1BoringOldMan invited me, after I commented on his site that I was uncomfortable – in a vague way – when he wrote about Schizophrenia, to elaborate. In several posts (here and here), references were made to “A list” conditions – always including Schizophrenia – that correspond more directly to biomedical conditions than the vast majority of diagnoses in the DSM. A number of years ago, if I had made a list like that, Schizophrenia would have been included. But when I do that thought experiment now, my list remains blank.
When I finished my training in psychiatry, it was clear to me that the concept of depression was amorphous. The kinds of people who would fall into the category of Major Depressive Disorder were so varied as to make the term almost meaningless. The various explanatory hypothesis for the causes of their troubles were broad, ranging from childhood trauma to unconscious conflicts to recent life stresses to abnormalities in their neurotransmitters. I found it confusing and frustrating. Although some of these explanations may be valid, I did not have an accurate way to apply a particular explanation or set of explanations to any given individual. In supervision and discussions with colleagues, everything was on the table; there seemed to be a problem with quality control.
At that time, I was not as confused when it came to the people I met who were experiencing problems that I label psychotic – hearing voices, having beliefs that did not appear to be true, having confused thoughts. The conditions – as manifested in different individuals – did not appear to be as varied. I was more comfortable with the categorizations of Schizophrenia and Bipolar Disorder. I was more comfortable using a disease model to understand their problems.
Over time, my thinking on this has changed. The easiest way to express this is that I am now as muddled in my thinking about the nature of psychosis as I am on just about everything else in psychiatry. After a career of spending my days talking to people who hear voices or have beliefs that no one else shares or have a confused or disorganized manner of communicating, I see more variation among them than similarity. People who “have schizophrenia” are asocial? Well how does that comport with the vast social network so many of the people I work with have? People diagnosed with Bipolar Disorder have episodes of illness interspersed with periods when they are symptom-free? So how does that comport with the fact that so many of these people struggle to some extent in between their so-called episodes? I have been told many times by colleagues something along the lines of “Well I think he has Schizophrenia but he is so social.” Or, with one of the worst phrases uttered in our field when a person with, let’s say, psychosis remains troubled in some way after taking our drugs, “I wonder if there is some Axis II going on here?”
But equally important is the observation that the line that I thought demarcated psychosis from other states of consciousness is at best a big, blurry, and indistinct smudge. This has been an area of curiosity and interest for me for many years. What is the line between religious belief and religious delusion? One person I know once said to me when I asked him about voices, “Well doc, I know you don’t believe this but I am not hearing voices anymore. But God is still talking to me.”
What is the line between political delusion and fanaticism and passionate ideology? Another person I knew initially thought that the government was communicating with him through the airwaves and he was a covert operative, paid monthly through what others thought were his Social Security checks. As he “got better”, I found him one day reading a book about the JKF assassination. It was a book suggesting some conspiracy theory. Was he still ill? Is everyone who believes there was a second shooter in the JFK assassination ill? He showed me a picture of Howard Hunt taken in Dallas in 1963. Hunt was one of the guys who broke into the Watergate complex during the Nixon administration. I was obsessed with Watergate in 1973. Was I ill when I was so preoccupied with Nixon and Watergate? Was I ill when I was convinced that Nixon was involved even before there was full disclosure and then recovered when the tapes were revealed? (Apologies to those of you too young to remember this time.)
Many of us look at the same political system and come away with deeply held but opposite formulations of the situation. Am I mad when I read the psychiatric literature and come up a different interpretation than many of my colleagues? I honestly do wonder, when I spend a quiet Saturday writing this, what keeps me so preoccupied while others can walk away and still feel good about their careers in psychiatry. I do not ignore or dismiss that some ideas are more profoundly disturbing for the individual and those around him than others. My only point is that I no longer see a line that clearly demarcates sanity from madness.
I used to think I could tell the difference between the voices experienced by someone labeled with schizophrenia and the voices of someone who is experiencing a dissociative episode. The former, I thought, would be related to some distinct – probably fixed – altered brain state. The latter due to a more transient and reactive state. The former would best be treated with drugs, the latter with psychotherapy. I even wrote a paper about this many years ago. Although I still suspect that there are a variety of different kinds of conditions or states which might result in a person hallucinating, I no longer feel confident in being able to make that distinction. I am also not sure they are entirely distinct. Maybe they are overlapping. Remember; I admitted to being muddled on this.
