Tuesday, November 12, 2019

Comments by Scott

Showing 42 of 42 comments.

  • Hi Sandra,

    Thanks again for a balanced and interesting approach on this blog from an actual clinician. I particularly agree with your point about treating each person individually. Serious short term risk often has to be balanced against the potential for negative long term consequences. There isn’t an algorithm and like you, I still believe that neuroleptics are helpful for some people and should be used in some situations.

    I wanted to point out something about the Wunderink study which I don’t think was apparent from your post. It is my understanding that the trial participants were treated with a neuroleptic for the first 6 months and once stable were then randomized to either drug reduction or maintenance arms. It is an important point because it means that the data only directly comment on this specific group. That is those with first episode psychosis who become stable for 6 months with neuroleptic treatment.

    I think the study is very interesting and valuable, but accurate understanding of the context in which the data directly apply is critical. It is certainly not by itself evidence that supports not using neuroleptics at all. In fact, one could argue it supports rapid stabilization on neurleptics followed by judicious attempts to reduce dosage or wean off completely. For a balanced editorial on the article see, http://archpsyc.jamanetwork.com/article.aspx?articleid=1707649. Unfortunately many will not be able to access it due to journal paywalls, but some may be able to read it.

    I understand that there are many types of data that people cite in regards to the negative consequences of neuroleptics. It isn’t my intention to get into that, just to point out that this article applies to a narrow spectrum of patients with first episode psychosis who were successfully treated with neuroleptics prior to being weaned off.

  • I’m curious what makes you think that that the DSM:

    “encourages the use of psychoactive medications as psychiatrists’ default treatment recommendation and derogates the use of psychotherapy to help persons in distress” ?

    I understand some of the points being made about DSM, but it is a diagnostic manual not a treatment manual. I wonder about the wisdom of stating that you have never read it and then reviewing the book in a way that seems to misinterpret the nature of the text.

  • Thanks for the article Sandra, I think you are very brave, balanced and patient. I’m certain you are a fantastic caregiver. I have so many thoughts and like those here so little time. However, I think I have to say something, at least on this thread.

    I think the headache analogy is apt. In science one has to categorize in order to attempt to reduce a problem of inordinate complexity into units which can be understood. That’s science, it isn’t people. However, neuroscience finds itself in a difficult place because it’s really trying to understand people, or rather human behavior. This same scientific model yielded a detailed understanding of molecular genetics in our lifetimes and has and continues to revolutionize treatment of human cancer. By trying to apply this model to understanding psychiatric disorders, neuroscience finds itself in conflict with people who suffer from the conditions in a way that cancer biologists could never have imagined. Reductionism in the scientific process though should not be mistaken for reducing or labeling people or their suffering. Reductionism is a tool and only one way to understand, but it has been an effective way to gain mechanistic understanding of natural phenomena.

    I think there are several ways in which the issue gets confused here and elsewhere.

    1) Psychiatrists are not neuroscientists, or at least the vast majority are not. Their understanding of neuroscience is often as weak as that of the general public. It is a huge problem for the field because the principles of basic neuroscience which could be used to build an understanding of psychiatric disorders are largely mysterious to them. So, when a psychiatrist tries to explain or justify biologic underpinnings of the disorders they treat or how drugs might work, their explanation is often woefully misguided, inaccurate and even potentially absurd. This has led to often simplistic explanations which have been stated as facts such as ideas of chemical imbalance. It is worth noting that there is a vast field of basic, academic neuroscience which is founded on understanding how the brain works normally. Many, many of these scientists are academics without ties to pharma or other undue sources of influence. Ideas from these neuroscience fields, largely from non-human research, form the true evidence base from which one could argue that neuroscience offers significant potential to understand psychiatric disorders.

    2) Neuroscience or “biological explanations” of psychiatric disorders should not be set up as deterministic. I agree that the profound plasticity of the brain is amongst the most important insights of neuroscience. This cannot be stated too clearly or too often. The issue keeps getting lost in a false nature vs. nurture dichotomy which infuses the way people think about this issue as much as the false concept of mind-brain dualism. These ways of thinking are so deeply ingrained in our psyches that it is difficult to think clearly about them even when one is trying to. The environment is constantly in interaction with the underlying structures of the brain from the moment the first neuron is born until the existential realization that takes place at the moment of death 80 years later. Anyone who talks about this purely from one or the other perspective should likely be mistrusted. However, I don’t think it is really accurate to say that psychiatry as a field has rejected this idea. It is true that pharmacotherapy has come to dominate modern psychiatry, but many psychiatrists lament this fact. The principles of therapeutic relationship, psychotherapy, influence of trauma and impact of psychological and social environment are still central principles.

    3) Current psychiatric medications are not the result of neuroscientific inquiry in psychiatry. They do work via mechanisms that exist in the brain and perhaps neuroscience has been used to justify their use. However, they were discovered by accident. They were not found or designed based on any neuroscience understanding of the biology of psychiatric disorders. Some of them have been modified by organic chemists to develop new versions, but this isn’t neuroscience either really. The search for neurobiological mechanisms is really motivated by the well documented inadequacy of current treatments (including drugs) and founded on the hope that understanding how the condition develops, persists AND RESOLVES in the brain will provide insight for new treatments. The new treatments could be drugs or psychotherapies or environmental manipulations or biofeedback or any number of things. That is the neuroscience approach, that the better we understand the brain, the better positioned we will be influence the course of mental suffering. The full understanding being that this includes both the underlying substrate of the brain and the environmental impacts on it.

    Okay I’m burnt out now. I apologize for using the medicalized terminology of mental suffering, I know that gets people upset. I feel kind of stuck about this, because it is hard to talk without using these terms, at least for me. I think it’s hard for others here too because we are often just using the same words and putting quotes around them which I think speaks to the lack of alternatives. To say “human distress” also seems not right to me though because it seems to put me in a place where I’m saying all human distress is a psychiatric illness which I don’t at all think. Anyway I get distracted on this topic.

    Thank you again Sandra, I support your efforts to explore alternative models from within psychiatry.

  • Hi Duane,

    I agree that there should be a high threshold for sure. dangerousness to others, dangerousness to self or inability to care for oneself to the point where life and limb are at risk seem reasonable to me. I also of course believe that due process, evidentiary standards and legal rights should be very carefully respected and followed without exception.

    I’m not really making the argument for specific places to put people or interventions here. Just trying to make the point that I think at some point it becomes reasonable to intervene. People keep trying to say that I’m therefore advocating for all sorts of horrible evils (I’m not saying that you are). I’m not saying that the current state of matters is ideal or correct at all – I’m not advocating for that here. Though some will still say that I am no matter what I say.

    I just think it is an important point that we are not just talking about people who are depressed or manic or have psychosis and are acting unusually. These sometimes are not benign states and people can hurt others or themselves. I’m not trying to say there is no alternative either and I’m learning about those alternatives here.

  • Donna,

    Who put the diapers on the people with Alzheimer’s you’ve seen NOT covered in feces? I’d be willing to bet they didn’t diaper themselves. If they were wandering the streets or left alone, you can bet they would have trouble caring for their basic human needs.

    Those individuals because of their illness were unable to care for themselves and thus society or their families were forced to take away some of their autonomy out of compassion. You are providing an example of the same approach I would advocate for anyone who for ANY reason reached this degree of inability to care for themselves. I DO NOT suggest that anyone in that state is disgusting, depraved or deranged as you rigidly insist, I do not think that and it is not the point. I do think that it suggests a profound disability, easily recognized by anyone. I do think that by even the loosest standards of human decency and compassion one is obligated to do something to help that person.

    As to whether this happens or not? Ask a social worker if you don’t trust anyone in medicine. It is convenient to ignore the fact that people suffering from extreme mental experiences can SOMETIMES reach an extreme inability to care for themselves. You suggest I should not bring this up out of decency, but how does one decently or compassionately ignore it? Most people with psychiatry related problems won’t have this issue, thank god. Those that do are likely unable to voice their opinions on this blog. However, they do deserve to be incorporated into any model of “so called mental illness” and what to do about it. Whatever you think about psychiatry, this issue must be addressed by any alternative model. It may feel good to focus ONLY on denouncing psychiatry, but it is not particularly constructive.

  • Hi Meremortal. On the balance I totally agree with you. In fact my overall experience at MIA has been one of really being impressed by the depth and thoughtfulness I’ve encountered. That’s the reason I’m still here, because I really think there are important things to learn here. At least from my perspective, people like Morias, Faith and Joanna have made important points that really have influenced the way that I think, I hope that they would say the same. That would be my goal, but I don’t know if they feel that way and it’s OK if they don’t.

    It has been fixated on a bit that I said I felt unsafe, but no one has threatened me and I did not mean to imply that. There are obviously many ways to think about feeling safe and I didn’t say it to indicate I was afraid of bodily harm. I did not call MIA “toxic”, so again I hope that you didn’t mean the quotes as though you were quoting me. I’m fine with people disagreeing with me and I hope that this is clear from my comments. Truthfully, I’m here because I enjoy the feeling of expressing my ideas in an uncomfortable environment. However, that doesn’t extend to being asked for my address or feeling like I’m being attacked with abusive language or being repeatedly ascribed motivations that aren’t accurate. Mostly that has not been the case and again if I felt like that was the majority of what I experienced I wouldn’t be here.

