Mental illness as social construct

[solumanculver]

Hi, this quote was found on the wikipedia article on "mental health professional"

"Mental health is socially constructed and socially defined; that is different professions, communities, societies and cultures have very different ways of conceptualizing its nature and causes, determining what is mentally healthy, and deciding what interventions are appropriate."

I was wondering what you all think about this idea that mental health is socially constructed and defined? It seems like what the author is trying to say is that mental health is defined as deviation from the norm, whatever that norm may be in a given society, but I think that this is false. Or, if it is true, then it is equally true for somatic illnesses as well.

In a society where epileptics are revered and treated as prophets, does that mean that epilepsy is not a disease there? Should an epileptic be treated under these circumstances if treatment would actually lower their quality of life by taking away their social status?

Most people would say that epilepsy is still a disease under these circumstances, but the choice of whether to treat is influenced by non-medical factors. Why would a psychiatric disease be different?

I haven't been to medical school, but I was wondering, do you guys learn a rigorous definition for "disease" there? Particularly as applied to psychiatry...

Does an unrepentent pedophile have a disease? He is abnormal but pedophilia isn't exactly harming him... it's harming others. What if he lives in ancient greece or something where it's socially acceptable? Should we say that since mental illness is socially constructed that he has no disease, or that he does have a disease but social factors make treating it less urgent to treat?

In these cases would the presence or absence of biological markers even be relevant? Suppose pedophiles always have protein P in their bile... In a place where pedophilia wasn't considered wrong, pedophilia would seem to be a biologically marked disorder without any harmful symptoms. Or is it once again a real disease that's present in an environment that makes treatment only marginally useful...

It seems like it's in the best interest of biological psychiatry to assert the second option, that it's always a disease but not always needs to be treated...

Or maybe "disease" itself is a normative term and can't be objectively defined?

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[i61164]

They haven't really talked about this at my med school, but it seems like a philosophical question. In my mind, the word disease implies some kind of suffering. If there is no suffering either right now, or later in the person's life, then nobody cares. Genes don't always get expressed, so you biological markers are not a perfect way to characterize disease. Epilepsy is revered by the Hmong, but a really big seizure causes a lot of harm. So maybe they just have a higher threshold at which they would consider it disease. That gets into the whole idea of cutoffs for disease. If your blood pressure is 200/100 you have a disease, but what if its 130/90? It's hard to pinpoint sometimes. Still, if there are no consequences either now or later, then I would have a hard time calling it disease. Of course, consequences include "social" consequences.

 

[solumanculver]

Still, if there are no consequences either now or later, then I would have a hard time calling it disease. Of course, consequences include "social" consequences.

The problem with that is that we can't tell whether a person will have consequences later. What if a person had HIV their entire life, in Africa for instance, but didn't really suffer from it and died of unrelated causes. Does that mean that HIV wasn't a disease in that case?

 

[i61164]

I'm not sure if HIV really is the disease. Once HIV has become AIDS, the person is suffering and it is clear that it is a disease. If you had HIV and it was subclinical, and your immune system conquered it and it went away, you would not have had the real disease (which is AIDS).

But if 99% of people with HIV get AIDS, people will be willing to take some medicine to prevent the progression to AIDS.

The same goes with heart disease. If you have mild hypertension that causes you no trouble at all, the only reason you are willing to take a pill every day is to prevent the heart attack down the line. There was no 100% guarantee that you were going to have the heart attack and you still could have one even though you take the medicine.

I guess that I still think that disease is what you have when you are actually suffering. Before that, you have "risk factors" that mean that you are likely to progress to disease without some sort of intervention.

 

[solumanculver]

So are you saying that not only are mental illnesses social constructs, but physical illnesses are as well, inasmuch as illness can only refer to something that is actively causing harm...? But what about pedophilia that may actively harm others but not the pedophile himself, provided he lives in pedophilistan, where that behavior is ok? Does he have a disease?

 

[Chewbacca Jung]

I think a better perspective of medicine, mental health, etc,... is that the concept of "disease" is a social construct trying to describe an objective phenomenon. I think that pure objectivity is an ideal that will never be fully attainable- hence the social construct-- but there is some element of objectivity-- such as biological markers that you are talking about that we are building all of medicine off of. The real question is whether this biology thing is really directly relevant to anything, or whether it is all one big surrogate for something much deeper.

A large portion of mental health disorders entail a subjective experience. This is very influenced by the socio-cultural landscape. The swing of diagnostic thinking in the DSM however is moving in the direction of more objectifiable data-- actions as opposed to thoughts. According to this line of thought, a pedaphile is really someone who has acted out his thoughts. Someone merely contemplating or phantasizing, is at risk for pedaphilia. --is this definition of pedaphilia better than the definition you are refering to? is it more accurate, useful for prevention of harm and mobilation of resourses... I guess that's another philosophic discussion

One interesting theme is the concepts of judeo-christian sin and guilt and excusing abnormal behavior- (if not excusing, than trying to make meaning out of the behaviors). Most of psychiatry's foundation is built around these western concepts.

Also think about the concept that psychiatry deals with "taboo"-- the unacceptable in society-- drugs, hypersexuallity, laziness, uncontrollable urges, the insane... (I know I'm talking about generalities) Will psychiatry ever become acceptable to society at large? If any of these became acceptable in society, would it be a psychiatric issue any longer?


anyway, more food for thought...

 

[i61164]

So are you saying that not only are mental illnesses social constructs, but physical illnesses are as well, inasmuch as illness can only refer to something that is actively causing harm...? But what about pedophilia that may actively harm others but not the pedophile himself, provided he lives in pedophilistan, where that behavior is ok? Does he have a disease?

Well, if I was a citizen of pedophilistan, I would not think the pedophile was sick and so I would say that he does not have a disease.

In our society, it is not so clear to me. Is pedophilia a disease, a crime, or both? To what extent is the person responsible for their actions? Maybe this would be a good question for a forensic psychiatrist.

In my opinion (whatever that's worth) disease is not an a very precisely defined term. If that means that it is a social construct then I guess it is. Being labeled with a disease certainly has a social impact. It can change the way others see us, the way we see ourselves, and the way our employers and insurance companies see us. When a person get diagnosed with cancer, the disease did not begin the moment the physician wrote the diagnosis in black ink, but much of the suffering does begin at that moment.

 

[Zoom-Zoom]

My 2 cents... One of the best definitions of psychopathology is Wakefield's concept of "Harmful Dysfunction." He asserts that mental illness must be both dysfunctional- ie: some evolutionary trait has failed to do its function- and harmful- as in, the dysfunction is considered to be undesirable socially. Mental illness cannot be defined as an individual judgment for obvious reasons, and it cannot simply be defined as "abnormal" because many statistically infrequent mental processes and capabilities are not considered "illnesses." Likewise, what is considered mental illness changes drastically over time and across cultures. The social judgment is absolutely necessary.

 

[whopper]

I was wondering what you all think about this idea that mental health is socially constructed and defined?

This is why any good psychiatrist needs to really understand psychiatry, not just as a list of facts and logarithms but have a good view on what and what is not pathology.

Example homosexuality was once considered a psychiatric disorder in the DSM. Many of the diagnoses are voted on by committee. Before any antipsychiatrist jumps on and attacks the field, all medical norms are pretty much voted by committee. However the fact that psychiatry still is in the phase where there is less objective criterion, you still have to consider this in your judgement.

One clinical rule I consider is--is the patient showing something on a mental health level that is harmful to themself or another (not just physically, mental health wise too) that they want help with? If so, is this biological (if yes--more likely to prescribe meds), if not more likely to reccomend psychotherapy, self help & education.
If they don't want help, and they're not putting themselves in physical harm, I'll just tell them they really shouldn't see a psychiatrist at that point.

