A Psychiatric Diagnosis: Behavioral Problem or Brain Disease?

When the first edition of the DSM (the manual of psychiatric diagnoses published by the American Psychiatric Association) came out in 1952, it listed about 100 different psychiatric diagnoses. By the time the fifth edition was published in 2013, it listed over 550 separate ones! One has to wonder if early psychiatrists were just missing a bunch of them, or if normal but repetitive everyday problems in living due to trauma, stress, and interpersonal dysfunction have been turned into diseases. I vote for the latter.

At any rate, the DSM uses the word “disorder” to fudge this question somewhat, leaving a “to be determined” answer as to whether any of the diagnoses are brain diseases or just psychological or behavioral problems experienced by normal brains. So how do we go about making an educated guess as to which it is?

The question is complex because the phenomena under discussion are very complex. While our understanding of the brain is increasing by leaps and bounds, it is still very rudimentary. That is because the brain is literally the most complicated and complex object in the entire known universe, with about a trillion constantly changing connections between nerve cells. Remember when computers would go crazy and produce the infamous “blue screen” when two programs would conflict, and you would have to restart it? Imagine what might happen if the computer were not hard wired!

A lot of people, including many in the various mental health professions, seem to be prone to highly simplistic “either-or” thinking. If even one of the 550 DSM diagnoses is a brain disease, then they all must be. Or if one is a behavioral/psychological disorder, then they all must be. That is just stupid. But throughout the history of psychology and psychiatry, the field has often lurched back and forth between brainlessness and mindlessness (as described in Chapter One of my last book), incorporating what turned out to be ridiculous or misguided theories.

Autism is caused by refrigerator mothers. Schizophrenia is just a different way of experiencing the world or due to being placed in a double bind by your family. Sexual promiscuity is a genetically determined trait, and certain races are genetically inferior to others. Acting out by children is caused by underlying bipolar disorder. Obsessive compulsive disorder is caused by harsh toilet training. A central part of women’s psychology is penis envy. The list of nonsensical and grossly mistaken theories like these is nearly endless. I’m surprised that no one ever theorized that the memory deficits in Alzheimer’s disease are really a result of the defense mechanism of repression.

But even without such simplistic thinking, determining which diagnoses are truly diseases and which are primarily behavior problems caused by problematic learning and stress is not easy. You cannot just do an fMRI brain scan, as I described in an earlier post, because that test alone does not distinguish an abnormality from a normal conditioned response to a particular social environment.

And even if something is a brain disease, family stress and dysfunction can make it worse – just like with many physical diseases. Then there’s this: having a parent who gets manic and runs naked through the streets creates huge stresses for a child who observes it. Such children are at risk both genetically and environmentally.

Not only that, but you get into a chicken and egg situation: does having a controlling family create anorexia nervosa, or is having a child who is starving herself to death lead parents to become overly controlling? A child who is more temperamental is often somewhat more difficult to raise than one who is not, leading some parents to engage in problematic parenting practices with one of their children but not others.

The whole question of “what causes” a disorder is further complicated by the fact that with the vast majority of psychiatric diagnoses, there are no necessary or sufficient causes of any sort – only risk factors that increase the odds someone will develop a disorder, and mitigating factors that decrease those odds. And there are usually hundreds of these factors operating over time.

So what standards do I use in forming my opinions about various disorders? To me, by far the most important metric is whether the symptoms of the disorder only appear under certain social conditions, and disappear when the social conditions change. Real brain diseases like schizophrenia do not do that; they are present almost all the time. You see victims “responding to internal stimuli” whether you are talking to them one-on-one or observing out of the corner of your eye on a ward in a state hospital them when they don’t realize they are being observed by staff. They show them no matter who is talking to them, or even if they are put alone in a room in a psychiatric ER with a hidden video camera keeping a watchful eye on them.

