Apr 11

Cataloguing Human Suffering: The Next Frontier

In a recent Wired Magazine article titled Inside the Battle for Mental Illness (2010), psychotherapist Gary Greenberg, author of Manufacturing Depression: The Secret History of a Modern Disease (2010), addresses the controversy surrounding the imminent release of the fifth Diagnostic and Statistical Manual of Mental Disorders (DSM-V). As indicated in a previous post, Allen Frances, the psychiatrist who chaired the task force that developed the previous edition (DSM-IV), fanned the flames of discord when he expressed a number of worries regarding the future manual. In his article, Greenberg explores Frances’ arguments, as well as other psychiatrists’ responses to them.

Greenberg forecasts that if the DSM-V is a critical failure, the mental health profession may never recover: “It could cause the [American Psychiatric Association] to lose its franchise on our psychic suffering, the naming rights to our pain.”

But, why all this pessimism? After all, the DSM-V heralds the much-touted debut of a dimensional approach to diagnosis. Rather than the more simplistic Is his personality disordered, or is it not? question, diagnosing professionals will now be able to address the more complex Where does he fall on a spectrum of disordered personality? question. Unfortunately, the excitement over this new approach appears to be unwarranted. In any case, its addition is ultimately obscured by the decision to retain the long-standing, but decidedly outdated tradition of descriptive diagnosis. Although medical diagnosis has long been about finding causes beneath effects (i.e., symptoms), psychiatric diagnosis has long been about describing effects without attention to causes.

In fact, the DSM is really nothing more than a compendium of checklists. This leads to circular reasoning: why does a person have depression? Because he has depressive symptoms. Why does he have depressive symptoms? Because he has depression.

The purpose of descriptive and etiology-based diagnosis is the same: use objective criteria to separate mental pathology from mental health. Promoting the potential within the new dimensional approach to diagnosis, Darrel Regier, the vice-chair of the DSM-V task force, envisions the discovery of what Greenberg calls the holy grail of psychiatry: “statistically valid cut-points between normal and pathological.” This vision of a more ideal future betrays the sad truth that our current understanding of where mental health ends and mental pathology begins is rather “fuzzy.”

Arguably, if psychiatry is to be taken seriously, it needs to become about more than effects; it must become about causes. Medicine has its diagnostic tests: blood tests, x-rays, etc. Apart from further checklists (i.e., questionnaires), psychiatry unfortunately boasts no such tests. However, this does not mean it is not rising to the challenge…

According to Greenberg, a new movement of research “has launched an effort to transform psychiatry into […] clinical neuroscience. This project will focus on observable ways that brain circuitry affects the functional aspects of mental illness—symptoms, such as anger or anxiety or disordered thinking, that figure in our current diagnoses.”

The bottom line of this movement of research: if we can pinpoint the neurological causes of mental disorders, we can establish what Regier believes to be the “absolute threshold” between mental illness and mental health. Thus, as Greenberg puts it, we will know for sure: is he ill or simply miserable?

Greenberg, however, appears skeptical that such a threshold will ever be discovered: “[A] new manual based entirely on neuroscience—with biomarkers for every diagnosis, grave or mild—seems decades away, and perhaps impossible to achieve at all. To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched.”

While the thought sends shivers down my spine, I wonder if Greenberg is incorrect and the underlying biology of all human behavior will in fact eventually be mapped out. Let us pretend for a moment that this is achieved and that we find the biological causes of mental illness. Even then, would that truly prove the existence of mental illness? After all, psychiatrists are quick to say that attention-deficit/hyperactivity disorder is a real disease because the brains of those who suffer from it supposedly “work” differently (e.g., see Vincent’s Mon cerveau a encore besoin de lunettes: Le TDAH chez les adultes [My brain still needs glasses: ADHD in adults], 2009). But, this is interesting, because so do the brains of homosexuals (for a review, see Gulia & Mallick, 2010). Does that make them ill as well? Should we resuscitate the retired disorder of homosexuality?

Likewise, it is not unreasonable to assume that many other “unhealthy” behaviors (not considered mental illnesses) are biologically-based as well: excessive smoking, promiscuity, extramarital infidelity, racism, homophobia, murder, and so on. Should, then, these behaviors also be considered mental illnesses?

Let’s go a step further: what if individuals who engage in generally approved behaviors also show brain differences? Would they become ill should our approval vanish? Thomas Szasz wondered this in The Second Sin (1973): “Psychiatrists look for twisted molecules and defective genes as the causes of schizophrenia, because schizophrenia is the name of a disease. If Christianity or Communism were called diseases, would they then look for the chemical and genetic “causes” of these “conditions”?” (p. 102). Indeed, in recent decades, they have been and we did.

