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.