Unfortunately many psychiatrists I've seen are lazy and just want to lump some dx and slap on some meds so they can get their pay. Again before someone jumps the gun to use this to attack the field, this occurs in every medical field. There's lazy bums in every field. Just like the lazy surgeon doesn't scrub properly--and that's how laziness screws in that field, it screws up psychiatry because of the misdiagnosis and use of meds when not needed.

 

[toby jones]

Yes, Wakefields 'Harmful Dysfunction' (HD) view has been very influential. Other theorists (such as Boorse) take a similar line. Sometimes it is known as the 'two-stage' view. The notion is that in order for something to count as a disease there are two individually necessary and jointly sufficient conditions:

1) There is dysfunction.
2) The dysfunction results in consequences that are harmful.

The relevant notion of function is controversial. Wakefield goes with evolutionary function but that is problematic. One could go with current function instead (in the sense that Harvy understood the function of the heart well before Darwin). However you cash out the relevant notion of function, there are thought to be facts about malfunction that are objective, however. The notion of 'harm', on the other hand, is thought to have more to do with social norms.

There is controversy over whether there is an objective first stage. This is an assumption of the medical model, however.

One problem is that if mental disorders are mental malfunctions then if the mind wasn't modular there may be no mental functions for there to be mental malfunctions. It seems implausible that mental disorder committs us to a massively modular mind a-priori.

The debate continues...

Murphy maintains that focus on the analysis of the concept of mental disorder is an impediment to scientific research.

I'm concerned that it might well be an impediment to ethical considerations as well.

Not sure.

(There is a debate in the journal 'Philosophy, Psychology, and Psychiatry' if you are interested)

 

[Chewbacca Jung]

There is controversy over whether there is an objective first stage. This is an assumption of the medical model, however.

One problem is that if mental disorders are mental malfunctions then if the mind wasn't modular there may be no mental functions for there to be mental malfunctions. It seems implausible that mental disorder committs us to a massively modular mind a-priori.

So i'm intereted, but could you explain this part a little more explicitly? I don't quite follow.

 

[toby jones]

All this is controversial, and it is a bit of a mess to try and explain, but I shall do my best.

Firstly, it is important to note that there are a few terms lurking in the vicinity: disease, disorder, malfunction, dysfunction. Sometimes they are used interchangably, and sometimes different theorists define them a bit differently. I'm less interested in the normative arguments around how we should use these terms (which is what the debate is typically focused on) and more interested in the nature of the phenomena that is of interest, however. I'll use the term 'malfunction' throughout but you can substitute it for your favourite if you prefer.

OBJECTIVISM: Is the view that there are objective facts about function and thus (derivatively) there are objective facts about malfunction. E.g., the function of the heart is to pump blood. When the heart fails to pump blood then the heart is malfunctioning. There are problems with how you fix the relevant function (hence malfunction), but I hope you get the intuitive idea. (Part of the motivation for this is to distinguish between malfunction and 'problems in living' which are not due to malfunction. E.g., 'enhancement surgery'. Another motivation is to secure medicine on a scientific foundation where the facts that determine malfunction are objective).

CONSTRUCTIVISM: Is probably easiest understood as a denial of the above, which is to say it is the view that there aren't objective facts that determine that there is malfunction.

One could say 'since there aren't objective facts there is really no such thing as disorder'. One could say 'since there aren't objective facts we have discovered that disorder must be fixed by non-objective facts'. That is a dispute about how we should apply our terms, however, and I don't wish to get caught up in that.

If the relevant facts aren't objective (in the sense I defined above) then what are the relevant facts that determine that there is malfunction? One candidate is that the relevant facts are normative. One way of stating the view is that there are people who act in such a way that they break social norms. We notice that they break social norms and then we search about for something to medicalise (for some inner malfunction) in order to better justify our involountarily treating them. On this view psychiatry is a form of social control and not a form of medicine as the relevant facts are social and not objective.

Aside from the controversy over how you fix the relevant function there is also controversy over whether the function of a PERSON or the function of PARTS / SYSTEMS WITHIN PERSONS is primary. If you take the function of a person to be primary and the function of parts of people to be derived then there needs to be facts about the function of a person in order for there to be facts about the function of parts of a person. Whether there is any such thing as a function of a person is something that has been debated ever since Aristotle introduced the notion of function. Constructivists often attempt to argue that there is no objective function of a person hence there is no objective function of parts of a person hence there is no objective notion of function.

But surely there is an objective notion of function. (If there isn't then medicine isn't a scientific discipline). So...

One way to avoid this debate is to say that the malfunction that is relevant is a malfunction of a component system. Thus the function of the parts is primary and the function of a person is derived. You could thus say the person is malfunctioning in virtue of having a malfunctioning heart or you could simply restrict yourself to say that the person has a malfunctioning heart (I really don't want to get caught in this verbal dispute about whether this counts as a person malfunctioning or not). Either way, to talk about the function and malfunction of part of a person doesn't seem to rely on their being facts about the function of a person.

One notion is that the idea of a malfunctioning system within the person fits in very well indeed with the medical model. Trouble is that you need there to be systems that we can assign functions too, however. The problem for psychiatry is that there can only be mental dysfunctions if there are mental functions. Mental disorders are often taken to be paradigmatic examples of 'irrationality' but where is the mental system whose proper functioning is 'rationality'? If the functions are supposed to be fixed by a Millikan / Neander style evolutionary function then reading disorders won't count as malfunctions because the mechanisms that subserve language didn't evolve to have that as a proper function. Instead people talk about Cummins style current functions but that has problems too. There is a big debate in the literature about what the relevant functions are and about whether there are objective facts about the function of a system.

E.g., There is a TOM (theory of mind module) whose function is to attribute beliefs to others. People with autism have a malfunctioning TOM and hence autism is a mental disorder.

But is there any such thing as a TOM?

Lets try that again...

There is a SAM (shared attention mechanism) whose function is to enable mutual gaze. People with autism have a malfunctioning SAM and hence autism is a mental disorder.

Are we searching about for something to medicalise?

The trouble with defining 'disorder' as requiring malfunction is that if we take a paradigmatic example of mental disorder and we discover that there is no malfunction then that instance would not count as a mental disorder. That seems extremely counter-intuitive.

I think that we should start with the paradigmatic examples and try and figure out what they have in common. Trouble with this is that it does in fact seem as though we are casting about for something to medicalise...

But surely that is okay? It just means that psychiatry's status as a discipline within medicine is a bit tentative... And further facts could undermine that... More work needs to be done on the relevant notion of function I think. And... The function of a person. Axis V seems to be something along the lines of a function of a person...

