical Journal of Australia, 15:539-540, 1963)

So, the fact that “schizophrenia” looks similar across cultures is more likely to reflect an artifact of cultural colonialism than any intrinsic property of the so-called illness.  And this is not merely a matter of psychiatrists seeing what they expect to see.  Once the “diagnosis” has been made, psychiatrists and other mental health workers actually begin a process that consists essentially of training the individual in how to “be schizophrenic.”  This process entails “educating” the client on the “symptoms and course of the illness,” and encouraging him to self-identify with the label.

NEUROANATOMICAL CHANGES

Dr. Reidbord doesn’t specify which changes he has in mind.  The main change of this nature that comes to my mind is brain shrinkage, but I think that there is broad consensus at present that this is more a function of extended use of neuroleptic drugs than any putative underlying disease process.

. . . . .

ANALOGY TO AIDS AND HIV

The analogy to AIDS prior to the discovery of HIV is unconvincing.  All the “symptoms” of the various psychiatric disorders that Dr. Reidbord mentions are behaviors, feelings, or thoughts.  And for each, there are plausible and eminently credible explanations from psychology, sociology, and indeed from ordinary experience and common sense.  But the symptoms of AIDS are clearly indicative of biological dysfunction. These symptoms include:

• Fever
• Chills
• Rash
• Night sweats
• Muscle aches
• Sore throat
• Fatigue
• Swollen lymph nodes
• Mouth ulcers

It would be quite a stretch to conceptualize this cluster of symptoms as anything other than a biological malfunction.  But it is entirely plausible to think of “schizophrenia” in this way.  And indeed, Dr. Reidbord himself is restrained in his conclusion:

“Even though schizophrenia cannot be diagnosed under the microscope or on brain imaging, it is plausible that a biological mechanism eventually will be found.  ” [Emphasis added]

In my view, it is considerably more plausible that such a biological mechanism will not be found. This is particularly the case in that more than a hundred years of highly-motivated and generously funded searching for this “holy grail” of psychiatry has to date found nothing.

. . . . . 

But all of this, important as it is, is not the main point of Dr. Reidbord’s paper.  Let’s go on.

“Lately, however, some big names in psychiatry have taken a more ideological stance, declaring that psychiatric disorders in general are brain diseases — right now, no further proof needed.  Dr. Charles Nemeroff, widely published professor and chairman of psychiatry at the University of Miami Miller School of Medicine, writes:

In the past two decades, we have learned much about the causes of depression. We now know from brain imaging studies that depression, like Parkinson’s disease and stroke, is a brain disease.

Dr. Thomas Insel, recent director of the National Institute of Mental Health (NIMH) wrote:

Mental disorders are biological disorders involving brain circuits…

Psychiatrist and Nobel laureate Dr. Eric Kandel says:

All mental processes are brain processes, and therefore all disorders of mental functioning are biological diseases.

These claims by prominent psychiatrists agitate critics.  No biomarker for any psychiatric disorder has yet been identified. Genetic vulnerabilities have been discovered, but nothing resembling a smoking gun.  Functional brain imaging reveals biological correlates of mental impairment, not etiology, and no such imaging can diagnose a specific psychiatric condition.  Our best account for most mental disorders remains a complex interaction of innate vulnerability and environmental stress, the ‘diathesis-stress model’.  These psychiatric leaders know the research as well as anyone. How can they call psychiatric disorders brain diseases without scientific proof?”

At this point, readers might be thinking that, despite his earlier comments on biological brain dysfunction, Dr. Reidbord is arguing on our side of the debate.  But wait!  The argument progresses.

“The brain mediates all mental activity, normal or not.  Consequently, any psychiatric intervention — or influential life experience — acts upon the brain.  This is not a new discovery.”

…

 “It is a philosophical position, monism as opposed to Cartesian dualism, not a scientific finding.”

…

 “Psychiatric ‘brain disease’ is neither an exaggeration nor a lie.  It does not require scientific proof — and brain imaging has neither strengthened nor weakened the case.  For as long as one is not a philosophical dualist, it is surely true.  In theory, all psychology can be reduced to electrochemical events in brain cells. All psychopathology can be reduced to aberrant electrochemical events, i.e., brain disease.”