Someone with, say, a melancholic depression reacts at a snail’s pace compared to the way they usually react (psychomotor retardation) every waking moment no matter where they are or who they are with, and stay in that state all day every day, sometimes for weeks at a stretch. Luckily, when I trained we could keep patients in the hospital that long so we could see this; today’s trainees do not get to do that any more, so are more easily fooled.

On the other hand, borderline personality disorder symptoms are not like that at all. I would see patients with the disorder acting out with staff in a psychiatric hospital, but behaving completely appropriately with the other patients when they didn’t know I was observing them. In fact, they are famous for acting one way in the presence of certain staff members and exactly the opposite when in the presence of others, leading the two groups to fight with each other (the staff split)!

I’ve seen people I know who have the disorder out and about at music festivals and theaters acting as normally and appropriately as anyone else. In therapy, certain emotional reactions and provocative behavior would come out of them if the therapist did one thing, but would disappear quickly if the therapist changed to doing something else.

In looking at neuroscience evidence, an important metric in distinguishing disease from mere dysfunction is the sheer number of different types of brain anomalies and other neurological findings. As I said, a single fMRI finding alone tells you nothing. But a whole bunch of different fMRI abnormalities with some of them completely unrelated to the symptoms of the disorder suggests a brain disease. For example, people with schizophrenia tend to have a lot of different abnormalities, many of which have nothing to do with delusions or hallucinations. One cannot be certain, of course, but I would be hard pressed to explain many of these neurological findings in terms of conditioned responses to particular social environmental stimuli.

Conventional Wisdom that Seems Obvious Once Again Found to be Actually True

As I did on my posts of November 30, 2011,  October 2, 2012, September 17, 2013, and June 3, 2014, it’s time once again to look over the highlights of the latest issue of one of my two favorite psychiatry journals, Duh! and No Sh*t, Sherlock. We'll take a look at the unsurprising findings published in the latest issue of No Sh*t Sherlock. My comments in bronze.

As I pointed out in those earlier posts, research dollars are very limited and therefore precious. Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already known to be true but have yet to be "proven"? Such an approach increases the success rate of studies almost astronomically. And studies with positive results are far more likely to be published than those that come up negative.

 

5/28/14.  Physical activity program may reduce mobility disability in seniors.

USA Today (5/28, Painter) reports that for seniors, “losing the ability to walk a short distance often means losing independence.” Now, “researchers say they have found a treatment that, for some, can prevent that loss of mobility,” and that is “a moderate exercise program.” The Washington Post (5/28, Bahrampour) reports that the study, “called the Lifestyle Interventions and Independence for Elders and funded by the National Institute on Aging and the National Heart, Lung, and Blood Institute, was the first of its kind to test a specific regimen of regular physical activity for sedentary older people.” The Boston Globe (5/28, Kotz) “Daily Dose” blog reports that the study, published online May 27 in the Journal of the American Medical Association, “found that elderly people who walked and did basic strengthening exercises on a daily basis were less likely to become physically disabled compared to those who did not exercise regularly.” The study control group consisted of people who were instructed to take health education classes. 

I guess it's still OK for seniors to sit very, very still while posing as nude models for art students.

6/17/14. Study Shows Association Between Mental Illness Severity and Employment and Income.

More severe mental illness appears to be associated with lower employment rates in recent years, and people with serious mental illness are less likely than people with no, mild, or moderate mental illness to be employed after age 49, according to the report, “Employment Status of People With Mental Illness: National Survey Data From 2009 and 2010,” published in Psychiatric Services in Advance.

We now know for sure that employers are not always hot to hire people who are too mentally impaired to perform the work.

6/20/14. Brain Injuries Linked To Higher Risk For Headaches.