(I hope this will work for those with Muse access)
http://muse.jhu.edu/journals/philosophy_psychiatry_and_psychology/toc/ppp7.1.html

 

[worriedwell]

toby jones,

while I certainly appreciate your thorough post, I also would gently like to let you know that you will engage more dialogue and pique the interest of more people if you use more plain language and less philosphy-speak.

here's what I'm thinking (and a little introspection makes me realize that I may start from a point of wanting to validate my own existence as a psychiatrist in training, so that is a disclaimer):

a subset of people in our society are cognitively or emotionally suffering and thus unproductive. while the suffering is oftentimes difficult to measure (but I don't get TOO bogged down in trying to measure it, it is often enough for me as a clinician to note subjective suffering and then want to help someone with that), productivity of a person is not as hard to measure. an easy way is through the measures of ability to work, ability to engage one's peers and be in relationships, etc.

the argument against medicalizing certain parts of psychiatry are...when a millionaire goes to the psychiatrist and says "I feel empty inside" or "my life doesn't have meaning?". these people, who you can sit with for 1 hour weekly for 5 years and charge an arm and a leg are not going to a "doctor", they are going to a guru or they are getting mental cosmetics. you don't need to be a physician to treat that. are they really "sick" or lonely? and when is it our role as a society to tell them to suck it up, because they aren't sick they are just being whiny and they don't have a right to be?

should there be a difference between what a psychiatrist treats and what a psychologist treats? should the "whiny" people just go to see psychologists such that psychiatrists only see themselves as medical doctors. I don't think so neccessarily at this stage in time, partially because the line is so gray based on our lack of good measuring tools of brain dysfunction. i think psychiatrists should use the training of good medical background, good psychotherapy training, and good use of psychosocial resources to best help a patient or refer them to what they will benefit from. if that means that i have a bias towards medicalizing behavior then so be it...keep in mind though, i'm not advocating medicating everyone, and the balance for when medicine is neccessary is continuing to be worked out (with some large influence from pharmaceutical companies of course). but as the "medical" knowledge of mental illness grows, it will make it more imperative for the psychiatrist to be the single best trained diagnostician and treater of mental illness.

the definition for who is sick is arbitrarily set by "thought leaders" in psychiatry the same way the cutoff for hypertension is arbitrarily decided by thought leaders in medicine (after determining where morbidity and mortality are worst). but these disease states in other fields have evolved and are continuing to evolve as the years go on. remember when the food pyramid with lots of carbs at the bottom was thought to be the ideal diet? now its all about low carb. i realize diet is a slightly different example but you get the point about what definitions exist and how they evolve. it doesn't mean that the fields of medicine are invalid, it just means they adapt and revise.

in psychiatry, measuring morbidity and mortality are defined by different constructs though than other fields, but they are always constructs.

at this stage, symptom relief for constructs of diseases is the best we can do. as dsm evolves and brain research evolves, then maybe diseases can be identified and make the medical paradigm more valid. does that then make the illness something that neurologists treat? no, not at all-and then maybe people will have this debate not about "psychiatry" in general, but about diseases that have yet to have brain evidence for them. the brain is the final frontier though, and a lot of that is going to take a while.

and by the way, involuntary hospitalization is a different conversation regarding "medicine" vs social control that we probably should not get into in this thread.

one thing that i do notice though is that for doctors going into psychiatry or thinking about going into it, there is a big concern that the nature of being a psychiatrist is not "medical" enough for them. and the irony is that "better" applicants are going into psychiatry these days because the "medical" aspects of psychiatry especially in relation to the brain are becoming more clear and the excitement is there for the future (not to mention the lifestyle is better than other fields). but the reality is, as a practicing psychiatrist, one thing you have to start getting comfortable with (if you want to be good at what you do) is that you often are not acting the way other "real" doctors act. the paradigm of illness that you treat is much more poorly defined. get used to it.

it just blows my mind that some people though wouldn't think of something like Schizophrenia, Bipolar, OCD etc as a true malfunction of certain brain mechanisms. how is it not a disease? now is sleep work shift disorder a disease? i don't know. but just because some illnesses are best treated through behavioral mechanisms doesn't mean they aren't diseases. heck type II diabetes, when at an early stage, is best treated through behavioral mechanisms too (excercise and eating less), but we still are very comfortable calling that a disease and we don't jump down internal medicine doctor's throats for prescribing a pill to treat the illness. but the hypocrisy remains because of mind body dualism. science in the end will end this debate, just give it some time.
best.
worriedwell

 

[toby jones]

I'm sorry that wasn't clearer. It is hard to try and extract a few central issues without unnecessary confusion.

The notion of suffering is a tricky one. I've heard it said that sociopathy (as one example) is primarily a problem in that OTHER people suffer rather than the individual who is supposedly mentally ill. People with borderline personality disorder are more vocal with suffering than most and yet psychiatrists often try to discharge them into the care of other health professionals saying that axis II disorders aren't 'really' mental illnessess. People in the grip of a manic episode aren't suffering, and yet they can be involountarily committed because they are regarded as being mentally ill. There are many people who suffer who we don't regard as mentally ill as well. That means that suffering seems to be neither necessary nor sufficient for mental disorder.

> they aren't sick they are just being whiny

are you planning on saying this about all your patients who you don't know how to help?

> the line is so gray based on our lack of good measuring tools of brain dysfunction.

precisely what is at issue is whether there are facts about mental dysfunction that determine whether or not an individual is mentally ill. It is important to distinguish between the current state of things and some idealised 'final science' state of things. The debate is supposed to be about the future state of things rather than the present state of things, however. If objectivism is true then if we know the facts about mental functions and the facts about a particular individuals brain we would know whether they were mentally ill or not... If constructivism is true, on the other hand, then facts about malfunctioning brains aren't suffucient and we would need to know the facts about the norms of the persons society in order to assess whether their behaviour violates the norms or not.

(A problem with constructivism is that it needs to tell us what norms are relevant for mental disorder. We distinguish between someone who breaks societies norms and yet doesn't count as mentally ill (e.g., someone who wears underwear outside the pants) and someone who breaks societies norms and does count as mentally ill).

> the definition for who is sick is arbitrarily set by "thought leaders" in psychiatry

but surely we want to distinguish between 'good' and 'bad' decisions? for example, when political dissentors in Russia were diagnosed with sluggish schizophrenia on the basis of their belief in supply-side economics don't we want to say that even though these people were breeching social norms psychiatrists were mistaken about their being mentally ill? don't we want to say that there are facts about whether addiction and sociopathy and homosexuality and pedophilia are mental disorders or whether they are moral failings or whether they aren't either of the above?

> the cutoff for hypertension is arbitrarily decided by thought leaders in medicine (after determining where morbidity and mortality are worst).

i think that the part about them determining where morbidity and mortality are the worst is fairly crucial. i guess the trouble with the present state of psychiatric diagnosis is that it is based on behavioural symptoms. as such 'schizophrenia' is fairly similar to a 'cough disorder' so it is unclear that morbidity and mortality statistics will help us.

whether psychiatry and neuroscience will eventually merge is a matter of controversy. typically biological reductionists are in favour and those who take no level to be fundamental (e.g., advocates of the biopsychosocial model) are against it. social constructionists think that the relevant facts that determine whether or not we judge an individual to be mentally ill are social facts. as such the merger wouldn't happen unless neurology is similarly shown to be fixed by social facts. that doesn't seem likely though.

> it just blows my mind that some people though wouldn't think of something like Schizophrenia, Bipolar, OCD etc as a true malfunction of certain brain mechanisms.

i'll give you an analogy (from Wakefield):

the Y2K problem was a software problem and not a hardware problem. There was nothing wrong with the computers. The computers hardware was not malfunctioning. The problem is that the input (00) was outside the designed range in the sense that it wasn't designed into the software that the computer should read 2000 instead of 1900. If the systems had have read 1900 then that would not have been a malfunction but it would have produced 'faulty' output. Another example would be that if a person produces neurotransmitter at the high end of the normal range and has receptors that are at the high end of the normal range although the system is within normal range outputs can be devient. It is far from clear that devient outputs must be caused by devient inner functioning. Another way you could get devient inputs without inner malfunction would be when the input is outside the designed range (as in the computer example) such as being persistently told that you are worthless, for example... Whether mental illness is always caused by inner malfunction or not is an empirical matter but it seems plausible that it is not. Which brings us back to why it is that we judge the behaviour to be devient... And the problem of a function of a person (not to suffer you think).