I am not someone who finds it useful to make a distinction between the mind and the brain. In my view, we are talking about the same thing but at different levels of abstraction. What we think, feel, hear, and see is all processed through the brain. Some of this is easier to parse out. In my college neurobiology class, I learned from the Nobel Prize winning scientist David Hubel how the brain “sees” moving objects. We saw neurons “react” to the alterations in light. Of course that is a long way from understanding why we think a particular painting is beautiful but it is a start. Even before I moved to Vermont, I knew of one of our most famous citizens, Phineas Gage, whose personality changed after a tamping iron was lodged in his brain’s frontal lobe. This was an early confirmation that things as complex as social comportment and motivation were related to brain function.
I also understand that in all of medicine, the concepts of illness and disease are increasingly amorphous. We tend to think about the clearly defined entities – a strep infection that clears with a 10 day course of penicillin – and forget the many shades of grey. Many of us harbor pathogens that do not make us sick. There is an increasing focus on the microbiome – the many bacteria that live on and within our body. Most of them not only do not make us ill but may promote our health. Even cancer is defined more on a gradient than in a categorical way. There are many lesions in the body that are not clearly cancerous but are also not clearly normal. The notion that there is a clear line between health and illness in this realm is fuzzy – we all have cells that have a malignant potential but our body polices and eradicates them most of the time. Yet, to tell someone who is dying of cancer that she does not have an illness or that the condition that is killing her is a construct begs absurdity.
Does this inform us about how we think about psychosis? Does the problem just lie in a popularly held but antiquated notion of what an illness is? Is it possible that a complex array of events – genetic vulnerability, nutritional deficiencies, life stress – can culminate in one person experiencing some passing phase of mild altered thinking that will resolve with sleep and support from friends while in another person lead to a sustained state that holds on for months if not years? Is a state induced by heavy drug use similar to or different from a state that appears to be induced by intense emotional or physical abuse? Do we really need to understand the workings of the brain to help a person who suffers in this way? Does our message – that this is a disease – relieve guilt and shame or exacerbate it? Is it helpful to have psychiatrists? Are we doctors of the brain or of the mind? Do we just confound and confuse?
Although I end up with more questions than answers, there are people who have helped me gain some clarity. One of them is the British psychiatrist, Joanna Moncrieff. In her books, “The Myth of the Chemical Cure” and “The Bitterest Pills” she makes the distinction between a drug centered and a disease centered approach to thinking about psychoactive drugs. She has written about this on MIA, where there is also a critique of her recent book. The disease-centered approach is predicated on the notion that a) we have identified the specific disease or pathophysiology that underlies a particular symptom or syndrome and b) the drug targets that particular abnormality. The drug-centered approach takes into account that a drug has psychoactive effects. Some of those effects may be useful for some people but, if so, it is not because it is correcting a specific underlying problem. An important advantage of the drug-centered approach is that it is more intellectually honest since we have yet to define any particular diseases or brain abnormalities associated with the various mental states that we label as disorders. It can also help to protect us from minimizing the problems these drugs cause. In the disease-centered model, these problems are considered side effects that need to be tolerated in order the treat the disease. In the drug-centered model, we are more likely to consider all of the effects of a drug and then determine with our patient whether these effects yield more benefit than harm. The disease-centered model has resulted in our forming the premature conclusion that we understand these altered states, and it has contributed to some of us being more sanguine about forced treatment because it allows us to think that – rather than just tranquilizing people to contain problematic behavior – we are treating a disease.
Another blogger whose work I admire is Nev Jones who writes at her site Phenomenology of Madness. Nev and her colleague, Layasha Ostrow started LERN. Nev writes about her own and her family experiences with – to use her term – madness. One of her more poignant posts is here. She is so articulate and careful with her language (among other things, she is philosophically trained) that I hesitate to say more and risk misrepresenting her. She is an activist and a scholar and I find her courageous in her willingness and ability to articulate difficult and sometimes unpopular positions. But if I were to encapsulate the one point Nev has so clearly articulated for me, it is the concept of heterogeneity. Any attempt to label just stomps upon the rather vast conditions or states or experiences – words just plain fail me here – that I observe almost every day.
A friend who has been a helpful editor has commented that I sometimes end rather abruptly. I fear I have done it again. As I said, I am pretty muddled. But this is already pretty long so I hope anyone who has made it this far is not too disappointed.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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