Posted by: thealienist | July 13, 2011

In Defense of Biological Psychiatry

As I have been reading psychiatry blogs, I have noticed that the idea of biological psychiatry is often the target of strong negative feelings.  This may be due to past bad experiences with psychiatrists who seemed to rely too heavily on the biological model.  It may be due to a simply philosophical difference between the commenter and the biological psychiatry community.  There may be any number of additional reasons not to like biological psychiatry.  Still, biological psychiatry is a science and is based on a sound philosophical basis.

As part of my blog, from time to time I would like to post some ideas that show that biological psychiatry has value.  My goal is NOT to show that it has all the answers or even all the most interesting questions.  My goal is also NOT to defend every assumption or assertion made by every biological psychiatrist.  I would simply like to discuss the ideas underlying the field and how they are used to address the ideas of mental illness and what it means to be human.First, the fields of biological psychiatry and biological psychology, go back to the arguments for and against mind-body duality.  I will not re-hash all of these arguments here, but suffice it to say that there were philosophers who believe that our mind and our bodies were made out of different stuff (the dualists) and others who thought that our mind and body were made of the same stuff (the monists).  Among the monists, there were those that thought that the single stuff was “mind stuff” (the mentalists), that the single stuff was “material stuff” (the materialists), or that mental processes and brain processes were the same thing simply described from different points of view (the identity position).

Over time, the monists seemed to gain the upper hand in this philosophical debate, and the materialists and those holding the identity position became the most influential monists.  The dualism popularized by Descartes, fell into disrepute (by many but not all); and scientists of the mind increasingly became studiers of the brain.  This was not a random choice, however.  Throughout history, people had observed that those with head injuries often had alterations in their mental abilities.  Injuries to the back of the head often resulted in blindness.  Injuries to the front of the brain led to impulsive behaviors.  Strokes in the left hemisphere led to inability to understand or produce speech depending on where the stroke was.  Neuroscience began to reveal specialized areas of the brain and physiological processes capable to storing memories.  The more we knew, the more we became convinced that the mind is a function of the brain.

This explosion of information about the brain and how it produced sensations, movements, memories, physiological control of our bodies, and innumerable complex behaviors, led to immediate improvements in the field of neurology.  Neurologists quickly became adept and localizing lesions within the nervous system and predicting the likely effects of nervous pathology.  But still, there were behavioral problems that did not seem to correspond to any known brain lesion.  What were scientists to make of that?

The answer depended upon your philosophical views.  The scientific materialist saw such behaviors as signs of a malfunctioning brain.  Various metaphors were used to illustrate it such as clocks and computers.  Freud, however, developed theories based on a dynamic unconscious and explained at least some of these behaviors as extreme types of “normal” interactions among conflicting unconscious wishes, desires, beliefs, drives, anxieties, etc.  He developed a method to reveal these dynamics and improve the mind’s ability to manage such conflict.  This led to the development of a variety of “talking cures” for mental illnesses.  This view of mental illness could still be claimed by the scientific materialist since “unconscious wishes, desires, beliefs, drives, anxiety, etc.” are nothing other than functions of the brain.  Thus, even in this case, if these brain functions do not work together to enable a person to live a tolerable life, it can be addressed by fixing the brain.  Easy, huh??

The debate between the relative values of biological and psychological approaches to mental illness (a false dichotomy, IMHO) teetered back and forth for many decades.  Early triumphs of biological approaches include the discovery that General Paresis of the Insane was caused by syphilis and that complex behavioral changes could be caused by deficiencies in vitamin B-12.  The obvious behavioral changes caused by alcohol, opiates, hallucinogens, and stimulants showed that behavior could be pharmacologically manipulated.  More recent discoveries that some cases of obsessive-compulsive disorder are caused by Streptococcus infections and that depressive syndrome can be caused by hypothyroidism, lend further credence to the idea that our mental state rests on a foundation of biological processes.

Thus, it seems that biological approaches to mental health are here to stay.  There is a great deal of controversy over how this information may be used and what price we pay for relying on it.  Some believe that its benefits outweigh the risks.  Some believe that the risks of using this information is too great.  Regardless, the ideas behind biological psychiatry and psychology have grown to be foundational ideas in our society.  Even many of those who think they reject biological approaches to mental health unwittingly endorse it (e.g. “Don’t take those drugs; take my vitamins.”)  These beliefs are so prominent that they have practically become invisible.  I believe that these ideas are also very powerful and are worth careful consideration and serious critique.

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Responses

  1. General paresis is the stumbling block placed before the biological psychiatry. The problem is that no brain lesion (analogous to that of spirochetal disease) has been found for schizophrenia, depression, or any of the so-called serious mental illnesses. But whereas “the ideas behind biological psychiatry… have grown to be foundational ideas in our society”, so has the myth that bona fide pathology gives rise to these conditions.