 

[worriedwell]

of course the measurement tools we use are socially constructed. is being paralysed on half of one's body a social "norm". didn't that happen because of a stroke which is a medical illness? we wouldn't give a crap about improving the stroke risks or treating the stroke if we didn't care about the social consequence of the illness. they are not inseparable. its the difference between trying to distill things into a theory that differentiates constructivism vs objectivism or just realising that all of medicine incorporates both theories practically when defining the role of "doctors" and the definition of diseases. maybe i'm not getting something or maybe this is just about semantics and the argument has no relevance to real life, but singling out psychiatry as different than other fields of medicine is what bothers me.

it requires defining the term doctor and the historical role of doctor in general to have this discussion. it also requires an understanding of history and how many VERY VERY "medical" diseases as the advent of antibiotics has shown as one example, used to have extremely bizarre and elaborate social constructs and consequences. the diseases are initially identified and called into question due to the social ramifications of things.

and yes morbidity and mortality are central, but again it requires morbidity to be defined in all of medicine.

but almost all rheumatologic illnesses or other syndromal type illnesses are widely accepted as diseases and doctors who treat them are using the limited tools they have to diagnose and treat. oftentimes diagnosis is based on patterns of recognition (or checklists of symptoms). you don't get people calling that into question though (with maybe the exception of fibromyalgia). but there is an inherent bias against psychiatry (i think its appropriate for you to claim any affiliations with scientology now if present, as a full disclaimer of bias).

why is it not acceptable for behavioral medicine to have a subset of conditions that are well defined "brain disorders" by imaging and post mortem analysis as well as genetic testing or other endocrinological markers, and a subset of "learned" disorders based on how they were raised psychologically or socially, and more realistically to realize that much of what will be recognized is some interplay of these factors?

and by the way, mania clearly is a form of suffering when objective functionality and consequences of actions are measured (of course, with an unavoidable element of social values being factored in, just like all other medical illnesses). is delirium suffering? we can never ask a patient if they are and we treat them against their will. again, i don't want to get into the argument of involuntary hospitalization because that clouds the picture a bit because there is a clear and undeniable aspect of "safety" to society that exists in the job of a psychiatrist that doesn't in other fields of medicine which may contribute to the stigma against the field as a whole.

its completely circular to argue about "disease" being socially constructed because the sick role is mainly what defines disease. doctors treat organs using logical conclusions about the illness's consequences without ever losing sight of the bottom line aspect of morbidity and mortality of patients. you could argue that some disease constructs in society right now are too loosely defined especially characterological traits. but addiction is very clearly evidenced to have biological underpinnings of dysregulation (of course after the initial choice is made to use, but even before then, one sees certain objective markers that are abnormal). and the sad thing is that there is no treatment for the disease but the biopsychosocial elements in place can keep the morbidity and mortality at bay for a percentage of people that have the resources. this is no different than a diabetic having the resources to hire a personal trainer and to choose to eat right. in fact, a lot of obesity work right now involves studying the mechanisms of addiction through both behavior and neurobiology to try to improve the morbidity and mortality of "being fat" which people seem to be ok with "medicalizing" and paying doctors to try to treat the condition. is this flawed logic? is there not a biopsychosocial aspect of this condition? and i'm not being a biological reductionist by feeling that scientific advancement will improve the condition of obesity by mapping out genetic, psychiatric, endocrine, and other conditions that will further solidify the biological underpinnings of something like obesity. believing in science does not exist mutually exclusive with believing in the importance of biopsychosocial approaches.

is it a slippery slope to medicalize all things that have a "behavioral" element? maybe. but most medical diseases including cancer having behavioral components to them. and many medical illnesses have psychological component to them (psoriasis flares for example). so we aren't really talking about "fringe" illnesses in my opinion until we start talking about thinks like sociopathy or pedophilia which there is a legitimate debate to. but its absolutely wrong to lump "psychiatry" into this field of "social constructs" that is somehow different in its entirety than other areas of medicine. I will agree that the practice of it is quite different than some fields of medicine, but thats why we train in subspecialties as physicians. we remain, however, physicians first in spirit and in philosophy with the sad limitations of what we can offer being apparent.

 

[Chewbacca Jung]

while I certainly appreciate your thorough post, I also would gently like to let you know that you will engage more dialogue and pique the interest of more people if you use more plain language and less philosphy-speak.

I'm going to have to disagree. I think toby jones brings up some important concepts that psychiatrists would do well to learn about and keep in mind. This isn't just an exercise in semantics-- these are basal concepts to the heart of psychiatry, which tend to get pretty muddied. He's defining some concepts, that are essential to any debate about psychiatry. There is nothing scientology about it. Without defining these concepts, in fact, you are much more likely to end up with the endless semantic debates that tend to occur on this forum.

but singling out psychiatry as different than other fields of medicine is what bothers me.

Psychiatry IS different than the other fields of medicine, for the reasons toby jones stated, and many, many, many others. That is why I am so exited about going into it. Live with it, learn about it, don't feel so insecure about it.

Normal

Normal, normal, normal-- what's normal? How do we know humans are even normal-- or that abnormal behaviors are actually abnormal?


it just blows my mind that some people though wouldn't think of something like Schizophrenia, Bipolar, OCD etc as a true malfunction of certain brain mechanisms. how is it not a disease?

There are many layers to your amazement. Nosology alone presents a formidable problem to accepting these disorders as is. For example:

People who exhibit abnormal behaviors along with aberrant thoughts tend to cluster in their behavioral and thought patterns. This is what we know for sure. The leap from that to various d/o in the DSM is a result of historical context, some bench research, empirical therapy, and a lot of politics. Is schizophrenia or any of these d/o's one disease entity-- or the end result of multiple counter crossing disease pathologies-- could they possibly eventually be subdivided like Multiple sclerosis, i.e. chronic progressive, intermittent remitting... . The behavioral and thought clusters could be revised in a number of different schema-- Functionally, biochemically, diagnostically, medical billing-ly...

Reproducibility of these disorders in a clinical encounter also dims the light on these disorders. Bias, incentives, parental pressure, billing... all put a strangle hold on the objective nature of mental disease.

 

[worriedwell]

I think toby jones brings up some important concepts that psychiatrists would do well to learn about and keep in mind.

I agree with the above statement, I didn't say he isn't bringing up important concepts, just giving the advice that it takes energy to engage in the language he used and finding ways to make the language more accessible is of benefit to getting psychiatrists to "learn the concepts" as you so smugly imply.

And when one as a "therapist" is engaging in all the tools at his disposal, I believe that clinically (not sure how much clinical experience you have) it is an endless circular argument that does not have significant bearing in terms of how you practically DO your job per se. Its like asking an airline pilot to be able to describe every part of the plane motor and the physics behind all of the engine. Sure it might help them be the most self actualized airline pilot they can be to be at peace with knowing why they are flying, but thats more for his or her own mental masturbation. Until there is significantly more scientific knowledge or a major societal paradigm shift, the argument is a philosophical one that is DEFINITELY important but not practically a major driving force in the day to day aspects of how you react to people sitting in a chair in front of you. Because the doctor-patient relationship and the paradigm in which it exists is the fundamentally most important aspect of what we do as psychiatrists without question AT THIS POINT IN TIME and likely indefinitely.

Psychiatry IS different than the other fields of medicine, for the reasons toby jones stated, and many, many, many others. That is why I am so exited about going into it. Live with it, learn about it, don't feel so insecure about it.

It is also the same as other fields of medicine in the ways that I described. Do you have anything to say about that? THE CONCEPT OF THE ENTIRE EXISTENCE of PSYCHIATRY as a metaphor for illness or vehicle for social control represents the viewpoints of antipsychiatrist and scientologists. What should be debated is whether certain syndromes should be medicalized or not, but not EVERY SYNDROME described in psychiatry. hence the reference I used. I already gave a disclaimer about how I have a bias towards supporting the position of psychiatrist as a physician, whether that is insecurity or not is debatable and I'm open to being introspective about it.