Dr. Reidbord is entirely correct in stating that the brain mediates all mental activity.  It also mediates all physical activity.  I cannot lift a finger, shed a tear, recall my mother’s face, hum a tune, feel sad, or even absent-mindedly scratch my ear, without the corresponding neural activity occurring within my brain, and eliciting the thought, feeling, or action in question.

Dr. Reidbord is also correct in stating that, in theory, all psychology can be reduced to electrochemical events within and between brain cells.  In theory, a super-neurologist could identify exactly what happens in a child’s brain when the child learns that two plus two is four; or what happens in a person’s brain when he/she becomes depressed or happy or plays the piano, etc… But the key phrase here is: “in theory.”  This is because, firstly, the complexity and miniaturization of the brain’s circuitry probably precludes the possibility that this kind of detailed super-analysis will ever be feasible. Secondly, and more importantly, a detailed micro-analysis of an event can never capture the kind of qualitative factors that emerge from a macro-analysis.

Take, for instance, the action of a five-year-old boy kicking his teacher in the shin.  Let us pose the question:  Why did he do that?

Our super-neurologist – in theory – could give us a complete account of the entire neurochemical sequence, from the activation of the first sensory neuron to the activation of the last muscle fiber.  In theory, this account, which would run to millions (perhaps billions) of words, would, if accurate, constitute a complete and accurate answer to the question posed above.

A psychological assessment of the incident, however, might conclude that the boy had been raised in a violent home, had never been trained in effective anger control, routinely reacted violently when confronted or given instructions, and that the teacher had told him to stop running around the classroom and to sit down. So he had kicked her.

A sociological perspective might note that the frequency of such attacks in classrooms was increasing generally, and might note associations between this kind of violence and parental conflict, unemployment, cultural background, etc.

The critical point here is that although each account is describing the same incident, there are qualitative differences between them that are critically important.  The neurological account, no matter how complete and thorough it is, could never capture the uniquely human dimensions of the interaction, any more than the psychological account could capture the extraordinary complexity of human biology.  The issue here is not which account is correct, but rather which account is more suited for a given purpose.  If the purpose is to understand human biology, then the neurological account is more helpful.  But if the purpose is to understand the child’s actions and develop corrective measures, then the psychological account is clearly the preferred approach.

And this, of course, takes us straight to the heart of the psychiatric hoax:  that all significant problems of thinking, feeling, and/or behaving constitute brain diseases and are best ameliorated by modulating neurological activity.

Which in turn takes us to Dr. Reidbord’s conclusion in the above quote:

“All psychopathology can be reduced to aberrant electrochemical events, i.e., brain disease.”

And unlike his earlier premises, this conclusion is false.

The best way to illustrate this fallacy is with some examples, but first let’s clarify the language.  “Psychopathology” is a complex term, subject to diverse interpretation.  So rather than try to define this term, let’s use the APA’s Diagnostic and Statistical Manual as a starting point, and accept, for discussion’s sake, that any “diagnosis” or “symptom” listed in the manual constitutes “psychopathology.”

Childhood temper tantrums, for instance, are listed in the DSM as “symptoms” of oppositional defiant disorder, disruptive mood dysregulation disorder, and intermittent explosive disorder.  Therefore, according to Dr. Reidbord, temper tantrums of the severity and frequency specified for these “diagnoses,” “can be reduced” to aberrant electrochemical events.  The phrase “can be reduced to” in this context clearly means “can be conceptualized as,” or “are caused by.”  And the phrase:  “Aberrant electrochemical events, i.e. brain disease,” clearly means:  a malfunction in neurological equipment.

But in fact a child can acquire the habit of throwing temper tantrums without any neurological malfunction.  Generally speaking, there are two principal ways in which a child can acquire this, and other, habits: learning from results; and learning from imitation/coaching.