    Various “scientific” frameworks have been put forward to link putative pathology with the phenomenology of mental illness (the most recent are “chemical imbalance” and “genetic defects). To date, none of the links have panned out.

    Until such a link is proved, it remains unproved. To suggest otherwise is un-scientific.

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    • Rob,

      I don’t see general paresis as a stumbling block. Not all illnesses are supposed to present with a similar pathology. The importance of the example was that it reinforced the idea that mental illness could be associated with a biological cause. It would be interesting you have you explain what “bona fide” pathology would consist of and on what basis you would require it of a mental illness. For example (going back to the brain-as-a-computer metaphor), if I have a corrupted program on my computer, you could examine the components of the computer all day and find no problems. Would you be correct is saying that there is no problem there? Does the fact that the program does not work not carry enough weight to let us agree that “something’s wrong?” Is it meaningful to say that it doesn’t work but there is no problem?

      If you have the opportunity, please apply your thoughts to the example (or tell me why the example is not appropriate to illustrate your distinction). I would be interested in seeing where we do and do not make similar distinctions.

      Also, I was not defending the “chemical imbalance” and “genetic defects” models of biological psychiatry, just the concept of biological psychiatry itself. I may get around to addressing these later. I would agree with you that it is important.

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  2. “if I have a corrupted program on my computer, you could examine the components of the computer all day and find no problems. Would you be correct is saying that there is no problem there?”

    Indeed you have a problem. I’m no tech-guy but it sounds like the problem is the program, not the computer. To translate to the brain now, the problem is not the gray matter, the problem is what the gray matter does. I’m not a fan of the brain-mind duality. It is a false distinction. “Mind” is a verb. “Minding” is what the brain does.

    Allow me to swap-out analogies. Applying biological modalities to a “sick” brain makes as much sense as calling a television repairman because you don’t like the programs on the tube.

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    • Rob,

      Interesting. I think my metaphor still holds. The program is “embodied” in the computer. The instructions have a physical form. If we could see down to the smallest details, would it be correct (in your sense) to say, “Oh, I see that this switch should have been set to a ‘1’ but it was set to a ‘0’ — that was the problem.” If that is the case, could we conceivably see the synaptic weights of the brain’s neurons and one day say, “Oh, these synapses are too numerous (or too sparse, or too heavily weighted, or too lightly weighted), and that is the pathology of (disease X)?” What do you think?

      With respect to your analogy, I think it falls short because the program is not part of the t.v. Perhaps if we used a similar example — one of watching t.v. programs loaded onto a hard drive. The program is embodied on the hard drive just like a program is. True, you could say, “I don’t like the content of the program” and it would not be the computer’s fault. On the other hand, you could also say, “Hey, this isn’t showing my program right — something’s wrong with my computer.” Would the first be a matter of taste and the second by pathology?

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      • It’s true that the analogy isn’t very robust. It works better if you make your first statement, that the content of the program is not good but the hardware is in fine working condition. In fact, it is the maladaptive programming that is causing the computer to look screwed up. When you get down to 1’s and 0’s, the synapses are doing just what synapses do, fire or not fire, with a particular degree of strength and latency. They can do this just as they are “supposed” to do and still give rise to the phenomenology that we call “major depression” or “schizophrenia”. The neurons are working perfectly well. We observers, and sometimes the computer himself, don’t like the output.

        I claim, a la Thomas Szasz, that mental illness cannot exist by definition, because if there were a physical substrate for the illness, we would call these diseases “brain diseases” and they would be managed by neurologists. Unless and until the so-called serious mental illnesses are shown to demonstrate actual pathology, as in general paresis, they will remain metaphorical diseases.

        Here’s what I mean by “metaphorical disease”: Mind’s are “sick” the way jokes are sick, that is, metaphorically. It’s true that sick brains put out faulty outputs, but it is a logical error to claim that outputs we don’t like imply sick brains! People with schizophrenia “act sick”. But we commit the logical error if we infer from their behavior that their brains are sick.

        Now, to the claim that drugs making schizophrenics “better” proves schizophrenia is a brain disease: this too is a logical error. I claim that you so heavily sedate and immobilize schizophrenics with anti-psychotics that you blunt the phenomenology. Unless and until you can tell me what’s wrong with a schizophrenic’s brain in the first place, you cannot argue that the drugs are “working”. What do you mean by “working”?

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      • Hmmm. Why assume that the computer is working fine? Can’t the problem be with either the program or the computer? If you assume that the error must be with the program, then you are committing the same kind of error that the “true believer” in biological reductionism is making.

        You say that the synapses are doing just what synapses do…but are they? The information in the system is supposedly stored in the synaptic weights. What is the synapses are firing and appearing normal but they are actually miscoding information? Is that not pathology? If not, can you give a definition of pathology that would help us have a meeting of the minds?