Normal, normal, normal-- what's normal? How do we know humans are even normal-- or that abnormal behaviors are actually abnormal?


Blah, blah, blah...this is a very weak statement that just opens up a silly can of worms that I don't feel like getting into. it applies to any and every field of medicine by the way which again goes against the argument that singling out psychiatry as somehow inherently and drastically different paradigmatically. It is an existential conversation stopper and not useful in the conversation. The idea of mental functioning and behavior being defined as normal or abnormal is not the point. The idea of decreasing morbidity and mortality is the point, always, and if that means behavior is medicalized, then so be it. And of course mortality is pretty objective but morbidity is a cultural and socially and cognitively constructed phenomenon even in physical illness ALWAYS. Again, the same for psychiatry and all fields. The matter of whether behavior or cognition can be as effectively "treated" by clergy (and religious purpose) or by behavioral psychologists etc is an important question in terms of whether the "syndromes" should be taken away from a "medical disease" and moved into some other realm like religion or learning. However, my example of other so called "physical illnesses" like diabetes and hyperlipidemia, heart disease, copd, obesity and many more all having behavioral components that can be augmented and even eliminated by behavioral plans goes against the idea that disorders with learned or behavioral components don't "fit into the medical model of things". After all what is the field of preventative health all about?

The condition of "illness" is not in my opinion defined by the organ it inhabits (because the organs cannot exist independently and the disease is never limited to only affecting one organ). Rather illness is defined by examining if the condition or the measureable cluster of symptoms that don't YET clearly have a singular causal agent causes morbidity and mortality. It really should not go deeper than that in my opinion and in the real world, I'm not sure that it does.

There are many layers to your amazement. Nosology alone presents a formidable problem to accepting these disorders as is. For example:

People who exhibit abnormal behaviors along with aberrant thoughts tend to cluster in their behavioral and thought patterns. This is what we know for sure. The leap from that to various d/o in the DSM is a result of historical context, some bench research, empirical therapy, and a lot of politics. Is schizophrenia or any of these d/o's one disease entity-- or the end result of multiple counter crossing disease pathologies-- could they possibly eventually be subdivided like Multiple sclerosis, i.e. chronic progressive, intermittent remitting... . The behavioral and thought clusters could be revised in a number of different schema-- Functionally, biochemically, diagnostically, medical billing-ly...

Reproducibility of these disorders in a clinical encounter also dims the light on these disorders. Bias, incentives, parental pressure, billing... all put a strangle hold on the objective nature of mental disease.[/QUOTE]

No Sh#t Sherlock. I realize there are biases etc that cloud the judgement of disorders and diseases, and I love the field too because of the progress that needs to be done to distill some of these things, which again are not unique to psychiatry but probably most prevalent and disgusting in psychiatry based on "insecurity" and other pressures that you mention. And I never proposed to accept these disorders as is and just stop thinking about them or trying to better categorize them...even including schizophrenia. The DSM, like all other fields of medicine (read some of Dr. Robert Spitzers thoughts on the the subject) is a place to get started.

The genotype of schizophrenia at least in terms of "gold standard" objective types of measures like brain imaging is pretty compelling if not definitive that there is an organic quality to the illness. The same way we can do a cath and define coronary artery disease by how "clogged" the artery is, we can image the brain or use other measures of brain structure and function that show schizophrenia. Now our tool of measuring it is not as "gold standard" as a cardiac cath, which is why we currently define schizophrenia clinically, but I expect that to change over the next number of years as SCIENCE progresses.

Its interesting because what it means to BE a psychiatrist right NOW and for the near future means that one acts in many ways that are more generically "medical" based on the concept of what the doctor-patient relationship is and despite what you imply chewbacca, that is ok with me and in fact the most rewarding part of my job (god knows the current state of the science isn't very satisfying). But this is exactly what other medical fields of science have evolved through, yet they still are "medical" fields that used all the tools from medication to surgery to psychosocial measures to reduce morbidity and mortality based on the compilation of knowledge available to them at that point in time. Psychiatry is no different from that point of view. AGAIN I'm NOT SAY PSYCHIATRY HAS NOTHING UNIQUE ABOUT THE PRACTICE OF IT, but I am saying that I expect it to evolve such that at some point the philosophical debate about it's validity as having "medical components" will be more about naivety that anything else. Just like people used to think the world was flat. I'm frankly shocked that this debate is still so vigorous even among mental health professionals.

I've heard some posit that it is so strongly resisted partially because the paradigm of religion and the need to feel free to have choice (not to sound too much like Morpheus in the Matrix or anything) is so fundamentally important to people's identities of themselves that they can't accept that behavior has basis entirely in the brain. Finding strategies to augment behavior or cognition will change brain and we will be able to measure that (see Dr. Kandel's work). "Problems" in the brain give rise to distressing behavior and cognition and we will continue to refine how we measure that. Today's paradigm is science and unless the paradigm of science reverts to an entirely religious one, where the entire definitions change, then the argument is somewhat moot and very clearly already with unmistakable evidence. And of course, I currently operate under the assumption that the mind is derived from brain, so if that isn't where one is coming from, then the argument is apples and oranges.

Best,
worriedwell

 

[toby jones]

Do you agree with the following claim?

All behaviour is caused by the state of a persons brain.
(Or, if you are concerned that physics might turn out to be irreducibly indeterministic)
The probability of each behaviour is fixed by the state of a persons brain.
(You just need to accept one of those)

If you do accept this then the following is true:

The behavioural (including cognitive and verbal) symptoms of schizophrenia are caused (or made probable) by the state of the persons brain.

The behavioural (including cogntive and verbal) symptoms of autism are caused (or made probable) by the state of the persons brain.

So are the following:

Political dissentors behaviour (including cognitive and verbal) are caused (or made probable) by the state of the persons brain.

Psychiatrists behaviour (including cognitive and verbal) are caused (or made probable) by the state of the persons brain.

I hope you get the idea.

Now, a problem with psychiatric diagnoses is that they are made on the basis of the persons behavioural symptoms. That means that we are judging the person to be 'mentally ill' or 'not mentally ill' on the basis of their behavioural symptoms. I mean... You don't do neural imaging to try and locate the neurological malfunction in order to make a diagnosis - do you? Even if we did find neurological malfunction it seems we would have no grounds for regarding the person to be mentally ill if they didn't display behavioural (including cognitive and verbal) symptoms of the diagnosis.

That means we are distinguishing between 'mentally ill' and 'not mentally ill' on the basis of behaviours (and not on the basis of inner malfunction). So the question comes up: What is it about a persons behaviour that justifies our regarding the person to be mentally ill.

The reason why I keep bringing up involountary treatment is to draw peoples attention to the practical and social importance of regarding someone to be mentally ill. People are involountarily hospitalised and medicated on the basis of psychiatrists judgements that they have a certain kind of mental disorder and so we (as a society) would like very much for them to be getting things right and not just using their power as a form of social control.

So... How do we decide that a bunch of behaviours are indicative of 'mental illness' rather than mere 'social devience' (like the political dissentors) or 'strangeness' etc. You suggested that the criteria is 'distress' and I provided some examples to show that 'distress' was neither necessary nor sufficient for diagnosis.

Other candidates are:

statistical infrequency (which is neither necessary nor sufficient)
violation of norms (ditto)
personal distress (the one you picked out)
disability or dysfunction (ditto)
unexpectedness (which seems to tell us more about the state of the clinician than the state of the patient)

With respect to 'mental masterbation' I guess it is fairly normal to do that sometimes ;-) Kaplan and Saddock say you should ask 'how often do you masterbate' rather than 'do you masterbate'? The concern is that clinicians are trained to identify instances of mental disorder by bringing their judgements in line with the people who are training them. If that is all that it is about then if you were working in Russia you too would get good at classifying the political dissentors as mentally ill. We (or I at least) would like people to be diagnosed as being mentally ill BECAUSE THEY ARE MENTALLY ILL rather than being diagnosed as mentally ill BECAUSE WE HAVE HISTORICALLY REGARDED THEM AS BEING MENTALLY ILL or because MY SUPERVISOR TELLS ME THAT HE IS MENTALLY ILL.