    It is awesome that MIA exists and it definitely counts as one of the most fascinating and intriguing communities I have ever encountered on the internet.

  • Hi Donna. I believe a careful reading of what I have already said will answer most of the questions that you raise in regards to my opinion. You’re mischaracterizing me though because I’ve said that I do not think of anyone in this state is vile or subhuman. I’ve also I think over and over pointed out that I did not advocate to “rob people of all human rights” or “torture with lethal drugs”.

    I said that the example I gave is relatively extreme, but I don’t agree that it is impossible. I’ve personally seen people in that state many times and not just because of “mental illness” but also because of deliirium or traumatic brain injury or dementia, etc. These types of things do happen with some regularity and there have to be practical solutions. I definitely understand that the vast majority of people labeled with mental illness don’t look like this, but it does happen. When it does I do see it as evidence that the person may be gravely disabled and potentially viewed as needing help. Just because I say that does not mean that I advocate to rob them of all human dignity, forcibly poison them or lock them up forever. I’m not going to get into another debate about this, so let’s just agree to disagree about what I mean or advocate for.

  • What is with the smiley faces is this just fun for you?

    You can be damn sure I didn’t use an SSRI as that would be ridiculous. Yeah I asked the person or rather they have volunteered their thanks to me. Again I ask you what you would do?

    I don’t know your situation at all and I’m not presuming the situation I’ve been put in as a doctor is anything like the situation you were in. In fact I think I’ve given you enough details to demonstrate that it wasn’t. I’m not the European psychiatrist that gave you an injection against your will. I’m sorry that happened and I don’t defend it. I’m just saying come on… be a little reasonable. I did what I would want someone to do to me if I was in that same situation. For what it is worth, I’m talking about a patient who had been hit by a car while riding his bike. He was out of his mind because he had a massive brain bleed.

    Jesus Christ.

  • Look Cannotsay, my intent was not to compare me feeling unsafe here to the feeling you had of being threatened in your experiences in psychiatric hospitals in this or any other country. You set it up that way, not me.

    You’re insulted by me feeling unsafe by the hatred and vitriol I get from you? I really feeling like you’re picking a fight and I don’t see the need for it.

  • Quit putting things in quotes as though I’ve said them, like “European benign paternalism”, I’m not sure if you got that I’m from the US or not.

    I didn’t ruin anyone’s life, I’ve saved lives and prevented morbidity. I’ve had people on my service delirious having suffered serious traumatic brain injury. Swinging at nurses, trying to pull their IVs out and tearing at bandages that cover scalp flaps overlying missing pieces of skull. What would you do? Let that person in a blind unthinking daze hurt other people, maim themselves and walk out onto the street to die? Get real. I’ve given emergency medication to sedate that person and they and their families have thanked me. How dare you with your contempt.

  • Hey Morias.

    Fine we disagree 100%.

    So schizophrenia cannot arise in the absence of trauma? It would be nice if you could provide data that substantiates this.

    I’m glad you refer to your conceptual understanding as a hypothesis because I think that is exactly what it is. Not that mine isn’t a hypothesis too… I’ve tried to provide you some of the evidence that I see as supporting my hypothesis. It is not all twin studies and I’ll get back to that in a second. You’ve explained why you think the evidence is invalid and you’ve offered a set of philosophical analogies that describe alternative scenarios. In the end you’ve also got to provide evidence that what you are proposing is true. Not just that what I’m proposing is wrong.

    For example what is the evidence that all minds are equally resilient? That nothing genetic predisposes to schizophrenia? That no one can experience even mild trauma and still be OK? I mean data, give me data. I get that you’ve got ideas and that you are very smart and thoughtful. You say that I’m being dishonest with myself, I don’t know what you mean, but to me it seems like your view is self-evident to you and I’m trying the one trying to provide data. Give me the data.

    Yeah, we know autism is a bunch of things. I know schizophrenia is a bunch of things and it is a made up category which comprises a check list of behaviors that encompasses a Venn diagram of many overlapping syndromes or whatever. I’m so sick of this part of the discussion. Give me some credit – you know that I know that. There is no way to have a discussion using words in human language without using labels and saying autism is the only one I have that I know means something to you. You want to propose a different word or set of words then fine I’ll use those. I’m sick of having to delete words I’m writing so I can go back and put parentheses around them.

    You say some forms of autism are genetic disorders where we have found the genes. Yeah, I guess. Fragile X has phenotypic overlap with autism spectrum disorders, just like Huntington’s disease has phenotypic overlap with schizophrenia spectrum disorders. How is it any different? They each account for a miniscule percentage of all disorders that fall within those categories. DiGeorge Syndrome is a genetic disorder with phenotypic overlap with schizophrenia. I can go on… Genes can cause symptoms indistinguishable from schizophrenia, genes can cause symptoms indistinguishable from autism. The vast majority of autism and schizophrenia we don’t know the genes or environmental factors responsible, but they both have high concordance amongst relatives based on the degree with which they share genetic material. There is so much more evidence about this than just twin studies.

    The quotes you offer from this paper are EXACTLY what I’m advocating for… That type of scientific process rationally offers the greatest amount of hope for treatments that impact the underlying biology of the disease while limiting side effects or toxicities as much as possible. Problem is that thus far that process has yielded spectacularly few drugs that are in use in any area of modern medicine. Most medicines that we have in any area of medicine were not rationally designed… Doesn’t mean we shouldn’t try, I want us to try. That’s why the process they describe is EXACTLY what I’m advocating for.

    Finally, of course I advocate also for life long neuroplasticity, education, therapy and social interventions which will also alter the substrate that gives rise to psychiatric disorders (regardless of whether their cause is 100% environmental). And, further create an environment in which the organism can thrive given these new tools and the acute stabilization potentially offered by newly discovered medications.

    Sheesh Morias, you know I like you, but we are like ships passing silently in the night sometimes. At least that’s what I think. Note that I did not edit or re-read this rant, please don’t hold me responsible for minor points lacking clarity.

  • Wow, a lot of action. I’m going to start a new post.

    I am not a psychiatrist. I am a neurologist. So you’re all wrong 😉

    I have suffered myself with psychiatric forms of distress and so have those in my family. I’m probably not going to say too much more at this point because I’ll be honest in saying I don’t feel very safe in this space. I’m feeling some hatred for what I’ve said and I do feel uncomfortable.

    Cannotsay: I’ll take the $100 in unmarked 5’s and 10’s, you can leave them at an address I will post as a comment on the next article published on MIA. Just kidding. I doubt it will make much difference to you that I’m not a psychiatrist. For the record though I have not boasted any academic credentials to you and I have never asked you to accept what I’m saying as the “word of god”. Nor have I said anything about “unlimited power”. Along the lines of what Joanna said, please stop continually mischaracterizing what I’ve said. I know that you didn’t ask me to leave, but you’ve used hurtful and severe language and tone. I am here engaging and listening, I think some people welcome that and I stand by what I said, if I think that most people don’t want me here then I will leave. I know you didn’t ask me to leave and I won’t leave just because you wish I wasn’t here. OK?

    Joanna – I think the idea you propose is a good one and it might work well for some people. Probably it doesn’t happen enough. The truth is I really don’t know what to do in these situations which is part of the reason I’m here. I’m curious about these issues legally, experientially, scientificially, medically and philosophically. I do have some ideas, but I definitely don’t claim to know what the answers are.

    As far as psychiatrists not making the decision, they often don’t. In many parts of the country law enforcement officers, paramedics, firefighters and emergency room doctors can also place people on temporary holds. Psychiatrists don’t go out looking for people to hold against their will, someone brings them in, often already legally held against their will. When it comes to forced medication, a lot of doctors will medicate someone against their will if they are thought to be acutely dangerous to themselves or others at that moment. Yeah it’s a judgement call and I’ve made it as a doctor. For example when delirious patients or those with brain injuries are flailing around and trying to leave the hospital. It is hard, and I’ve only done it when I thought someone was going to hurt other people or hurt themselves. I don’t feel good about it and if there is one reason I’m glad I’m not a psychiatrist it is because I’m thankful that is a rare situation in my specialty.

    However, no doctor can just decide to force medications on someone regularly in non-acute situations, at least where I’m from. There are legal proceedings for determining if someone can have a medical procedure or medication given against their will. That is true no matter if we are talking about psych meds, surgery or antibiotics. So ultimately a judge decides. Maybe the judge just goes along with what the doctor says some will say and maybe there is some truth to that. However, the person is entitled to legal counsel and to appear in front of a judge. If we decide that this is wrong, we should decide to change the process from a legal perspective. As Joanna eludes to it is ultimately a political and legislative position change.

    Vanessa – In my mind whether someone wants help or not is almost always the most important question. Sometimes in rare or extreme situations though, I do think people need help and cannot say or are unable to recognize it. Not everyone will agree with that and I can accept that. When I told cannotsay I accepted his/her position I meant it, I think it is extreme, I disagree, but I understand and respect it. I do think society needs to intervene at a certain point and I am NOT SURE what form that help should take. That’s why I asked the question I asked. Not because I thought I knew the answer, but because I don’t know the answer.