LEARNING FROM RESULTS

If a child throws a temper tantrum, and the tantrum produces a positive result (e.g. a parent yielding to his demands), then, other things being equal, there is an increased probability that temper tantrums will become habitual, especially if they continue to produce the same kind of outcome.  This is not a function of aberrant electrochemical events in the brain cells.  In fact, it is exactly the opposite:  a perfect example of the normal human learning apparatus operating flawlessly.  It is not an example of something going wrong in the brain, rather it is an example of something going right.  We humans learn from the results of our actions, an obvious fact that has been verified experimentally countless times, and in addition accords perfectly with common sense and general observation.  And we acquire functional, productive habits in exactly the same way and by means of the same cognitive apparatus as counter-productive and problematic habits.  Acquiring the temper tantrum habit is particularly easy, in that babies are born with an anger apparatus which needs little encouragement to express itself in rage and aggression.  In fact, the opposite is the case:  teaching anger control is the challenge.

LEARNING BY IMITATION/COACHING

Imitation is another major component of our normal learning apparatus.  The child acquires skills and habits through imitating, at first his parents and siblings, and later individuals outside the home.

It is self-evident that through imitation and coaching a child can acquire habits that are useful and helpful; but it is equally obvious that he can also acquire habits that are destructive and counter-productive.  Through imitation a child can, for instance, learn to fear objects that are dangerous, but through precisely the same mechanism, he can learn to fear harmless objects such as spiders, closed-in spaces, open spaces, cats, hypodermic needles, air travel, dogs, heights, elevators, social gatherings, etc… All of these fears are “psychopathological” in the sense specified above, but all can be acquired, through imitation, by a person with a perfectly normal-functioning brain, provided the fear in question is being modeled by a significant person in the child’s life.  It is fallacious to assume brain pathology based solely on the fact that the acquired behaviors/feelings are counter-productive or distressful.

Similar observations can be made with regards to every “symptom” listed in the DSM.  Habits of paranoid speech, incessant speech, over-eating, self-deprecating speech, grandiose speech, rule-breaking, cruelty, violence, stealing, suicidal threats, suicidal gestures, apathy, etc., can all be acquired by a person with a normally-functioning learning apparatus, either through learning from results or learning by imitation, or both.  In the absence of specifically identified and credibly causative brain pathology, this is the most reasonable and parsimonious way to conceptualize the acquisition of these kinds of habits.

In his ground-breaking monograph, “The Jack-Roller” (1930), Clifford Shaw provides graphic, first person accounts of how a child can acquire the habit of stealing in this way.  For example:

“On the trips with William, I found him to be a rather chummy companion.  I regarded him, not as a brother, but rather as a boy friend from another home.  He was five years my senior.  He sort of showed it in his obvious superiority.  But I didn’t seem to notice that fault.  He was a ‘mamma’s boy’ at home, but oh, Lord, how he changed on our trips!  He taught me how to be mischievous; how to cheat the rag peddler when he weighed up our rags.  He would distract the peddler’s attention while I would steal a bag of rags off the wagon.  We would sell the rags back to the victimized peddler.  He also took me to the five and ten cent store on Forty-seventh Street, and would direct me to steal from the counter while he waited at the door.  I usually was successful, as I was little and inconspicuous.  How I loved to do these things!  They thrilled me.  I learned to smile and to laugh again.  It was an honor, I thought, to do such things with William. Was he not the leader and I his brother?  Did I not look up to him?  I was ready to do anything William said, not because of fear, but because he was my companion.  We were always together, and between us sprang up a natural understanding, so to speak.

One day my stepmother told William to take me to the railroad yard to break into box-cars.  William always led the way and made the plans.  He would open the cars, and I would crawl in and hand out the merchandise.  In the cars were foodstuffs, exactly the things my stepmother wanted.  We filled our cart, which we had made for this purpose, and proceeded toward home.  After we arrived home with our ill-gotten goods, my stepmother would meet us and pat me on the back and say that I was a good boy and that I would be rewarded”

And stealing is psychopathology:  a “symptom” of “conduct disorder,” “kleptomania,” and “antisocial personality disorder,” but I suggest it is clear that there is nothing wrong with the narrator’s neuro-cognitive apparatus.  He isn’t learning the behaviors approved by the dominant culture.  But he is learning the rules of the smaller group to which he belongs and feels connected.