        With regard to Dr. Szasz, I think he has some good things to say, but I think is message is fundamentally wrong. All specialties diagnose syndromes and don’t quibble over whether it is a “disease” or “syndrome” or “illness”. The idea that knowing the basis of an illness makes it a neurological illness is absurd. I agree that as our knowledge grows the fields of neurology and psychiatry approach each other, but this is not a new idea. After all, the board that certifies psychiatry is the same board that certifies neurology and the certification exams for each specialty has significant portions dedicated to the other. The truth is, we like to treat different kinds of illness. It’s the phenomenology that makes us different, not the level of knowledge about pathology. The scope of psychiatry will not diminish as our knowledge of the brain grows, rather it will expand (but it needs to expand responsibly).

        With regard to your third paragraph, I think you may be on shaky philosophical ground. Since our minds are the product of a biological mechanism, faulty output means either a sick (dysfunctional) brain or bad information (which is also stored physically in the brain). In one way or the other, something biological is wrong. Now, there might be a major malfunction that needs to be addressed on a global level (i.e. alter the brain function) or there might be a minor malfunction that can be addressed by tweaking the system (i.e. supplying corrective experience). We need to know how to tell the difference, and we need to know what tools are available for responsible, ethical treatments.

        Your final paragraph assumes much too much. We do not claim that schizophrenia is a brain disease because drugs make them better. We claim that schizophrenia is a brain disease because it is the product of the mind-brain. True, we do not have a full explanation of what the brain is doing in the case of schizophrenia, but that would be a terrible reason to not help those suffering from the illness. I don’t know what your experience is in the treatment of schizophrenics, but I have treated a few (it has not been the particular focus of my practice). Those who I have treated recently have come to me with severely impaired functioning on many levels. Some have had prominent positive symptoms (i.e. hallucinations, delusions, etc.) but most of their problems were from the negative symptoms (lack of pleasure, lack of will, poverty of thought, etc.) If you think you can sedate and immobilize someone out of the negative symptoms, you don’t understand schizophrenia. The medications I have used have enabled several of my patients to be able to participate more in their lives and to enjoy their activities more. This is what I mean by my treatment “working.”

        Thanks for your thoughtful participation in this conversation.

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      • “What is the synapses are firing and appearing normal but they are actually miscoding information? Is that not pathology? If not, can you give a definition of pathology that would help us have a meeting of the minds?”

        John, you clearly know more neurobiology than I, so explain what it means for a synapse to “miscode information”? To the neuron, it’s just information. Only the observer can judge that the information is miscoded. A devout Catholic believes the Eucharist wafer is the body of Jesus of Nazareth. The man doing cartwheels in the street believes HIS body is the body of Jesus of Nazareth. I say both are wrong. Whose neurons are miscoding information?

        Here’s how an on-line dictionary defines Pathology (second and third definitions. The first refers to the science practiced by Pathologists) 2. The anatomic or functional manifestations of a disease. 3. A departure or deviation from a normal condition.

        Returning to Cartwheeling Jesus and the Worshiper in Church. Which one’s synapses depart or deviate from the normal condition? Whose synapses manifest anatomic or functional manifestations of a disease? And what do those manifestations look like?

        I have yet to see a satisfactory account of pathological function in schizophrenia (or major depression, for that matter). The departure and deviation from normal condition is a moral, political, or legal judgment, not a scientific one.

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      • Rob,

        I can agree with you (in most circumstances) regarding the anatomy part of the definition, though in a few areas there are reversible anatomical changes that can be treated either with medications or psychotherapy such as in obsessive-compulsive disorder. Please realize that many who argue against use are relying on the “functional manifestation of disease” as their definition of pathology.

        Your point about assessing deviations from the normal is very important, however. This is the point where I think most of the arguments I have read (not just here) occur. You mention that two examples, the transsubstantiation beliefs of the Catholic and the man who believes He is Jesus. I think that this may be a good illustration to discuss. Let’s see what I can do with it…

        The person who believes in transsubstantiation (the change of sacred bread to the literal body of Christ) has a belief that is shared by many. That would be one point for the argument that it is not a deviation from the norm. This belief is usually (I can’t think of an instance) not associated with an inability to adapt to typical life stressors. That is, it is not dysfunctional in any significant way. This would be another argument against seeing it as an illness. Finally, the belief and the behaviors that stem from them do not conflict with necessary self-care or tolerable interactions with others. I think you might agree with most or all of this. If not, let me know.

        Now let’s consider our cartwheeling Jesus. It would probably not be hard to show him to be psychotic. Getting to know him, he would probably demonstrate very strange ways of “knowing” he was Jesus. Still, who cares if he thinks he is Jesus? People can think that if they want to. There is no broadly recognized harm in the thought. This would certainly place him outside the boundaries of “normal,” but who says we all have to be normal? Next, let’s consider his cartwheeling. There is nothing necessarily wrong with this. If it is not harming himself or assaulting others (i.e. if he has sufficient control over it) then I still see no problem. If this man is able to use his resources to take reasonable care of himself and not be a danger to others, then he certainly has a right to behavior and think as he likes.