  • I can see that you’re really angry at me, but I don’t feel like you’re being fair. Most of your anger seems to be directed at what some of the ideas I’m expressing represent to you. I don’t think it’s a fair characterization of what I’ve said. You don’t know me or what I’ve been through, but I can accept that the issue is a very emotional one for you. I’ve said that I can accept that your position is different than mine, but it doesn’t seem like you can accept that mine is different than yours. Perhaps it is time that our dialogue on this comes to an end.

    I’ve been enjoying learning about how people think differently than me. I find it stimulating and my philosophy is plastic. The least you can give me is I’m here listening to what people have to say. I thought this was supposed to be an open place where people with different views could exchange ideas. I hadn’t gotten the idea that most here want me to leave, but if I do then I will.

  • I agree with Joanna. I’m imagining if it were my choice to let a person leave and go to commit suicide. Let’s say it’s a 19 year old girl who has been traumatized and she says “I’ve got a gun in my car, I want to leave so I can end it all.”

    If it was within my power, how could I let her go? How could I look her parents in the face and justify that if she went through with it. Would I say “well it’s her choice”?

    I understand where you’re coming from Cannotsay with people having a right to end their lives if they want to. But isn’t there room to account for when people aren’t thinking clearly? I just disagree that this is black and white. I disagree that it is simple.

  • I’m not even really sure we disagree all that much Morias. I mean, I’m not sure I entirely follow the whole colors thing, but it seems like you’re willing to accept that a person’s genetics sets up their brain or ‘temperament’ in a way that can predispose them to developing “so called mental illness” under the right circumstances. I understand that you’re saying that everyone is set up for success and only when exposed to the “environmental pathogen” do they get manifest whatever variation on dysfunction they are inclined to. I don’t really disagree with that, I just think that some brains are more resilient. If you expose 100 people to a moderate trauma some are going get severely dysfunctional like “schizophrenia”, some are going to get anxious or turn into a jerk and some will probably be fine. Maybe we part company there, not sure.

    Where I’m pretty sure we part company is that I think some brains are really set up for something like schizophrenia. Or autism for that matter which is maybe cleaner because it happens so early that often there might not be time for anything that could possibly be construed as trauma. My basic point being that at least in some cases you don’t even need trauma or the trauma could be so subtle or minor as to almost defy the characterization of being traumatic.

    Hmmm… Autism. Now I’m curious, how do you think about autism Morias?

  • So we as a society could do it the way you suggest. Despite a reasonable concern that the person may harm someone else, die because of not taking care of themselves or at least continue to lead a miserable existence of suffering – We can say just let them be until they break the law.

    I really disagree that it is “not a very hard question” though. I think it is an incredibly challenging question. For one thing that guy in the mall with the sword is going to get arrested. If there is no other option, law enforcement will act and they will take him to jail. The jail has their own psychiatric evaluation system, but let’s say that doesn’t exist. He hasn’t committed a crime yet (though I’m sure the police can come up with a crime – weapon in public, resisting arrest, threatening in public). Anyway, it’s not a “real crime” and he would eventually be released from jail.

    But, I would also argue that there is a good chance he ends up back in the mall with the sword or somewhere else. Then the whole thing starts over again which sucks. He also then might eventually commit an actual crime. Hopefully he doesn’t chop someone with the sword, but he could. Probably more likely he trespasses or assaults someone or breaks something and then he really is going to be in trouble…

    Now, he could spontaneously get better or maybe he has a friend who nurses him and he recovers somewhat. But I don’t think it is the most likely scenario. He may stay that way chronically or he could get attacked because he is so vulnerable. Maybe he lives a miserable life for the next 5 years and one day gets hit by a bus and dies.

    You can most definitely argue that if he doesn’t want help, leave him alone. You can say that there is no higher principle than human autonomy. But, you really have to be OK with the possibilities I described. If you are, then that’s fine I understand where you’re coming from. I just don’t think that’s an easy or obvious choice at all.

    Now, you say that I “propose” that:

    “some shrink locks in that person indefinitely, regardless of whether that person had committed any crime whatsoever, forcibly drugs that person with poisonous drugs and labels that person “crazy” for the rest of his/her life.”

    But I didn’t really propose that. I understand you might have been assuming that is what I propose or you’re just saying that is what people propose on the extreme opposite end of the spectrum from you. I’m not trying to be snarky, I’m asking please not to typecast me to everyone unfairly.

    I also understand what I’m hearing from most people, which is what they don’t want. They don’t want the person ending up in the hands of evil psychiatrists. They don’t want them forcibly drugged with poison. They don’t want them labeled or locked away for the rest of their lives. Of course I get that.

    There are a lot of other options and I have heard a few ideas. I’m just trying to figure out from a practical perspective what people think should happen. I do think there has to be some intervention though. I understand that forcing anything is a really concerning concept and humiliating and stigmatizing people is horrible. But, I don’t think a compassionate society allows people to suffer like that. I don’t want to force anyone to do anything, but at some point, for people’s safety and out of human compassion I think you do have to do something. And I think most people outside of this site think so too. A lot of people with “so called mental illnesses” already end up in prison. If there isn’t an alternative, then how is that any different than criminalizing “mental illness”?

  • Some people despite having quite severe and disabling mental phenomena or “psychiatric disorders” don’t have the experience of having a lot of trauma in their lives. They know something is wrong, but they just don’t see it as having been the result of something that happened to them. Some of those people still want a name for what they are experiencing and to try to have an understanding of it.

    I’m just pointing out that there are other opinions amongst those who have “so called mental illness”. MIA is not the unanimous voice of everyone who has these types of experiences. Not discounting the feelings and beliefs of those on here… just saying some people feel differently.

  • Here is a link to a really interesting article on catatonia, http://archpsyc.jamanetwork.com/article.aspx?articleid=210437

    I don’t think the phenomena of catatonia can be dismissed, at least not entirely, like that given that it is quite common in “psychiatric illness”. The variant I described is called malignant or lethal catatonia. I think you could be right though! and maybe it is something like encephalitis lethargica. I think it’s a good thought.

    I’m also glad you brought up NMDA receptor encephalitis as I was just thinking about that. It is a very interesting condition which was only “discovered” about 6 years ago. It was around before that of course, but probably often got labeled as schizophrenia or brief psychotic disorder or catatonia or whatever. Was it a mental illness and now it is not? I think it is still a “mental illness”, just the same as it was before, now we just know something about the physiology.

    The thing is that I think you’re really making my point for me. Here we are shaving away at the impenetrable block of “the so called mental illnesses” which are not illnesses and supposedly do not have a physiologic basis. Maybe some catatonia is encephalitis lethargica and maybe some schizophrenia is NMDAR encephalitis. I still say it is a “mental illness” or whatever I’m allowed to call the things that we’re talking about. How much of “mental illness” have we accounted for with these two things? I don’t really know, not a lot obviously.

    Then again NMDAR encephalitis has opened the doors to a whole new class of mechanisms that could explain some mental illness. Since that time there have been discoveries of a number of other autoantibodies that cause neurological or psychiatric disease. How much of “so called mental illness” will ultimately be accounted for by this type of mechanism? who knows… maybe it could be 2%, 5%, 10%. We will really won’t know for a while.

    Here is my point though: If these things were psychiatric illnesses and now we know something about how they work, how can you be so sure that a physiologic basis won’t eventually be discovered for 25% or 50% or even more of what we are calling “so called mental illness”. Will they no longer be psychiatric illnesses? I say they still are, but if people are uncomfortable with that, fine maybe they can be neurological illnesses now or we can invent a new category of medicine to treat the illnesses that psychiatry treats now because psychiatry is too contentious of a name. It’s a little like doing away with the term schizophrenia which is fine too since we all know that schizophrenia is actually many different disorders (one of which is perhaps NMDAR encephalitis). This is what Tom Insel meant when he said DSM categories lack validity – schizophrenia is not a term that really does much to distinguish meaningful categories of disorders. It just lumps everything together and obscures the fact that there are many versions with different underlying mechanisms.

    Anyway, I’m just going to say this again. I just don’t understand how anyone can be so certain that other psychiatric phenomena won’t eventually have a physiological cause identified. I’m not saying they will all be autoimmune encephalitis type disorders, but something, anything. Something you don’t even know about yet. And that doesn’t mean the social environment isn’t going to matter we already know that social influences and trauma are critical, but that could interact with whatever the “disease” mechanism ends up being. Or induce the mechanism directly for that matter.

    So I’m not wedded to any of the names really. If, theoretically, I could prove that 50% of psychiatric illnesses had a physiological cause then I could rename them all and take some doctors and train them up in the new treatments for these new disorders and then call them “Mental Neurologists” or something. Sorry, I’m getting a little silly. Time to get some sleep.

    Peace 🙂

  • Hi Faith, Vanessa and Cannotsay,

    I just wanted to say that I’m not proposing to label anyone here or everyone with diverse experiences or extreme mental states as having an illness. I wouldn’t say that about anyone unless they were someone I knew well. I really don’t know where to draw the line on what is a mental illness and what isn’t. It just seemed like I was hearing that no matter what the experience or how disabling it might be it could never be considered as the person being sick.

    I don’t agree with that because I think people can have illnesses that affect their mind. Some of them are things like Huntington’s disease which I think most people would agree is a real illness. A person with Huntington’s disease can develop psychosis and really no one understands the mechanism. On the other hand someone can develop psychosis and become catatonic and we know even less about that than we do about Huntington’s disease. Then again some people hear voices and maybe they kind of keep to themselves but are otherwise OK or maybe someone just lives their life in a completely different way than I can understand. I’m perfectly comfortable with saying some of that isn’t illness.