Of course there are a variety of projects that the concept of mental illness is bound up in:

- law (while juries decide whether or not a person is responsible psychiatrists get to give 'expert' testimony)
- treatment (especially in the face of insurance)
- science (what is mental illness?)

The last project is what interests me the most. Here are some diagnoses whose status as mental illnesses is currently hotly disputed:

addiction (moral failing or mental illness?)
psychopathy (ditto)

Just becaue we find that neurological malfunction x is correlated with addictive behaviours that doesn't mean mental illness is a mental disorder any more than the finding that:

neurological malfunction x is correlated with pedophilia means that pedophilia is a mental disorder.

and... there are arguments to show that neurological malfunction is not necessary for mental disorder (Wakefield's Y2K example of input outside the designed range producing devient outputs in the absence of neurological malfunction).

and then... there are all the problems on how you define 'function' in order to derive the relevant notion of 'malfunction'

 

[worriedwell]

I'm not trying to say (at least I don't think) that mind is completely reducible to brain nor am I saying that the state of a persons brain is causal for all behavior in that we have no outside control of our brain through free will to act. But all illness begins with either self report or with some sort of abnormal behavior that is witnessed. In other words, somebody tells you their chest hurts, or they behave like they are having a seizure. We then decide, if we have the tools, to use different measuring tools to objectively decide if someone has more definitive evidence of a heart attack or epilepsy respectively. And we feel morally obligated (without judging them to have a moral failing) to help them.

In the case of schizophrenia, the more objective measures are not yet refined to look further when someone has symptoms consistent with schizophrenia (for example auditory hallucinations are to schizophrenia what self reported chest pain is to a heart attack- and both are laced with a lot of unneccessary hospitalization and medical costs to work those things up). The problem in Schizophrenia is that due to the biological nature of the illness (in other words yes, I believe the brain causes schizophrenia's symptoms) a person acts in manners that are contrary to their own previously witnessed baseline of decisions (and this then becomes an unfortunate chronic downhill course). Thus, they are not choosing to be a certain way. They wish they weren't that way. The consequences to them in terms of their own societal productivity in a hundred different ways is adversely affected. And the validation is that if you've ever treated a person with early schizophrenia or other psychotic disorders and you INVOLUNTARILY treat them with antipsychotics, they often will recognize how ill they were and be appreciative that they are back on track. Of course, the treatment tools and long term benefits are not really seen, but it gives you a glimpse into the fact that this individual is clearly assuming the sick role and benefits from your intervention on their brain. The same goes for mania. While they don't like being treated in that current state of mind, when you talk to somebody after successful treatment and they have insight into what happened, they feel that they were in distress and were making stupid decisions that they wouldn't make in their own baseline state of mind.

Of course, then we extrapolate, and use the addition of societal safety issues to justify the practice of involuntary hospitalization. Of course, this is a flawed system and subject to being abused but it is often a gut wrenching ethical decision when you are in the emergency room wondering whether this is the right decision or not. And by the way, this is absolutely unique to psychiatry and one of the reasons it is so easy to start going down the Russian analogies of political dissenters for somebody who argues against it. I still have some sleepless nights about how involuntary treatment comes into play here. But benevolence is primary in the decision making process for me, as opposed to volitionally controlled people who are peacefully disagreeing with my opinion.

The biggest sticking point is that society (and they have done this in this country with things like tarasoff laws) has put a burden on psychiatrists that is completely dangerous which is to say that they have some burden of responsibility of having predictive power over who is dangerous to themselves or others and encourage erring on the side of involuntary treatment instead of protecting the persons independence. You can blame the litigation for that to some degree but it also says somethings about the values of society which cannot be separated from it.

Often I wish that the burden of responsibility to involuntarily do anything to anybody is not mine because it is an absolutely awesome (not in the good sense of the word) responsibility. But that would entail suicidality to be an impossible thing to prevent or catatonic depression would just see somebody die of dehydration as they lie there with a "mental illness" when both of those "states" can be treated with a few zaps of electroconvulsive therapy or an antidepressant. And then when the person is effectively treated, they thank you for saving their life (and thus being a doctor who prevented mortality).

The idea of rational choice is very tricky of course, but is defined by the society with benevolence in mind for physicians who took the hippocratic oath. That is why it remains in the spirit of being medical illness.

When does one become defined as volitionally just being a bad person and making irrational choices? When should they just be put in jail and being punished as opposed to being treated regardless of their biological markers? I don't know and I struggle with it. Well if the spirit of jail is rehabilitation and safety, then it isn't so different from involuntary treatment. But that is why the involuntary nature of things opens a can of worms that make the conversation (or maybe just my point of view) more difficult to have.

It still comes back to distress for me or an extrapolation of anticipated distress with the benefit of the doubt that all humans in a society share experiences and patterns in some sort of normative experience.

You gave a bunch of examples which are sort of a slippery slope argument in the danger of deciding that all decision is behavior is caused by brain and therefore we shouldn't use any behavior as a marker for disease. Its an interesting point, but then when you say:

You don't do neural imaging to try and locate the neurological malfunction in order to make a diagnosis - do you?

To which I would say, I sure hope one day soon we are doing that, just as neurologists do. But of course they still are inferring based on pattern recognition and historical data and what the clinical intuition of what their professor says. And they have limited imaging techniques for strokes and MS and all those other diseases. Thus they use clinical judgement on patients reports of distress (ie-pain, inability to perform functions that they are socially supposed to perform and they have LEARNED how to do in the past, etc) or based on observed behavior that is outside of the norm of what they rationally expect for a human being in that culture to do. This includes, by the way, as part of the diagnostic process, whether or not somebody is depressed or psychotic. Then they make a diagnosis and treat, usually with a medicine if they have one.

Even if we did find neurological malfunction it seems we would have no grounds for regarding the person to be mentally ill if they didn't display behavioural (including cognitive and verbal) symptoms of the diagnosis.

Actually no, there probably will be a time where imaging "vulnerability" studies based on some subsyndromal or other screening symptoms will probably lead to prophylactic treatments due to risk of disease progression. This is done routinely in other fields of medicine even if someone is asymptomatic. Calling them "mentally ill" is the sticking point, because the stigma that is carried by that label is so large. Nobody says, "I have diabetes, I am physically ill". They say, "I have diabetes". They don't get lumped into a category of physically ill that coincides with cancer and other things. But probably a large reason for the discussion is due to the stigma of mental illness and the idea of "moral failing" being in play. Morality itself is socially constructed and yes, things that push the limits of that society's morality are then placed in a separate category called either crime or mental illness. But that was before behavior could be biologically and scientifically studied. As that continues, and it already has started, maybe there will be a time when all crime is not "punished" just for the sake of "an eye for an eye". Instead maybe they should be "treated". But now as I type this I realize that it really is about where you draw the line and that reintroduces involuntary treatment and slippery slope arguments and genetic engineering debates that really start to push the limits of even what I think is ethical. But it makes me realize the whole point of things which is that it is all socially constructed and society deems these things how they deem them based on the moral structure of that society. That moral structure inevitably evolves based on paradigms of the day.

You suggested that the criteria is 'distress' and I provided some examples to show that 'distress' was neither necessary nor sufficient for diagnosis.