        Now, let us think of the transsubstantiationalist with a little different back-story. What if this man suddenly realized that all unleavened bread was the body of Jesus and that if it was consumed by heathens or outside of mass that it would be sacrilege? Well, if his mind worked well enough that he continued to take care of himself and not endanger others, he would be demonstrating sufficient impulse control and frustration tolerance to not require treatment (though if it bothered him enough, he could seek help, we would still call it an illness and offer treatment). On the other hand, if he were not able to tolerate the frustration of his thoughts or resist the impulses to snatch bread off of other’s tables or steal it from the supermarkets, then he would hopefully be given help to deal with this.

        Similarly, if the cartwheeling “Jesus” believed that he must crash funerals to raise the dead and have himself killed so that he could be resurrected in three days, we would say that that level of dysfunction would require treatment.

        I’m sorry that my argument seems to be more appropriate for the “Involuntary Hospitalization” post, but my point is that the distinction is not between good mental health and bad mental health. This is too “black-and-white.” We would be better off to consider a distinction between “good-enough” mental health and bad mental health. Instead, psychiatry has long recognized that we all have psychopathology to different degrees. For example, take Freud’s “Psychopathology in Everyday Life.” The difference is whether the problems are severe enough to be considered “ill.” All branches of medicine have to deal with this problem. Is this blood pressure too high? Is this potassium level too low? Is this behavior too dangerous? These are serious questions that demand serious answers. The borderline cases can be vigorously argued and will likely have moral, political, or legal solutions in the absence of a scientifically “black-or-white” pronouncement. Science can tell us what is, it cannot tell us what should be.

        The current state of the art seems to be to focus on four aspects of behavior in evaluating mental illness (“The Four D’s”): deviance (from the norm), dysfunction, distress, and dangerousness. No single aspect defines mental illness.

        Finally (sorry this is so long and rambling), your question about miscoding information is also very much on point. We do not currently have a lot of information on the synaptic coding of information. At our current level of understanding, most neuroscientists believe that changes in synaptic weights encode information in the brain. The “accuracy ” of the coding would represent how well a set of neurons modeled the information and relationships presented to them. These representations may be very accurate or very biased. Psychologists have found many ways in which our nervous system biases information. For example, normal brains appear to be wired to preferentially respond to hot stimuli over cold ones under certain conditions. Phobic individuals respond more quickly and strongly to their phobic stimuli than non-phobics. Schizophrenics have decreased ability to bias their responses toward important stimuli when they are presented with other, less-important stimuli. Depressed patients show bias in attending to an overestimating the severity of negative stimuli. Such distortions are presumed to reflect underlying biasing mechanisms in the brain (either innate or acquired). If my mind-brain receives a stimulus and records the memory of it as markedly more traumatic than it actually was, then this bias might be considered a miscode. If my mind-brain receives several stimuli and associates them together improperly (or fails to associate them properly), then this bias may be considered a miscode.

        I’m sorry this response was so long. I’m not sure I have addressed your comments well. Still, I am going to stop now since I think I could ramble forever if given the chance. Thanks for your input.

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      • sorry, in my last paragraph I meant to add that I haven’t seen a satisfactory account of pathological ANATOMY or function in schizophrenia

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  3. Perhaps the idea of a neurochemical mind/self is perturbing for two seemingly contradictory reasons. On a practical level, and as reflected in comments already made, the concept so far has promised far more than it has delivered (in the form of reliably effective and well-tolerated treatments).

    But on a deeper level, if the self is a biological machine then it is also theoretically and infinitely modifiable and contingent, with respect both to oneself and others. The idea of the ineffable soul is comforting because it is *given*, and beyond a certain point, not up to us. But the prospect of the totally self-aware, self-monitoring biological machine is nightmarish inasmuch as there would be no end either to one’s vulnerability or to one’s responsibility, depending on what persons in any given situation are in control. With the model of the machine comes the imperative either to manipulate or be manipulated.

    The only way out would seem to be to acknowledge that while we are biological machines, it is not possible to meaningfully live as machines; that is, we must maintain a blind spot as to our own nature. Spirit is a necessary fiction.

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    • Hi, Novalis.

      I think you are right. The “true believers” in biological reductionism oversold the promise of biological psychiatry research. I also agree with your statements about the difficulties of what it means to be human when humanity is reduced to a machine metaphor. My only quibble would be that I don’t think that “spirit” is a fiction or a product of a necessary blind spot, but this opens a whole different area of discussion.

      Thanks.

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