    When it comes down to what is and what isn’t it shouldn’t have to do with “normal” it should have to do with suffering and not functioning well. In my opinion somewhere along that continuum there is profound suffering and dysfunction and it is reasonable to say the person is sick. If the person doesn’t want to say they are sick then I guess that’s OK, but in the severe cases they probably still need help (in whatever form) and I think they should get it. I really don’t see that as a moral judgement either, I see it as a compassionate perspective. In my mind if you are sick you need help to get better, it doesn’t mean you are bad or defective. And that goes for me too if I am sick.

    I can understand that some people think the label is unproductive because it connotes that something is defective and you’re stuck that way. That isn’t how I think of it, but I get it. I don’t like the idea that there is something defective about me either. That’s a personal thing, how you view the circumstance if you find yourself in it. For a lot of people it probably does help recovery to have an alternative perspective. But many are suffering and their mind is clearly not functioning well. Many are at risk of hurting themselves or other people or dying because they’re not drinking water even. If that person says I’m not sick I’m just fine this way, leave me alone – how can I in good conscience go along with that? I have to say I disagree.

    *** I want to propose one final scenario – at the risk of people here calling for my beheading. And it’s a serious question and I really want to know what people think. Let’s say a someone walks into a crowded mall, they are swinging around a large sword and they are dirty, covered in their own feces. People are freaked out and the police are called. The person isn’t aggressive, but they are confused, talking nonsense. They seem frightened and unpredictable. The police believe that people can have illnesses of the mind and so they don’t arrest the person, they take him to the local emergency room which seems like the right thing to do to them. A doctor sees the person and determines that they aren’t on drugs and there is no evidence of “medical” illness except dehydration and malnutrition. The person is trying to leave. What should we as a society do in this situation? ***

    I’m curious about two types of answers, 1) practically given the reality of our world as it is and 2) in an ideal world with limitless resources. It’s a fairly extreme case and I know it doesn’t match everyone’s experiences. Still, this type of stuff happens a lot at public hospitals in urban areas and I think it is a reasonable question. It ignores all the distraction about illness, and DSM and mental death industry and biological causes and neurodiversity. It is just a practical question.

    It’s a tough call. You can let them go, but they might hurt someone or get beat up or die from exposure. Who knows. You could keep them, but not give them any medication as someone suggested. What if they don’t get better? What’s the humanitarian thing to do? I’m not posing it as an impossible question, I know people have ideas and I’m really curious to hear them.

  • Hi Faith, I wanted to respond to the catatonia thing briefly and no room above.

    You are exactly right, what I’m describing is exactly like neuroleptic malignant syndrome except that it was described long before neuroleptics existed. There is also neuroleptic malignant syndrome a rare but severe side effect of antipsychotics. Fascinating that the disorder and the a medication can both lead to such similar phenomena. You are also right that at least in this extreme form called ‘lethal catatonia’ or ‘malignant catatonia’ it is rare. I was just, as an exercise, trying to think of an example of a psychiatric condition which would be difficult to say was not an illness. I thought this might qualify because of it’s physical findings and potential lethality.

    I’m not sure I agree with you that because the reference is from the late 80s it is going to be invalid. I mean it is a reported phenomena, it’s not a reference which posits a mechanism or something that might be out of date. The reports could be false I guess, but we aren’t talking about one report and it seems pretty widely accepted that this is an extreme presentation of schizophrenia.

    Anyway, thanks for your civil responses, I’m enjoying the conversation.

  • Hey Morias – Always a pleasure… Thank you so much for your very reasonable and substantive reply. I was thinking about going underground and observing from afar again. I realize I have to be meticulously careful about what I say here as it isn’t my intention to anger people or hurt feelings.

    I follow what you are saying and it is quite clever. I would still say if the twins with temperament “s” are ending up with “S”, schizophrenia at a higher rate than the rest of the adoptees then it indicates heritable factors influence the development of schizophrenia. In other words, heritable factors influences the form of the dysfunction in the setting of the environmental stressor. In your model the causality is 100% environmental regardless of this and it is internally consistent. I guess my main thought is that it strikes me as quite a bit of mental gymnastics to put the causality 100% in the environment. I’ve been trying to avoid the word “cause” because, as you know, I don’t think the causality is 100% genetic or 100% environmental. So, my personal opinion is that the model you propose isn’t likely, but it’s definitely possible and I appreciate that it is at least in theory falsifiable.

    As you know there isn’t going to be a study in the past or future that is perfect and indisputable. My interpretation of the data would just be that if the if the separated twins are 50% concordant and only 10% of the adopted non-twins develop the disorder it really seems a striking result to me. Sounds like maybe you agree, but just put the causality regardless entirely in the environment and the genetic background just influences the form the dysfunction will take. I will have to look more into the size of some of the more recent twin studies. I know there are some really large and detailed data sets from Sweden which people have been looking at recently. It might be that schizophrenia isn’t the best set of phenotypes to look at in addressing the question. There is one recent large study of twins (hundreds of twin pairs) reared apart that looked at the heritability of regular tobacco use which is interesting (Arch Gen Psychiatry. 2000 Sep;57(9):886-92). http://www.ncbi.nlm.nih.gov/pubmed/10986552.

    I do think the issue is of more than simply academic interest, but I think we will have to save that discussion for another thread. Good discussion.

    Also: I think that psychosis of the severe form I described has been around a lot longer than antipsychotics. So I understand that you have a concern that medication in the long run could worsen psychosis, but psychosis is also still a real thing that can be profoundly disabling. Anyway, I brought the example to bear on a point I was trying to make about whether the person could be considered sick or not.

    Haven’t read AoE yet… Don’t tar and feather me, I still plan to read the bible. 😉

  • Dear Suzanne,

    I think you’re being unfair. I admitted that I may have been unclear in my original statement. Then I clarified what I meant. You seem to be ignoring that.

    I didn’t dismiss the article because it was poorly written. I summarized my interpretation of what they were saying and explained why I don’t agree that this disproves my point. I thought it was pretty clear and reasonable.

    The reason I said it was poorly written is because I noticed in the abstract it says something like, “people with schizophrenic.” I just thought it was kind of a blatant typo for a published article. I guess I should have said it was poorly edited. Anyway I guess I set myself up for that.

    Your study actually supports my clarified point which is that the rate of concordance is 50% in identical twins reared apart. They interpret that data a little differently than I would, but now I’m repeating myself again. It’s unfortunate I wasn’t more clear in my original statement – I’ve read it over again several times and I think I meant to say something like ‘RISK’ instead of ‘RATE’. Anyway, I think I’ve clarified what I really meant.

    I’m not getting the sense that you really want to reasonably debate the idea. My final point is that what you referenced is not “a study” it is a review which does not present new data, but provides an interpretation of previous data.

  • Perhaps I was unclear… I guess I have to spell everything out carefully.

    I do not think nor was I saying that genetics causes schizophrenia or any other mental illness. If I was trying to say that I would have said that identical twins are always concordant for schizophrenia. What I’m suggesting is that if one identical twin has schizophrenia then the other one is more likely to have schizophrenia than would be expected based on the rate of schizophrenia in the general population. If this is true it suggests the presence of a heritable factor. NOT that it is caused by genetics or that it is 100% inheritable. In fact that it is something like if one twin has schizophrenia then 50% of the time the other twin also has schizophrenia. Doesn’t really matter what the actual number is as long as it is higher than the rate of schizophrenia in the general population. If this is true for identical twins separated at birth it largely eliminates the potential confounder of a shared schizophrenia inducing environment.

    I do not discount the influence of social or environmental causes on the development of schizophrenia or any other mental illness. These are obviously huge influences on the development of mental illness. The presence of heritable factors does not mean anything about being pre-determined or there not being an influence of environment.

    The article you reference is a brief review from 1982 which is not particularly well written for one thing. The article also finds 50% concordance in referencing a very few small comparisons of twins reared apart, similar to the number I mention above and suggesting heritable factors. They appear to find a way to discount from the data set most of the concordant twin pairs for methodological reasons. It seems like they think they weren’t separated from each other early enough to be valid. I still think these data strongly suggest heritable factors. Regardless, it is a minority opinion in the field to say the least. There are much larger studies which address similar questions of heritability in mental illness and other traits which I think overall strongly implicate heritable factors. The reference definitely comes nowhere close to proving that heritable factors play no role in mental illness whatsoever. I will wait anxiously for a study that provides evidence in that regard and not just an opinion that the idea is false or an explanation of why other people’s work is invalid.

    For most ideas it is not hard to dig something like this up (see global warming). It is the weight of the evidence taken as a whole which must be interpreted. That is how science works “cannot say 2013”. If I were saying something as ridiculous as schizophrenia is a 100% genetically determined and 100% penetrant condition, then all it would take is one counter example to prove me wrong. That is not what I’m saying and it is not that simple.

  • Well I can’t address all that, but here are a few points:

    1) Saying that DSM diagnoses have poor validity does not mean that there is not a process underlying the phenomenon.