See my point about mania and schizophrenia above. Distress is not as simple in my opinion as what one feels in that moment. And if it isn't sufficient, then that plus violation of norms, plus statistical infrequency, plus dysfunction all must be sufficiently present or inferred to be present. However, the phenotype that is displayed by the illness may be subclinically present. Such that judging the behavior as primary to the disease is not the sin equinon goal but it is the PRACTICAL goal. This happens in medicine all the time in all fields. People are walking around with subclinical things all the time, the question becomes when to screen for "genotype" evidence of the illness even if it isn't apparent in the person's behavior in order to prevent morbidity and mortality.

addiction (moral failing or mental illness?)
psychopathy (ditto)

disagree that addiction is moral failing based on the brain evidence that is some of the most profound and obvious in all of psychiatry with very strong theory with grounding in evolutionary mechanisms for why behavior is hijacked to seek the drug.

Just becaue we find that neurological malfunction x is correlated with addictive behaviours that doesn't mean mental illness is a mental disorder any more than the finding that:

neurological malfunction x is correlated with pedophilia means that pedophilia is a mental disorder.

and... there are arguments to show that neurological malfunction is not necessary for mental disorder (Wakefield's Y2K example of input outside the designed range producing devient outputs in the absence of neurological malfunction).

Then the phenotype is expressed without the genotype? This is probably more a reflection of the inability to measure the malfunction in genotype of the system being measured (the brain) rather than there being something abstract or magical about the behavior that is outwardly apparent, but again the social element is never absent in all of medicine, so it becomes more of a thought experiment than a useful thing clinically.

and then... there are all the problems on how you define 'function' in order to derive the relevant notion of 'malfunction'[/QUOTE]

Function is defined as how society wants its members to act or think or behave ideally. It changes. Obesity is an illness because of the loss of productivity and the social negative consequences to western society. However in some societies it was a revered quality. Now that longevity productivity is the primary functional goal in Western society, all disease is defined through the lense of what decreases either longevity or productivity. Depression is second only to Heart Disease on that measure. What does that say about the construct of the disease? Is it real? Is it moral weakness? Is heart disease not moral weakness because we love to eat cheeseburgers?

 

[solumanculver]

So are the following:

Political dissentors behaviour (including cognitive and verbal) are caused (or made probable) by the state of the persons brain.

Psychiatrists behaviour (including cognitive and verbal) are caused (or made probable) by the state of the persons brain.

I hope you get the idea.

I'm not sure that I do get the idea... Of course I agree that the behavior of political dissenters and psychiatrists is determined by their brains.

The cognitive and verbal behavior of psychiatrists and political dissenters can also be altered by biochemical intervention, just as patients with Schizophrenia, but I'm not sure what that is supposed to show...

You can also alter healthy liver and kidney function with biochemical intervention, but it's a pretty bad idea to do so.

Now, a problem with psychiatric diagnoses is that they are made on the basis of the persons behavioural symptoms. That means that we are judging the person to be 'mentally ill' or 'not mentally ill' on the basis of their behavioural symptoms. I mean... You don't do neural imaging to try and locate the neurological malfunction in order to make a diagnosis - do you? Even if we did find neurological malfunction it seems we would have no grounds for regarding the person to be mentally ill if they didn't display behavioural (including cognitive and verbal) symptoms of the diagnosis.

First of all, I think that Neural imaging could play an important role in diagnosing psychiatric illnesses in the future, so there is nothing conceptually different here between psychiatry and neurology. So far it's just a practical difference of figuring out what to look for to diagnose psychiatric disorders.

As for the situation in which a person was found to have a characteristic brain malfunction associated with schizophrenia, but didn't have any of the symptoms of schizophrenia, I think that our ordinary medical model can deal with that. It warrants a kind of "wait and see approach", if you become psychotic then we'll know why... It could be something parallel to a benign tumor. Does a person with a benign tumor have a disease? But when it ceases to be benign they do... Although I don't really know too much about tumors, to be honest.

I'm not trying to say (at least I don't think) that mind is completely reducible to brain nor am I saying that the state of a persons brain is causal for all behavior in that we have no outside control of our brain through free will to act.

It seems like we have to say something like this to maintain a scientific worldview. I think that mind, for all that it's relevant to psychiatry, is reducible to brain. And even though free will is a knotty puzzle, it's not particularly relevant to medicine, inasmuch as if we do not have free will, then no medical treatment can alter that...

 

[Chewbacca Jung]

I want to reiterate that these concepts are not moot. They are very relevant to the clinical encounter. I'll give an example that I learned from an experienced clinician-

Many consider "normal" personality to be fixed and stable throughout life. But please consider, for a moment, the opposite-- that personality is in fact "normally" highly variable-- even from moment to moment. Personality can be redefined as clusters of response patterns that change based on context. For example-- you exhibit and experience different sets of behavioral attributes, tendencies to internally react, and coping mechanisms, depending if you are in a clinical encounter, are at the theater, at a party, if you are drunk, at church, talking on the phone, ect... You change behaviors automatically and unless you are observing yourself, you don't even notice the change in personality when you change contexts. At the same time A "normal" person observing the discontinuity of your personality traits in each situation will automatically string the conceptual events together (as the brain tends to do when presented with discontinuous data) and the gestalt concept of a your stable personality is perserved in that observer. Whether you are deemed to be acting erratically is determined almost entirely on the situation. This is also why it takes a while to "get to know someone". Because it is impossible to predict someone's entire personality spectrum based on only a few encounters.

This concept is essential to understanding personality disorders, as an Axis II is basically the fixed inability to adapt your personality to the context. Another part of the pathology of personality disorders--particularly boarderline PD-- is that these people have a hard time understanding the constant changes in other people's personality when the situation changes. For instance, a boarderline PD patient may see you after clinic with your family at the mall, or at a party... and they feel betrayed because you are acting entirely different to them in the more social context (and you are also trying to avoid them as well). They don't understand that both personalities are yours.

DID--priorly known as multiple personality disorder (and still conceptualized by many as such)-- according to this reasoning is not actually a multiplication of personalities, but actually restriction of personalities. And these personalities are similar to axis II PD-- they are fixed, and often bizarre with respect to the context. This explains why the name has been changed-- because the "pathology" is not in the multiplicity of personalities, but in their dissociation with the context.

This has implications for Axis I disorders as well, as an Axis 1 tends to exacerbate any existing Axis II. Why does a patient's behavioral repertoire constrict as their disease manifests itself--- i don't know.. but the point is this kind of introspection into mental illness gives a construct for understanding mental illness in a way that biology would have a hard time explaining (as toby jones has pointed out). It is much more than mental masturbation. Whether it is objectively correct or not, I'm not sure. However:
1.It satisfies your demand for clinical relevance,
2.It propose a mechanism in part by which context is part of the mechanism of disease-- therefore mental illness is not all in the brain. I admit that it may not be the perfect example for this point, but it is one mechanism of how phenotype can be determined in large part outside of the genotype-- though in this case, genotype still plays a significant role.
3. It also shows that how you define normal can determine what conclusions you derive about a clinical encounter.

Finally, Please excuse my lack of clinical experience. I am merely trying to contribute to a largely ignored part of clinical medicine/psychiatry-- the base. I really don't want to turn this discussion into an experience vs. innovation quagmire. A lot of what you say has merit-- and I am not trying to discount your experience in any way. I can see the forest, but I'm looking at the trees and trying to discover the roots as well. Please don't discourage people from using educated and well-thought-out language/concepts in an open forum, even if you can't see the immediate clinical significance behind them and it "takes energy" to understand them. I'm trying to learn.

