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.

A Great Attachment Debate?



It seems as though the nature versus nurture argument will go on forever, even though we now know a great deal about how the two of them interact in order to affect human behavior.

In the March/April issue of the Psychotherapy Networker, the cover story is titled "The Great Attachment Debate: How important is early experience?  The "debate" is over the issue of whether or not the quality of the relationship between babies and toddlers and their primary attachment figure has a profound effect on  mental health and relationships when the child grows up.  In particular, "attachment" refers to how secure the child feels and behaves with its primary caretaker.

The  two sides of the "debate" in the issue are represented by Jerome Kagan, Ph.D. on the one hand, and the tandem of Alan Sroufe, Ph.D. and Daniel Siegel, M.D. on the other. Kagan researches the effects of inborn temperament, personality, and neurobiology.  Strouffe is a developmental child psychologist.  Siegel is a UCLA psychiatrist who wrote a highly influential book called The Developing Mind.



Jerome Kagan




Alan Sroufe



Daniel Siegel

Jerome Kagan thinks that the "pro" attachment side downplays the importance of both cultural influences and inborn, genetically determined temperament in creating an adult's personality and vulnerability to psychiatric disorders.  "Temperament refers to an inborn predisposition to experience certain feelings and display particular behavior during the early years," he explains. 

The intial work on innate differences in infants in qualities such as activity levels and reactivity was done by child psychiatrists Stella Chess and Alexander Thomas.  The temperament issue represents the "nature" side of the nature-nurture debate.

The "nurture" side of this debate centers around the thesis that the emotional quality of our earliest attachments is a far most important influence on human development than inborn temperament.  Attachment theorists pay particular attention to something they call attunement, which they believe is more important in creating the quality of the infant's attachment than, say, the mother's general traits such as maternal warmth.

Sroufe and Siegal explain, "Attunement, or sensitivity, requires that the caregiver perceive, make sense of, and respond in a timely and effective manner to the actual moment-to-moment signals sent by the child."  The parent has to figure out, for example, how much emotional stimulation a baby needs at any given time.  Too much or too little can disturb the baby, and the baby's need is not a constant but varies widely over even brief periods of time.

I think this whole debate is somewhat silly and depends for its existence on an assumption about attachment that really does not make a lot of sense to me, as I will describe shortly. 

So what do I think is more important in human development, inborn temperament or attachment relationships?  Well first of all, both of these variables always contribute to development.  Second, inborn temperament itself affects and alters attachment patterns.   For example, a colicky infant with an insecure  and anxious mother is a bad combination, while the same mother with a quiet child may do a lot better parenting job in regards to attunement.

The answer to the question as to whether temperament or attachment patterns has the greater effect on ultimate development is, as with almost any question in psychology, it depends.  If the family is accepting and validates the innate predispositions of the child, you get one result.  If they invalidate and denigrate them, you get an entire different result.  The way the child acts also can elicit invalidating reactions from peers and teachers, leading to a sort of self-fulfilling prophecy, as Kagan points out.

Neither side talks about the importance of the choices a person makes, the reasoning they use, or their problem solving strategies in the determination of how a person ultimately acts.

Furthermore, the attunement of the parent to the baby, and what behaviors the parents validate or invalidate, can be quite different at different times. Plus,  there are literally hundreds of other influences on the child which also vary in time. 

With all these factors at work, there is also an effect from what scientists refer to as chaos, in which small changes in initial conditions can lead to big differences in complex phenomena like human behavior later on. This is known as the butterfly effect: the presence or absence of a butterfly flapping its wings could lead to creation or absence of a hurricane. 

It is interesting that the debaters do seem to agree on some points.  Both agree that serious neglect or abuse of infants during their first year or two of life can harm the child's future psychological development. 

I actually disagree somewhat and think that infants are more resilient than they seem to think.  For example, say the mother had an untreated post-partum depression during a baby's early life, but then got treated and became far more attuned to the child.  Chances are, any ill effects of the child's experience during the first two years of life would then be reversed.

 
In this vein, both sides also agree that human psychology can change depending on later experience.  If it could not, then they would both have to think that psychotherapy would be a complete waste of time.  They agree that neither biology nor parenting experience is destiny.  I should certainly hope so.  If we could not adapt to changing environments, our species would have died out eons ago.

Kagan also says another important thing which sometimes gets lost in nature versus nurture debates. Genetic influences on behavior do not determine later personality variables so much as limit them.  This is easier to see with physical traits.  No matter how much Danny DeVito might have trained as a young man, he would never have been able to swim as fast as Michael Phelps did.  Wrong constitution!  This does not mean, however, that training would not have improved DeVito's lap times.
 
A hidden assumption in the whole debate that drives me bonkers is that the most salient patterns in the primary relationship between children and their parents somehow no longer influence a child past the age of two.  Or if you are a psychoanalyst, past the age of five.  Attunement, invalidation, the interactions between the temperaments of parents and children - in short, all of the most salient aspects of their relationship - often continue on and on in slightly altered forms, almost until somebody dies. 
 
If you study the "persistence" of temperament and the security of attachment from childhood to adulthood, and draw conclusions based on just what happened in the first two years of life, you ignore this fact.  If a two year old has an insecure attachment with an unattuned mother, but is taken away from that mother and raised by someone else, you would get a very different view of this "persistence."  Similarly, if you limit the effects of attachment to only early attachment, you are ignoring the effects of extremely important family dynamics all through childhood and early adulthood. 
 
Both sides in the "debate" define attachment the same way.  Since controlling for all the variables is impossible, findings in the research literature will often conflict with each other.  Depending on how studies were structured, it is easy to find studies that over-estimate the importance of attachment in the first two years, and others that under-estimate it.   If on the other hand you assume that the early influences might continue on in time, and determine what they actually were, the "debate" all but disappears.