HealthDay (6/20) reports that research scheduled to be presented at the American Headache Society meeting suggests that “U.S. veterans of the Iraq and Afghanistan wars who suffered brain injuries are at a much higher risk for headaches, especially migraines.” This “study included 53 veterans who had suffered a traumatic brain injury during deployment and...53 veterans without brain injuries.” Investigators found “that all of the veterans in the brain injury group said they experienced headaches, compared with about 76 percent of those in the control group.” Eighty-nine percent of the headaches in those with brain injuries were migraines, while just 40 percent of the headaches in the control group were migraines.

Now just a minute. Bodily injuries produce pain?? Since when?

9/1/14. The relationship between premorbid body weight and weight at referral, at discharge and at 1-year follow-up in anorexia nervosa. 

European Child and Adolescent Psychiatry, 09/03/2014: Focker M, et al.  In this study, the relationship between pre-morbid body mass index (BMI) percentile and BMI at admission was solidly confirmed. In addition to pre-morbid BMI percentile, BMI at admission and age were significant predictors of BMI percentile at discharge. BMI percentile at discharge significantly predicted BMI percentile at 1–year follow–up. An additional analysis that merely included variables available upon referral revealed that premorbid BMI percentile predicts the 1–year follow–up BMI percentile.

Oh, I did not see it before, but I get it now. More severe disorders have a worse prognosis.

11/25/14. Talk Therapy May Prevent Suicide in High-Risk Patients

Talk therapy may decrease risk for future suicide attempts and completions in patients who have already made a previous attempt, new research suggests. 

God, I should hope so, or I'm in the wrong business!!

1/13/15. Self-injurers experience greater negative emotionality, particularly self-dissatisfaction, compared to individuals with no NSSI history.

Self-injurers also reported less positive emotion, but these effects were smaller. The pattern of results was similar when controlling for Axis I psychopathology and borderline personality disorder.

And here I thought cutters and burners did so because their joy was just soooo unbearable.

1/30/15. Repeated Blows To Head In Boxing, Martial Arts May Damage Brain.

HealthDay (1/30, Preidt) reports that research published in the British Journal of Sports Medicine “supports the notion that repeated blows to the head in boxing or the martial arts can damage the brain.” Investigators studied “93 boxers and 131 mixed martial arts experts,” as well as 22 individuals who had never suffered a head injury. “MRI brain scans and tests of memory, reaction time and other intellectual abilities showed that the fighters who had suffered repeated blows to the head had smaller brain volume and slower processing speeds, compared to non-fighters.”

So I guess I should quit beating my head against the wall trying to get researchers to actually look into things we actually do NOT already know.

1/30/15.  The US Food and Drug Administration (FDA) has approved lisdexamfetamine dimesylate (Vyvanse, Shire) to treat binge eating disorder (BED) in adults.

The drug is the first FDA-approved medication to treat this condition. "Binge eating can cause serious health problems and difficulties with work, home, and social life," said Mitchell Mathis, MD, director of the Division of Psychiatry Products in the FDA's Center for Drug Evaluation and Research. "The approval of Vyvanse provides physicians and patients with an effective option to help curb episodes of binge eating." The efficacy of Vyvanse in treating BED was shown in two clinical studies that included 724 adults with moderate to severe BED, as reported by Medscape Medical News. In the studies, participants taking Vyvanse experienced a decrease in the number of binge eating days per week and had fewer obsessive-compulsive binge eating behaviors compared with patients in a placebo group.

Shocking new finding: appetite suppressants reduce eating.

January 2015.  Alcohol, Depression potent risk factors for suicide.

BERLIN– Alcohol dependence and major depressive disorder are similarly potent yet independent risk factors for suicidal behavior, according to Dr. Philip Gorwood. Although alcohol use disorder and major depression are extremely common and often comorbid, the mechanisms by which they boost the risk for suicidal behavior are very different, he said at the annual congress of the European College of Neuropsychopharmacology.

Insert your own joke here. No prize will be awarded for best gag, but let's see what you got!

And yes, it is OK to joke even about suicide. Black humor often helps us all to squarely face up to very serious issues, and is therefore to be encouraged.