In God’s Brain (2010), anthropologist Lionel Tiger and neuroscientist Michael McGuire set out to uncover the evolutionary and biological underpinnings of religious belief. In fact, some studies have suggested that believers and non-believers’ brains “work” differently (e.g., Inzlicht & Tullett, 2010). These authors do not attempt to pathologize religion, but crossing that line is easy to do. In The End of Faith: Religion, Terror, and the Future of Reason (2004), author Sam Harris writes: “[It] is difficult to imagine a set of beliefs more suggestive of mental illness than those that lie at the heart of many of our religious traditions.” Similarly, in the conclusion to the documentary Religulous (2008), comedian Bill Maher calls religious belief a neurological disorder. Since these statements are backed up by “hard” biological neuroscience, I guess that settles it: religious belief is a mental illness.

Not so fast: religious belief (or atheism for that matter) is no more a mental illness than adolescent misconduct, depression, psychosis, pedophilia or borderline personality. In fact, none of these are illnesses at all; they are categories of behaviors. Whether we choose to call some “illnesses” and not others depends on whether the behaviors are regarded positively or negatively.

Back in 1973, Szasz quipped that “[we] will discover the chemical cause of schizophrenia when we discover the chemical cause of Judaism, Christianity, and Communism. No sooner or later” (p. 102). As we have seen, Szasz appears to have been wrong: we have begun and will continue to find the biological causes of all sorts of behaviors.

The point is: the mere presence of biological causes is not enough to support the presence of mental illness. After all, we are not made of fairy pixie dust. We are biological creatures, and so all of our behaviors, be they the source of pain or pleasure, have biological causes. Where there are behavioral differences, biology (always interacting with environment, of course) is necessarily at play; since brain and behavior are tied, differences in behavior can certainly be linked back to differences in the brain.

Several decades before the advent of neuroscience, in The Myth of Mental Illness: Foundations of a Theory of Personal Conduct (1961), Szasz reasoned: “Pathological changes in the body, especially in the nervous system, cause abnormal behaviors. Hence, it is not unreasonable to assume that abnormal behaviors are due to pathological changes in the body. As we know, medical research has lent some support to this assumption—for example, in cases where “mental disorders” can be shown to be the consequences of infections, metabolic disorders, or nutritional deficiencies. However, the criteria for what behaviors count as abnormal are cultural, ethical, religious, and legal, not medical or scientific” (p. 296).

A further complication: if we say that brain pathology underlies mental pathology (and find proof for this), then the term mental disorder becomes obsolete. Psychopathology ceases to exist, and instead becomes neuropathology: “If mental illnesses are diseases of the central nervous system (for example, paresis), then they are diseases of the brain, not the mind; and if mental illnesses are the names of (mis)behaviors (for example, fear and avoidance of narrow spaces, called “claustrophobia”), then they are behaviors, not diseases. A screwdriver may be a drink or an implement. No amount of research on orange juice and vodka can establish that it is a hitherto unrecognized form of a carpenter’s tool” (from Szasz’s The Medicalization of Everyday Life: Selected Essays, 2007, p. 28). In other words, we cannot have it both ways: either mental disorders are really brain disorders, or else they are simply behaviors and thus not disorders at all.

Which is it then? As mentioned previously, while behaviors are biologically determined, they remain just that: behaviors. And which behaviors are considered to be abnormal (and thus which brain processes are considered to have gone awry) is entirely the product of social consensus.

Despite the numerous shortcomings, Greenberg does not deny it is useful to label certain behaviors as disorders. These labels mobilize social awareness and encourage developing resources to alleviate our human difficulties. At the same time, however, the patholigization of behavior increases “psychiatry’s intrusion into everyday life,” giving us “tidy names for our eternally messy problems.”

Personally, what worries me is that this intrusion is theoretically limitless, because the jurisdiction of psychiatry includes everything that we do, think, and feel. Indeed, everything that we are. In his article on the DSM-V, titled It’s Not Too Late to Save ‘Normal’ (2010), Frances expresses fears that the new manual will “extend the reach of psychiatry dramatically deeper into the ever-shrinking domain of the normal.” To be sure, psychiatry’s conceptualization of what constitutes abnormality is evermore taking over what most of us still consider to be normal. In The Myth of Mental Illness (1961), Szasz argues that while medicine discovers diseases, psychiatry invents them. This trend could prove disastrous, leading to the uncritical acceptance of all of our hardships as disorders. Let us then, both helping professionals and clients alike, finally assert ourselves and put a stop to psychiatry’s shameful attempt at medicalizing our everyday life… before it is, in fact, too late.

Additional references:

Gulia, K. K., & Mallick, H. N. (2009). Homosexuality: A dilemma in discourse! Indian Journal of Physiology and Pharmacology, 54, 5–20.

Inzlicht, M., & Tullett, A. M. (2010). Reflecting on God: Religious primes can reduce neurophysiological response to errors. Psychological Science, 21, 1184­­–1190.

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