    2) If you want to say renal dysfunction or impairment instead of kidney disease I think that’s fine. I do think you are mistaken that “actual diseases” have medical treatments that correct the actual underlying dysfunction. In reality I would say almost all medications only correct problems symptomatically. Often the underlying cause of the disease is unknown or it cannot be corrected. Surgery is one of the few fields in medicine where causes of disease are actually fixed.

    3) The variant of catatonia I alluded to is a clinically reported phenomena which is called malignant or lethal catatonia. Feel free to destroy the validity of this. (Am J Psychiatry 1989;146:324-328, for example) I am concerned though that the comment about destroying the validity of anything I bring up indicates that your position is that you cannot be wrong about any of this no matter what I reference.

    I understand this is a very personal issue for you and I’m truly sorry that you’ve had such horrible experiences. I’m certainly not saying any of this to trivialize anyone’s experience with “mental illness”. I’m mostly just curious.

  • Please clarify Morias. You dispute that such studies exist? Or you think that they are fatally flawed and do not bear on the question?

    I’m not so dull as to think there is not a pre-packaged answer as to why twins reared apart data do not demonstrate anything useful. I’m just curious what flaw is supposed to be.

    The real problem here is that I don’t think equal skepticism is being applied on both sides of the problem. Where are the studies that prove that there is no heritability for psychiatric disorders?

  • What about studies of identical twins separated at birth who end up having exactly the same rate of a mental illness despite having been raised in completely different environments?

    I say mental illness, but you can call it what you want. I think it is reasonable to call it this way because whatever it is causes serious problems in the lives of people with the difficulty. Difference is fine, but disorder only connotes that the difference leads to function that is less healthy. When people’s kidneys don’t function within the range of normal we say that they have kidney disease we don’t say that it is a manifestation of renal diversity.

    I can understand not wanting to uniformly label all these states as diseases so I’ll call them whatever you want. I’m not meaning to be disrespectful. It seems you all still call it the same thing, you usually just up quote marks around it. So it seems you are having the same difficulty. I just don’t understand why when we talk about the mind a completely different terminology should apply.

    When I see someone with severe psychosis, disheveled, unable to speak, unable to take care of their basic human needs I do think they are sick. They certainly seem more sick than someone with a mild kidney disease. Why is it so wrong to say they are sick? When in that state the person could easily look indistinguishable from other “real illness” states. Alternative explanations would include delirium or a brain tumor for example.

    I’d also point out that these “mental illnesses” can also have physical findings similar to other “real diseases”. For example, schizophrenic catatonia which has motor findings like rigidity (similar to Parkinson’s disease), sometimes can have fever and can even be fatal in the absence of intervention. How can that not be a disease? I understand these are relatively extreme examples, but I think the movement here does damage to itself by not recognizing that things are not so black and white. Maybe some people that hear voices are neurodiverse or having a response to severe struggles in life that should be considered within the range of normal human experience. I can see the viewpoint that labeling that as a disease is misleading or does a disservice to the person. But surely there is a range of severity and on one end some of this is organic disease. The question in my mind is where to draw the line and I agree that it is not clear. But then again maybe everyone here disagrees that there is a line at all.

  • The other thing I don’t necessarily get from all of the posts on this forum is what one should do with an acutely psychotic patient. If someone comes into the emergency room in a horrible state, unable to care for themselves and/or a danger to themselves and others what do we do?

    This is extremely common in many hospitals and I just don’t know what the alternative is. Psychotropics do seem to work for acute stabilization from what I know. I’m curious what the recommendation would be both theoretically (in an ideal world with limitless resources) and practically (in a poorly funded public hospital). It’s a serious question and I am curious to know what people think.

  • I think it is important to realize that untreated psychosis may also lead to long lasting plastic changes in neural connections. One theory of the fixed delusions that often accompany chronic psychotic illness involves similar plasticity. Misperceptions of reality in early psychosis if they continue could coalesce into more permanent changes in connectivity underlying delusions. If we assume that both D2 blockade and psychotic illness represent shifts away from a preferred state, they will both result in longer term homeostatic changes in neural circuits.

    Perhaps Sandra will attempt to address this in her next post.

  • The recent article by Smoller et al that you are referring to has nothing to do with epigenetics. Thus use of neuroleptics cannot explain their findings.

    There is a problem when people who don’t understand the science use it to support and refute their preconceived idea as it is convenient.

  • The recent article by Smoller et al that you are referring to has nothing to do with epigenetics. Thus use of neuroleptics cannot explain their findings.

    There is a problem when people who don’t understand the science use it to support and refute their preconceived idea as it is convenient.

  • By the way, you say “If you try to look at the disorders as discrete entities things will get more and more complex until they become absurd – which is where I’d say psychiatry is at the moment”

    That is where psychiatry is at the moment I agree. It could go either way. I think we will be able to identify some discrete entities or at least categories which are similar enough to be meaningful. I can’t prove it yet, that is just what I think.

  • Oops I meant I will read Anatomy of an Epidemic, not the other one.

    I’m going to try to keep this brief and to the point for the sake of my sanity. We are actually not that far apart in our understanding in some ways and I it seems we might be butting heads over semantics in some ways. However, there are other ways that you appear to be drastically misinterpreting my position and I believe drawing flawed conclusions.

    In principal, your gene G and disorder D analogy looks OK to me. It could work that way.

    You say, “this gene gives you a propensity to develop disorder D”, so they start giving everybody with gene G (whether they have been exposed to contaminated food or not) medication which somehow ameliorates the symptoms of intoxication but does not prevent intoxication if exposed to contaminated food.”

    This is a gross mischaracterization of anything I’ve said. I don’t know who “they” are, but I have never proposed something like that. I am not saying that if you have whatever gene variant then you should get a medicine even if you don’t have symptoms. The disorders are not that simple and it won’t make sense to treat people in this manner.

    You say, “at this point, if you are still thinking in terms of genetic disorders things get very complicated and nothing makes any sense anymore”

    Just because things get very complicated, it does not follow that nothing makes sense anymore. It does not mean that the idea is wrong either, you note that the environmental influence is also complex, but you readily flatten it to a concept like trauma in order to discuss it or to the concept of a toxin in your analogy. That’s fine, it is what we have to do… Why don’t you have an issue with the complexity of how all the different variants of trauma affect all the diverse variants of disorders? Why is that concept not equally complex and therefore doesn’t make any sense and is therefore wrong?

    Also, why should your analogy not be interpreted in the opposite direction? The exposure to the toxin leads to a propensity to develop disorder D, but only those with gene G actually develop the disorder, etc. This isn’t really exactly what I think, I’m just saying that we are talking about associations and the arrow of causality can not be determined with enough precision to say A CAUSES B over B CAUSES A. Really I’m totally fine with the way you set up the interaction of genes and environment in the analogy and if you read what I’ve written already you will clearly see that I have not said that I think heritable factors CAUSE schizophrenia, etc. I’ve said that they “contribute” to its development and this is also true in your analogy. Here is where I think this intellectual hula hooping is more about semantics than anything else.

    I do think yours is the more extreme position though, because you steadfastly believe that the arrow of causation always originates in environment. My position is that sometimes it originates in the environment, sometimes it originates in the building blocks of brain (“genes” if you will), but vastly more often it is probably not as simple as one or the other. I’ve already given one example where it almost entirely originates in a gene, Huntington’s disease. If you have the Huntington allele you will develop a psychiatric disorder. I’m certain there is an equally extreme position on the environmental side where if you are exposed to X, 100% of the time you develop psychosis. Don’t get me wrong though, I think those are the extremes.

    You seem to be under the impression that no gene variant can exist which is not fundamentally healthy for the organism. I apologize if I’m simplifying your stance, but something like this seems to be at the root of your ideas. What about the Huntington’s allele? How is that a good version of a gene to have? If it reduces reproductive fitness then YES, it should be selected against. However there are many ways in which it can stick around despite negative selection. I won’t get into all the ways that could operate, but suffice it to say “bad genes” (or at least unhealthy variants of good genes) do exist in the population. I gave you one example in Huntington’s and I can give you a dozen others off the top of my head. Mutated versions of genes also arise de novo at a certain rate in populations mind you, along with variations in the copy number of certain genes – this definitely causes disease. Just pointing out that the system does not need to indefinitely maintain unhealthy variants as they are introduced to the system.

    You say, “Now, would you say that gene G codes for a disorder? No, it doesn’t, in fact in normal circumstances it actually makes you healthier since you get more nutrition from the same food.”

    No it doesn’t code for the disorder in your example. I’ve never said anything so simplistic, except perhaps in my Huntington’s and even then I would not say something as obtuse as that it codes for the disorder. It codes for RNA. I’m not saying that your example can’t work, but its just one of a range of possibilities and I do not think it ALWAYS works that way. See above.

    Regarding diabetes – I wasn’t trying to say kin selection explains diabetes, just that there are complex models of how genes can be selected for on a population basis. Forget about kin selection. Diabetes on the other hand… I do not see how you can say this has no role as an analogy. Diabetes in part probably works exactly like the analogy you proposed.

    In your model: Gene G leads to better uptake of nutrition, but in an environment with the toxin has the “unintended” consequence of leading to higher toxin uptake leading to disorder D.

