Two glaring omissions stand out in the recent widely publicized Yale study in the Yale News, titled “Adolescent Brains Develop Differently in Bipolar Disorder.” Using MRI to compare a group of teens with the diagnosis of bipolar disorder according to DSM criteria with a group that did not have this disorder, they found volume decrease in the area of the brain cortex known to be involved in emotional regulation.
The first omission is any mention of the possible effects of medication. While the newsletter does not even mention medication, the study itself does say that the teens carrying the bipolar diagnosis were on medication but that “medication was not systematically studied.” The long-term effects of psychiatric medication are unknown. A study in the Archives of General Psychiatry suggested that one group of drugs, the atypical antipsychotics, which are often used to treat bipolar disorder, might themselves be linked to decreased brain volume.
But perhaps the more glaring omission is anything about the early history, or life story, of these teenagers.
Elegant and compelling research by Harvard psychiatrist Martin Teicher and colleagues demonstrates that mental illness in the setting of what they term “maltreatment” is a very different entity, in terms of course of illness, response to stress, brain structure, and gene expression, than the same DSM-named “disorders” in the absence of these experiences.
Maltreatment is broadly defined as being “characterized by sustained or repeated exposure to events that usually involve a betrayal of trust.”
It includes not only physical and sexual abuse, but also emotional abuse, including exposure to domestic violence, humiliation, and shaming as well as emotional and physical neglect. The incidence of childhood maltreatment ranges from about 14% in one-year prevalence to 42% in retrospective reviews covering the full 18 years of childhood.
The way maltreatment is defined has great significance in the way we think about the connection between childhood experiences and adult mental illness. The word “trauma” itself may convey a kind of “not me” response, but when the term is defined in this way, we see that these experiences are, in fact, ubiquitous.
This research shows that it is meaningless to talk about mental health disorders, as defined by the DSM system, without knowledge of this early life experience.
But perhaps more importantly, the language we use has great implications for treatment. The Yale study authors recognize that the brain is “plastic” so prevention is possible. But without recognizing the role of early life experience in the development of brain abnormalities, the treatment might very well end up being a drug. Broadening our understanding of the cause of the brain abnormalities, as Teicher’s work demonstrates, shows that true prevention lies in supporting young families and intervening early in families where children are at risk for experiencing maltreatment.
Teicher recommends starting with the way we name these disorders:
We propose using the term ecophenotype to delineate these psychiatric conditions. We specifically recommend, as a first step, adding the specifier “with maltreatment history” or “with early life stress” to the disorders discussed here so that these populations can be studied separately or stratified within samples. This will lead to a richer understanding of differences in clinical presentation, genetic underpinnings, biological correlates, treatment response, and outcomes.
The Yale study, tellingly published in the journal Biological Psychiatry, gives the impression that these “disorders” are biological in the way that, to use a frequent comparison, diabetes is. This view is a disservice to our humanity, to the way our lives have meaning because of our relationships with others and the stories we tell. The first and critical step in prevention of “bipolar disorder” is to recognize that these stories exist, and to make space and time to hear them.