The habits of thinking, feeling, and behaving mentioned above make perfect sense when viewed from the individual’s perspective, but appear counter-productive and dysfunctional from the perspective of so-called “normality.”  But within the context of psychiatry’s intractable commitment to the medical model, the search for a “diagnosis” precludes any search for meaning or sense in the “patient’s symptoms.”  For psychiatry, the “patient” is “sick.”  His brain is assumed, without evidence, to be broken.  There is no meaning or sense to his “symptoms.”  And in this way, psychiatry has locked itself in a cocoon of comforting but destructive and condescending certainty, which they show no inclination to leave.

. . . . .

At this point, Dr. Reidbord’s paper takes another interesting twist:

“Without elucidating the causative mechanisms, however, this reductionism amounts to little more than political rhetoric.  Calling psychiatric disorders brain diseases serves no clinical or research purpose, it only serves political ends: bringing psychiatry into the fold as a ‘real’ medical specialty, impressing Congress and other funding sources, perhaps allaying stigma.  As a tactic it smacks of insecurity and self-aggrandizement, wholly unbefitting a serious medical specialty.”

To which I would certainly agree, adding only that the reductionism also constitutes an invalid inference, as outlined above.

. . . . .

“Freud’s psychoanalysis acts on brain cells, and ultimately alters chemical bonds in those brain cells.  We could rename psychoanalysis and psychotherapy ‘verbal neuromodulation.’  But to what end?  A reductionistic account of this sort, festooned with pseudoscientific verbiage, has no practical significance.

Brain research is a young field.  It should be vigorously pursued for what will surely be learned.  If history is any guide, many conditions currently considered psychiatric will eventually be explained biologically — and ironically, they will no longer be psychiatric conditions, as was the case with Huntington’s disease, brain tumors, lead poisoning, and many other diseases that now belong to other medical specialties.

Stumping for psychiatry as clinical neurobiology will be justified when basic research in this area affects clinical practice. Until then, ‘brain disease’ is only a philosophical technicality, a spin, to give our clinical work and the institution of psychiatry an air of scientific credibility.  Particularly in light of how diseases leave psychiatry once they are well understood, the field should embrace uncertainty, not preempt it with the premature use of brain disease language.”

So what we’ve got here is an interesting and curious mix of very commendable honesty and professional self-interest coupled with the oft-heard psychiatric assertion that sometime in the future the brain pathologies will be discovered.  In the meantime, Dr. Reidbord contends that promoting clinical neurobiology is not justified, and will not be justified until basic research affects clinical practice.

But, in my view, Dr. Reidbord misses the essential point:  that the “real-illness-just-like-diabetes” assertion has been, and continues to be, widely and avidly promoted by psychiatry, and that clinical practice is already based almost entirely on the false contention that all problems of thinking, feeling, and/or behaving are best conceptualized as neurological illnesses.  It is extremely rare to encounter, or even hear about, a psychiatrist who offers any kind of “treatment” other than drugs or high voltage electric shocks to the brain.  On his website, Dr. Reidbord tells us that his clinical practice “skews towards dynamic psychotherapy” and that he has “a healthy skepticism of commercial influences on medical practice.”  Again, this is commendable but rare.

Dr. Reidbord downplays the practical significance of the “aberrant electrochemical events” falsehood by calling it a philosophical position rather than a scientific finding.  But from either perspective, it is problematic.  From the former it is fallacious (as shown earlier); from the latter it is non-existent (such research does not exist).  Nevertheless, it is widely promoted within psychiatric circles, and is routinely used to medicalize non-medical problems, and to legitimize the use of dangerous drugs to “treat” an ever-increasing range of human problems.

. . . . .

And, incidentally, in another interesting twist in the paper, Dr. Reidbord actually seems to be saying something very similar to this:

“Freud could then have made it a point to declare, as Drs. Insel and Kandel do now, that all mental disorders are biological diseases.  No additional science was required even a century ago.

He didn’t because there was nothing to gain.  The best treatments at the time were psychological, not biological.  There was no grant money at stake, no research agenda to support.  The status and livelihood of early psychoanalysts did not depend on their treatment being biological.”

In other words, if I’m understanding Dr. Reidbord correctly, psychiatry is positing the brain disease concept today because it is good for business.  And in this, of course, he is absolutely correct.  But, ironically, by asserting the falsehood that “all psychopathology can be reduced to aberrant electrochemical events, i.e. brain disease” Dr. Reidbord is himself contributing to, and legitimizing, the hoax.