    In my diabetes model: genes lead to the better uptake of nutrition in the environments where they were selected for, namely those with scant food resources. These genes are greedy and help suck up and store energy. Now put someone with those genes in an environment where you have the toxin. The toxin is easy access to cheap, high energy foods (McDonalds, soda, whatever). Now the genes lead to disorder D (D=Diabetes), those individuals store more fat, develop insulin resistance then high blood sugar then organ damage, etc. See anything about the Pima Indians or even look at the rate of diabetes in Mexican-Americans and this effect is obvious.

    I’m not saying it is that simple. I’m saying that like psychiatric disorders, diabetes is extremely complex, it runs in families, twin studies would show heritability. We have not identified the genes involved, we cannot explain how they contribute to increased risk or even totally understand the environmental factors and how they contribute. We can certainly do a better job explaining diabetes than psychiatric disorders, but only because it is less complex and easier to study.

    Maybe I can even give anyone diabetes no matter what genes they have if I feed them enough of these types of toxins… Just like your model. I’m not sure if you can give 100% of people diabetes that way or not, probably a lot. Can you give everyone schizophrenia with the right environment? I’m also not sure, but I’m not convinced you can. Either way, I think they are both disorders and not exactly the same, but similar enough to be instructive in terms of thinking about how these things work.

  • Dear all – I have been eager to make a response to several comments, but have been tied up with work, please forgive the lag.

    I wanted to say first of all that I’m generally impressed with the responses that I’ve received to my comments. Not only in the quality and thoroughness of the responses, but for the most part in how a dissenting viewpoint has been received. I didn’t expect this dialogue to last long, but here I find myself enjoying the discussion quite a bit and I appreciate that we’ve been able to find a fragment of common ground here and there. I suspect we will never reach agreement on some fundamental issues, but I didn’t start commenting just to stir things up, I’m really interested in understanding why so many of you think so differently about these issues. At the very least, perhaps we will come away with a more thorough understanding of each other. I’ll try to keep this brief and not comment on every point raised.

    To Altostrata:
    re: [“reductionism of the worst kind”]

    I don’t see reductionism as a dirty word. It is just one of many ways of trying to discover how the natural world works. I would argue that it is by far the most effective way if you look at success in physics, chemistry, biology, etc and the way it has transformed our world. It is not the only way and some would argue that there are better ways or that at least there are better ways of understanding “psychiatric disorders” and I’m fine with that viewpoint which is I think what you are trying to say.

    As an aside: I find myself struggling with terminology here. I feel that I keep using inflammatory terms: “psychiatric disorder”, “biological basis”, “mental illness”, “psychiatric symptoms”. I’ve tried pretty hard to avoid using “disease”, but come on I’ve got to use some word to describe what I’m talking about. I will do my best to avoid terms that are overused, but I suspect I will still say things that others feel the need to put in quotes… bear with me.

    relatedly I will respond to Altostrata: [“brain circuitry” proponents in psychiatry propose that disorder or disease underlies only those thoughts, feelings, senses, etc. of which they disapprove and have designated as “abnormal,” when they may not be abnormal at all.”]

    This is not just a problem with brain circuitry proponents. We can define a disorder however you want: typically it leads to some dysfunction in the person’s life and hopefully they themselves define it as a problem. Anyone who tries to help someone in any way will have to define what is a problem that needs addressing versus what is an acceptable variant of “normal” behavior. That is not to say I don’t appreciate the issue or that I don’t empathize with say members of the ADHD or autism communities that feel their brain architecture is a variant of normal with challenges and advantages and one to be celebrated in the name of neurodiversity. That seems reasonable to me and I have no desire to track them down and drug them up or anything like that I promise you. Then again I did just slip back into the assumption that those individuals are unique as a direct result of having a different type of brain than your average person and I know this is not widely accepted here. Forgive me, point stands. This all said though, I do maintain that wherever you draw the line there is a point at which people suffer quite severe dysfunction and suffering. I would call that a disease or a disorder. I hope that somewhere along that continuum you can agree with me, if you really don’t think that any behavioral state, no matter how extreme can be said to be abnormal or disordered then I fear we have reached the limit of this debate.

    STEVE – thank you for your kind words and I appreciate your response.

    [ want you to see that it is an assumption and not a scientifically proven fact. All we know for sure is that biological changes correlate with changes in emotional state, but correlation is not causation.]

    I will grant you that my assumption is that all emotional states in human beings are caused or at least mediated through the brain. As you point out I cannot prove that with existing technologies and the limitations of human subjects research. However, it is not an uneducated assumption. Direct manipulation of neuronal activity in animals demonstrates that these alterations can causally influence a range of subtle behaviors. Further, humans who have lost specific parts of the brain lose specific abilities or have their behavior affected in distinct ways (see Phineas Gage) and manipulation of the brain activity of living humans during neurosurgery or with transcranial magnetic stimulation causes specific behaviors or emotional states. Taken together, to me these types of data indicate that if a disorder affects the brain it will/can cause psychiatric symptoms.

    I am beginning to understand that some here view the brain as mediating these symptoms, but not causing them. I admit I’m still trying to come to a complete understanding of this idea. But I think it goes something like this: Things happen in the environment which induce a state or epiphenomenon in the complex system which is the brain and that affects behavior or symptoms. There is nothing “physically” wrong with the brain, though the brain is required for this to happen and the concept is consistent with a mechanistic world view. I’m sure I haven’t gotten it quite right for everyone’s taste, but I actually quite like this idea. In fact I suspect a lot of what are called psychiatric symptoms are operating in this manner – thank you for helping me to think more clearly about this idea.

    That said, I still don’t think this is the only thing going on. I still think that brains are different from each other and that if a brain is constructed in a way that makes it highly probable to enter into one of these states it can be viewed as a physiological illness or disorder. For example, a young person who is prone to psychosis or schizophrenia or whatever you want to call it – maybe throughout their life their different brain manifests itself in subtle ways, as they get older something happens and they enter a state called a psychotic break and they are clearly suffering. No matter what you think is the best thing to do for this person, in many cases they will struggle with staying on the more functional side of that razor’s edge for a good part of their life. In a lot of cases (not all) I think it will turn out that there is a physical difference in how that person’s brain is constructed, maybe it will be subtle but I think that it is there. I don’t know what that form will take, I think there is evidence which supports this though I accept that for many here it will fall short of their standard of proof.

    Another reason I think this is the following: That is how all other illness in the human body works to my knowledge. My observation is that for any complex system in the body I can point to an example where there are individuals who have either a congenital or acquired problem in the physical functioning of that organ which leads to disease. I am unaware of exceptions. The brain also has disease/disorders – I think many agree that there are neurological disorders for example. Strokes that cause paralysis, epilepsies which cause seizures, problems of brain formation that cause intellectual disability. Alzheimer’s which causes memory problems, difficulty with spatial navigation and personality changes. Huntington’s disease is an interesting case because it causes motor problems, but also an array severe psychiatric symptoms. It is by the way as close to 100% genetic as you can get – if you have the gene variant you will develop the disorder, though the severity can be quite variable. But I digress – The point is that in complex systems such as emotion, thought, motivation, etc. I have a hard time believing that there will not be physical dysfunction which leads to disruption of normal functioning. I think that this type of process causes some and in my opinion a lot of psychiatric illness (particularly in its more severe forms). Let’s be done with this topic though.

    [“Back to science. The 25 year earlier death rate is not something I made up. Read the following article for a taste of the issue, but this stuff is published in mainstream psychiatric journals as well. It’s not news: http://usatoday30.usatoday.com/news/health/2007-05-03-mental-illness_N.htm“]

    Steve, my original interpretation of what you were saying about a 25 years earlier death rate was that you were saying that treating a psychiatric disorder caused patient’s to die 25 years earlier than if they had not been treated. Perhaps I misunderstood. The article referenced here supports the idea that those with psychiatric illness die 25 years earlier than those without psychiatric illness. Many of these people were treated and it is unclear to what extent the drugs they were exposed to are responsible for this effect. Certainly the drugs, particularly long-term use of anti-psychotics, have the potential for many negative effects on health. This study does not directly address the influence of medication separate from the influence of having the psychiatric disorder in the first place. To determine that, you would have to compare treated vs. untreated patients with psychiatric illness controlling for factors like illness severity. I would be very interested to know the results of this study, but I am not convinced that it would come out the same way. Many of these medications could certainly cause someone to die younger, but so could the sequelae of untreated psychiatric illness (homelessness, poor access to healthcare, substance abuse, suicide). My assumption being that these would be more prevalent in those who were unmedicated, at least in the case of more severe disorders like schizophrenia. I don’t have data in front of me to support this at the moment I admit. My assumption is also that in specific types of cases medication is helpful, if even for acute stabilization. For example an acutely psychotic individual or an acutely manic individual, each at high short term risk of suicide or other dangerous behaviors. I know that many here will not agree that this is the case. To summarize my overall point though, I think one should be careful in interpreting the result of this study as indicating that psychiatric medications kill people 25 years before their time… I agree that medication side effects probably contribute, but the study does not demonstrate that medication is the prime driver of the effect.

    [“There was some big flap about loss of brain tissue, but more recent studies (Nancy Andreasen, for instance – see http://archpsyc.jamanetwork.com/article.aspx?articleid=211084) have shown that this appears to be a result of neuroleptic treatment rather than a characteristic of the “disease.””]

    This is a really great and I think important article, thanks for drawing my attention to it. This looks like a good study to me and it makes me think more carefully about the long term risks of antipsychotic treatment. I would however caution against over interpreting the results – even the author’s conclusion is that antipsychotics likely contribute to the tissue loss seen in those with chronic schizophrenia, not that this is the only reason there is tissue loss. In fact they state that there are differences in the volume of certain brain structures at the outset of treatment compared to controls, suggesting there is a difference in brain structure prior to treatment, though medication may hasten the process. A brief perusal of the literature around this issue indicates to me that there are a lot of conflicting studies about whether there is loss of brain tissue in schizophrenia that can be definitively dissociated from treatment with medication. I do not know the answer – but I have never thought of schizophrenia as a neurodegenerative condition anyhow so I’m not troubled if there is no loss of brain tissue. It is interesting that you point to an article by Nancy Andreasen though, as she is clearly a staunch supporter of the idea that there is a physical, physiological, biological, whatever cause in the brain for schizophrenia. It need not of course be loss of brain tissue.

    Just a few key quotes from that article:

    ~”Antipsychotic medications are the mainstay of treatment because there is strong empirical evidence that these drugs reduce psychotic symptoms and relapse rates in schizophrenia patients.”~

    ~”Our results must be interpreted in the context of additional limitations. Identifying an association does not necessarily indicate a causal relationship. […] Even with the most sophisticated statistical methods, we may not be able to fully distinguish the potential confounding influences that illness severity or other sources of unmeasured variance could still have on the relationships between progressive brain volume reductions and antipsychotic treatment.”~

    ~”Are antipsychotic-associated GM and WM volume reductions “bad” for patients? The implicit assumption is that brain volume reductions are probably undesirable because patients with schizophrenia already have diffuse brain volume deficits at the time of illness onset.”~

    ~”Given that these medications have substantially improved the long-term prognosis of schizophrenia and that schizophrenia is a disease with significant morbidity, continued use of antipsychotics is clearly still necessary. However, our findings point toward the importance of prescribing the lowest doses necessary to control symptoms.”~

    * Please understand that I am not trying to minimize the negative side effects of medication, these are serious issues, the medications are rife with problems and they can be quite dangerous. I do not think everyone should get medication or that those who do get it should stay on it indefinitely. I do not think the current medication are adequate and in some cases they may not work at all.

    The clear exceptions in my mind are mood stabilizers and antipsychotics, particularly short term use in the acute patient. I would direct you to the writings of Kay Redfield Jamison (An Unquiet Mind) and Elyn Saks (The Center Cannot Hold). Each of these authors suffers from a psychiatric disorder, Bipolar and Schizophrenia respectively, and each has written about their struggles with exceptional thoughtfulness, power and intellect. Each believe very strongly in psychotherapy as a treatment modality and are far from across the board supporters of psychiatry – Yet each comes down unequivocally on the side of medication being essential in their recovery and ability to achieve long term stability.

    [why should we buy into the assumption, which you kind of agreed isn’t really true, that just because two people fit the subjective description of “schizophrenia,” they have the same thing “wrong” with them?]

    Like you said that’s not what I think. I also think anyone with a modestly nuanced view of the disorder doesn’t really think this. Schizophrenia (or any DSM category) is a pretty broadly cast net that is going to catch a broad set of entities with overlapping sets of symptoms. I would say it also almost definitely catches people who I would not categorize as having a disorder or a disease too. I’m sure I fit criteria for a number of disorders if criteria are strictly applied and I’m not the first to make this criticism. It is an unfortunately poor system for making diagnosis I admit. That said, while there are probably many different conditions being labeled as schizophrenia I expect that the number of basic problems in the brain that can cause a schizophrenia is not infinite. Also, it is not a meaningless category… Two people labeled with schizophrenia are probably more similar than they are to someone with autism for example. Schizophrenia may be too heterogenous a group to study I agree – that may be exactly the reason there is so much conflicting data… Perhaps a treatment is only effective for a small subgroup. I think that identifying subgroups and parsing schizophrenia into more uniform groups could really be critical and I know we hate genetics, but I think genetics could help with that aspect some day.

    [” Whitaker really does bring us back to what is known. I think you should re-read his book.”]

    I have not read it yet, but I’ve looked into it and I’ve decided that I will purchase and read this book.

    MORIAS: Thanks also for your comments and appreciation for a dissenting voice. I hope that some of what I said above addresses parts of your comments. For the most part I’ll focus on what you said regarding heritability and evolutionary advantage vs. disadvantage.

    [“You cannot prevent a genetic condition (other than through eugenic practices) but you may be able to prevent an environmental condition.”]

    I’m assuming you meant something like ‘you can’t prevent a 100% genetic condition’? I see that you followed with a more nuanced discussion about gene-environment interactions. Just to clarify my position though: I see no reason why you cannot in theory prevent the development of a 100% genetic condition. I even have hope that one might be able to prevent the development of a disorder like Huntington’s or at least attenuate its severity. Plus, we are not talking about disorders that anyone (or at least not me) are calling genetic in that sense (I don’t think you are either). Nothing supports the idea that psychiatric illness is ‘predetermined’ and so I think it is very likely you could prevent it even if it is somewhat heritable.

    [“Of course at one level schizophrenia is an interaction between genes and the environment (what isn’t?) but in what sense would it be an inheritable disorder?”]

    If you agree that it is an interaction between genes and environment, how could it not be relevant which versions of genes you inherited? I really don’t understand the difficulty with conceptualizing schizophrenia as an at least partly heritable condition. I do of course give you credit for stating that it could be, but I still don’t understand why you think it is so clear that it is likely to be “100% environmental”. I mean even if it was 99% environment and 1% genetic, why is it so hard to give any credence to the idea that your genes play a role?

    I’m not as well versed in why you think the twin studies are so flawed, but I gather that if I ask I will be redirected to the Whitaker book which is the namesake of this whole blog. I gather that it has to do with this equal environments assumption and the fact that identical twins experience more similar environments than fraternal twins. I further gather that this flaw is considered a central piece to the argument against an influence of genetics in psychiatric disorders. I don’t know enough about twin studies and its too late to get into this for me. Beside it seems that this particular aspect of the debate has been had out more than once already. Aren’t there any identical twin studies where they are separated at birth? (I don’t know)

    I will say this though: In science there is no such thing as a perfect experiment, often and particularly in the case of something as difficult to study as human psychiatric disorders we have to look at the overall weight of the evidence and perhaps then go with our instincts in forming further hypotheses. Above all else it is most important that we apply the same standards of evidence to competing hypotheses. It follows that one cannot say something like the following: “the evidence is not airtight in support of genetic influences, there are always environmental confounders and this idea has not been unequivocally proven – Therefore it is likely that the alternative (that schizophrenia is entirely environmental) is correct” OR even that the two hypotheses are equal at that point. I still think that it is likely that heritable factors are relevant to the development of something like schizophrenia. At the very least I consider the idea that schizophrenia is 100% due to the environment to be as unlikely as that it would be 100% due to genetics, I just don’t think that these things work that way.

    [“Explain to me why all the research is directed towards the least likely etiological hypothesis of schizophrenia instead of into much more likely hypothesis.”]

    Again, I don’t understand why a combination of heritable factors and environment is in your mind “the least likely etiological hypothesis”.

    [“Now, when a disorder has such complex genetic architecture as schizophrenia should have (since we have more or less discarded all the simple options) it becomes increasingly difficult to consider it a disorder, since it is not possible to account for how such a complex genetic architecture could evolve in the face of negative natural selection (and all disorders are negatively selected unless they confer an advantage in certain environments, like sickle cell anemia-malaria).”]

    I do want to try to address your thinking here. First of all if you think it has such a complex genetic architecture (I agree that it does) – why is it so hard for you to believe that the versions of genes you inherit have an influence?

    As regards whether it can still be a disorder, I don’t really get your thinking. If the only way genetically mediated disorders can exist is through conferring advantage in particular environment then we should have a lot fewer disorders, there is no malaria in the United States so by your thinking we shouldn’t have anymore sickle cell anemia or at least soon we shouldn’t? I don’t think so or at least I think we will have it for a while since the environment of the US isn’t really selecting against it that strongly. Type II diabetes is a disorder that has a complex genetic architecture but also depends critically on environmental factors. I’m not sure on what grounds you will disagree with me… Perhaps you will say that there is no evidence for a genetic contribution to diabetes, I don’t know. For that matter what is the evidence that anything is a heritable disorder? Regardless of how quantifiably heritable it is I suppose you can always say that there is some environmental factor that is not being controlled for which is actually confounding the experiment and causing the association.

    Anyway, back to diabetes… I’m not saying that there cannot be an advantageous aspect to the individual genes that are inherited which underlie the disorder. Diabetes for instance is probably partly caused by sets of genes which were/are advantageous in times where food supply was limited. Those same genes do not confer a relative advantage when there is a McDonald’s on every other block selling super size meals for $5 and they probably help to cause diabetes. The genes are not well selected against at this point because there is good medicine which keeps you alive past the point of reproduction. I totally agree that genes underlying the complex architecture of schizophrenia could code for traits which have some advantage in particular environments. I also don’t remember saying “weakness” maybe I did and don’t remember it, not sure. There is also by the way a concept which I believe is called something like kin selection, meaning that the gene doesn’t have to help the particular organism it is in survive, it just has to help those around it with the same gene survive better so that on whole that gene is replicated. Wow… I’m getting way off track here and really doing a poor job on this point. Really need to get some sleep and I apologize for not doing this justice.

    I’ll just say this: If you say there shouldn’t be any disorders with complex genetic contribution partially explaining their etiology then that should also apply to all the other disorders like that in other systems.

    [“Research into environmental factors is notoriously difficult, but that doesn’t mean we shouldn’t even try it.”]

    Yeah! I think we should definitely try it.

    Thanks for reading, if you made it this far 🙂 It has really been helpful for me to write it and to help clarify my thinking on some of these issues. If anyone responds further I will be delighted.

    I will read Mad in America OK? You’ve convinced me, so please don’t just say that I need to read this book as a response to my points.

    -Scott

  • Hi Steve thanks for your comments.

    [As to “brain disorders,” you continue to assume that a “disorder” such as “schizophrenia” exists as a distinguishable entity that has a physiological etiology of some sort. What evidence is there to support that?]

    Everything has a physiological etiology, unless it is magic. Brain states give rise to feelings and behaviors. If you don’t believe there is a disordered correlate in the brain of someone who exhibits disordered thinking like psychosis then it sounds like you don’t believe that the brain gives rise to behavior.

    [How do you know “schizophrenia” isn’t just a reaction, like a rash, to a variety of causes, some physical, some psychological, some existential?}

    That is sort of what I think. If you have a rash and a dermatologist biopsies your skin they will find a physiological correlate of the process causing the rash. Many rashes look alike, but have different causes. Many things are called schizophrenia, but as you point out there are probably different entities with different causes.

    [If there’s no physical way to distinguish those who “have” and “don’t have” schizophrenia, how do we know the sufferers have anything physiological in common?]

    If it were as easy to biopsy the brain as the skin, we might have a way to determine those who have and don’t have schizophrenia. Even with the limitations of studying the brain there are measurable differences between those who do and don’t have schizophrenia. Those are not yet sufficient or available enough to use as diagnostic tools, but I think it is only a matter of time.

    [You also need to read about the “Open Dialog” approach, and about “Soteria House.” It should help you see that social support and caring can be incredibly effective in treating the most severe “mental illnesses,” ]

    I will look forward to reading about some of the things you mention. To be clear however, I have not said anything to the effect that social support and caring are not incredibly effective. In fact, I said and continue to feel the opposite.

    [far more effective than the crappy chemical treatment that’s helping kill people off 25 years earlier than their untreated peers.]

    I would also be interested to know why you think that if someone is treated for their psychiatric issues with medication they will die 25 years sooner than they otherwise would have.

    [And there are plenty of people diagnosed with “severe disorders” who would take strong exception to trying to say their conditions aren’t caused or triggered by “existential suffering” or trauma or childhood neglect or simply being sensitive to the horrid social conditions in the world they live in.]

    I didn’t say that. I only meant to say that not everyone has a clear traumatic event which could be expected to cause their psychiatric problems. To be clear again, I have not tried to downplay the significance of these types of environmental triggers, at all. None of this is inconsistent with there being a physiological basis to mental illness.

    Finally, I agree with you that there are a range of techniques for studying the physiological basis of mental illness. Not everything is about genetics. Similarly there are many more theories than “brain chemistry” or “chemical imbalance” to explain mental illness. I never said anything about a “brain chemistry model”, I’m not specifically advocating these buzzwords which I can tell are viewed quite negatively.

    I am saying that mental illness has a physiological basis whether it is a reaction to heritable factors or to environment. I am saying that although non-drug therapy may even be the most effective way of treating most mental illness at this time, we should not abandon the idea that medication can help people. (many people feel that medication has helped them and better medications could someday help a lot more people.)

    Man, I never think I’m going to write this much, but then it just comes out…

    –Scott

  • Altostrata, you state that “psychiatric symptoms” that are caused by environmental factors tend to resolve spontaneously. Is that an admission that some psychiatric symptoms are not caused by environmental factors? What to do if it does not resolve spontaneously?

    My only point above with that comment was that there is no a priori reason that a condition with genetic underpinnings need require medication. The best treatment for such a condition could still be psychological therapy. It just seemed we were conflating the two.

    Not taking a pill is fine, it doesn’t mean no one should take a pill ever for symptoms that involve thought and behavior.

    I will also say that it seems this whole debate is caught up in an antiquated version of the false nature vs. nurture dilemma. Nature and nurture are really not so separable. The environment has dramatic effects which change the expression of genes. It’s not about predetermination, it’s about trying to understand what is physically changed in the brain when there are severe symptoms out of the range of normal – like being acutely psychotic. Drug addiction changes the structure of the brain and it is because of exposure to the drug which is 100% environment. It doesn’t mean that nothing can be learned about addiction by studying genes.

    I would challenge anyone to tell me why Alzheimer’s disease is fundamentally different than a psychiatric illness. Saying it isn’t even in the same ballpark doesn’t make it true.

  • It has not been my experience that a lot of psychiatrists tell their patients that the difficulties they experience are purely genetic and that stress is not relevant. Regardless, the degree to which a properly diagnosed disorder (a psychiatric syndrome not a feeling) is genetic vs. environmental really doesn’t relate to whether a drug is the best course of treatment. They are dissociable issues.

    The anecdote about your son is concerning because obviously it is critical to understand what happened to him in order to help him or to figure out if he is depressed. Even to make him feel heard and understood which could be therapeutic in and of itself. I would expect this of a primary care physician too, as you indicate is the case here, but psychiatrists are trained to do this. I suspect a psychiatrist would have done a better job.

    Still, as important as it is to ask that type of question, it might also be irresponsible to fail to offer an anti-depressant medication. The correct course of action for this physician would have been to assess for acute suicidality, assess for a major depressive disorder and offer what is reasonable for that setting: perhaps an anti-depressant, perhaps referral to other resources psychiatric or psychological counseling depending on the individual’s personal desires and details of their case. The key word is offer. A physician’s job is to offer options and though many here reject medication, there are many others who desire medication and feel strongly that it has been helpful to them. I do not think the offering is wrong and I do not think it indicates that the condition was viewed as genetic or that stress/trauma was not an important contributor.

    Regarding your second paragraph, remember that a medication does not change genetics. A medication changes the environment of the brain in a direct way. A physician may not be able to change a persons outward environment that much, so they may feel that the biggest change they can affect is through a medication.

    I think there is somewhat of a misunderstanding of the potential value of research in psychiatric genetics. The point is not to label disorders as genetic in nature or pre-determined as seems to be the assumption. I think the point is to try to get a foothold on what is physically different in the brain of someone with severe depression, schizophrenia, etc. There are after all, people who suffer from quite severe forms of these disorders who have nothing obvious in their environment which would have caused them. As in other areas of medicine, an understanding of the mechanism of a disorder or syndrome is critical in identifying more effective ways to treat it. That has been the case with all other dysfunction in the body which leads to medical conditions, many of which can now be effectively treated. The brain is orders of magnitude more complicated than the heart for example, so it is taking longer and that sucks for people who are suffering.

    I think it is a dangerous precedent though to decide that we should abandon research into the physical underpinnings of these disorders. Should we abandon research into Alzheimer’s disease? I think Alzheimer’s disease fulfills most of the same criteria here applied to psychiatric disorders. It involves the brain, it involves behavior/thinking/feelings, it is thought to be partly genetic and partly environmental, all the research has not yet lead to more effective treatments.

    Not everyone fits into the same box in psychiatry, but for those that suffer from severe disorders, not easily written off as existential suffering, we owe it to them to gain a better understanding of these conditions as brain disorders. Psychiatric genetics has suffered a lot of failures, but I think refocusing efforts is a better strategy than abandoning the search for what has gone wrong in the brain. People forget that research is hard, especially so with the most complex problem of the most complex organ. These are the biggest scientific challenges that exist today.

  • Dear Jay,

    I would argue the exact opposite. Psychiatry is a branch of medicine. Therefore, almost by definition psychiatric disorders are medical conditions. Perhaps there are disorders (personality disorders, relationship dysfunction, etc) which might be more effectively labeled psychological disorders. Biology being the substrate of all thought and behavior, they are still all biological in the strictest sense of the word.

    I also reject the idea that once a ‘biological basis’ has been identified for a disorder it becomes the domain of neurology. As an example, think of someone who is psychotic due to amphetamine exposure or depressed due to a thyroid problem – those are cared for by psychiatrists and I think they would meet your criteria for having a biological basis. They are also in the DSM.

  • These genetic data cannot simultaneously be false positives propping up a failed theory (a myth) and be used to support a separate theory that all psychiatric disorders are the same. Logical consistency dictates that the data themselves are either valid or not.

    I believe the conclusion of the study is not that schizophrenia, ADHD, Depression, etc are all basically the same, but that a similar process can confer risk for multiple disorders. These variants might underlie something like resilience so that when combined with environmental stressors (trauma) lead to a disorder which manifests differently depending on factors unique to the individual.

    I don’t believe that anyone is claiming that any complex behavioral phenomena is “caused by genes alone”. Every reasonable person, including these scientists, would agree that the environment an individual is exposed to plays a profound role in the development of psychiatric disorders. The reverse position would be that hereditary factors play no role at all and that seems unlikely to me.