 

[worriedwell]

Please don't discourage people from using educated and well-thought-out language/concepts in an open forum, even if you can't see the immediate clinical significance behind them and it "takes energy" to understand them. I'm trying to learn.[/QUOTE]

With all due respect, I appreciate your input and interest in the "trees", but in no way am I "discouraging people from using educated language in an open forum". Rather I am giving advice on my opinion of what is more readily accessible to the casual reader, especially beginners who haven't delved into the details. I said that actually because I think the "mental masturbation" of it is extremely fascinating and if I didn't I wouldn't spend an hour writing a response to the questions. I would ask you not to discourage me from giving advice about better reaching others about an important topic as well as about giving my opinion on how the concepts play out in real world scenarios. The reason I stress real world scenarios is that it has implications for why psychiatric disease is incorrectly separated from other illnesses. This line being drawn is arbitrary and the way disease is defined in other fields of medicine is not nearly as pure as the theoretical conversations in this thread sound. The point I am trying to make is that the entire concept of "mental illness" or "psychiatry" is not what the basis for the discussion should be about. This is a form of stigma against psychiatry even if it is subtle and in the spirit of open discussion. It is the equivalent of passive bigotry regarding racism if you are familiar with sociology concepts. This form of stigmatization is dangerous to the field and not productive in my opinion. Hence there may be a tone of antagonism in my posts which I apologize for (sort of).

And you make good points about clinical relevence, but its important to note that your examples were about Axis II disorders which I readily debate and am not sure about whether they are real "diseases" the way they are defined in DSM. See now, this is where the discussion becomes more gray for me and more clinically relevant. When you lump in mania and schizophrenia into the mix, the other argument to me loses real world credibility and falls into the realm of stigma or ignorance. In fact, there is a large contigent of psychiatrists who wanted DSM V to switch axis II from disorders to spectrums of traits, as in, somebody is high on the narcissism trait etc. This puts things more into the realm of descriptors of someone's personality which then might be important to know for barriers to treatment for their real "diseases".

But the disease model of psychiatry diverges from much of historical psychology and especially psychodynamic theory of things. That is why many psychologists are so against the idea of medicating people, because they feel that instead of "disease", people just need to change the way they think and act to function better in society even for many of the defined Axis I disorders. But it is clear that both medication and psychotherapy in general do produce brain changes which also correlates with disease remission. This is all preliminary stuff but interesting nonetheless. Does it mean that there isn't disease if you just need to relearn how to do things to have a more functional life or less anxiety or depression. I'm not sure, and this is sometimes why psychologists will say that for "severe mental illness" psychiatrists are best trained to be involved (essentially to use medication) but what they are really saying is that they are not capable of treating the illness with their training background. Well, what if there were psychologists whose primary goal was to "treat" early onset diabetes by using behavioral modification techniques and then when it became "severe" diabetes then they'd refer to a medical doctor. No it doesn't work that way because there is no stigma attached to taking a medicine for diabetes societally (although there is among many individuals). Society is resigned to the fact that this is a "disease" and therefore the "first" person they should see is someone who is capable of advising them about medication or lifestyle changes etc. Then they might see one of those dieticians or whatever to help them with their behavioral changes. Society should allow psychiatrists to do these evaluations first without having to justify their existence based on people claiming they are dealing with things like moral failing. The big problem though is that there is such a gray area "at this point in time" about who gets labeled with the disease and who doesn't. This is due to poor sensitivity and specificity of the tools we have in place to detect the brain diseases of psychiatry. For example, if you've ever seen bonafide recurrent major depressive disorder, you would know that it is unequivocally an episodic disease with a clear onset. It can turn into refractory chronic depression if not treated aggressively. This is why people need treatment urgently. But the term depression is such a part of pop culture, that it is used as a crutch for "disease" when it isn't really that for many people who are on an SSRI. The way to define it has to be to have more clear markers for it biologically. This does change how things like DSM would be structured, but it doesn't invalidate the construct of behavioral and cognitive symptoms being the primary presenting marker for disease. The mind and body are NOT disconnected (again psoriasis being exacerbated by stress being a prime example). Panic attacks causes autonomic hyeractivity like tachycardia and diaphoresis. Studies have shown that CBT is an effective treatment for panic disorder (as are benzos and ssris). But the fact that the symptoms are affecting the body and affecting quality of life, puts the disorder directly into the realm of medicine. It is an illness.

However:
1.It satisfies your demand for clinical relevance,
2.It propose a mechanism in part by which context is part of the mechanism of disease-- therefore mental illness is not all in the brain. I admit that it may not be the perfect example for this point, but it is one mechanism of how phenotype can be determined in large part outside of the genotype-- though in this case, genotype still plays a significant role.
3. It also shows that how you define normal can determine what conclusions you derive about a clinical encounter.

Is it normal to have a lump on your face that is discolored with irregular borders? No, and that is the initial reason that the dermatology says, I need to do a biopsy on that mole. He does this because studies have shown that people with that abnormal thing on their face will be at risk for morbidity and mortality. Thus, they should be evaluated and treated aggressively. You can go on down the line in all of medicine about how the initial presenting reason why people go to their "doctor" is because they are either experience some distress outside of their normal range of symptoms or they use societal cues to determine whether they have some abnormal symptom even if it isn't causing distress.

All diseases have some part of their phenotype which is situationally dependent. For example, being paralyzed is not just about legs not moving. It is about the situational loss of function in society. If society were set up that people could function in motorized carts exactly up to the ideal of how the rest of society can function, then being paralyzed would not be a disease. This is a bad example and probably can be shot down, but its the only one I can think of.

The point is, in science, because you can't find the genotype, it doesn't mean that you shouldn't look and just assume that the situation is deciding what is going on. Depression, anxiety, addiction, mania, may have exacerbating situational qualities but it does not mean that the "disease" that then results is not disease. Your brain is vulnerable to situational events that are external. Your liver is vulnerable to external situational stresses too and when the external stresser is too much for the liver to fight off, then you get hepatitis or fatty liver and you are defined as being ill.

PTSD is about a situational stress, but the disease is due to neurological dysfunction that manifests itself as behavioral and cognitive and emotional symptoms. Is it a moral failing? Not at all.

 

[toby jones]

Okay... Wow, there are a lot of ideas floating round. I'll try and just pick out a couple.

Firstly, I want to say something about my choice of language. I don't know anatomical terminology. That means that if I was attempting to describe the anatomy of the body I'd be using terms all over the place and I wouldn't be being very precise. I'm sure you all are much more familiar with anatomical terms than me and you would have a lot to teach me in that respect. I do know a little something about the terminology of the 'disease' / 'disorder' / 'dysfunction' / 'social construction' debate, however. Unfortunately, things are still at the stage where there are competing concepts and so it is especially important to be clear what you mean by terms (similarly to if I were to talk about 'area 17' of the brain you would want to know whos system I was using so you would be able to understand what I was talking about. I appreciate that the discussion is hard... Such is the nature of philosophy, however it is a technical subject as is medicine but i guess things are especially hard because interdisciplinary work runs the risk of your alienating yourself from both fields. please give me the benefit of the doubt, I assure you I am doing my best to be clear and straight-forward and not unnecessarily convoluted.

I'll try and use examples of real world cases.

So... Currently (and all the way into the past) people have been diagnosed as 'mentally ill' or 'not mentally ill' on the basis of their behaviours. What is it about their behaviours? Suffering plays a role, I'll grant you that. I don't think that it is necessary or sufficient, but I do indeed grant that it plays a role (and I do indeed grant that psychiatry is about helping people). Other factors (like statistical abnormality, norm deviation, unexpectedness, malfunction etc) play a role too, but none seem to be individually necessary or individually or jointly sufficient.

But there is indeed a current debate around whether inner malfunction is necessary. What is meant by malfunction is important to the debate so people are indeed trying to figure out the relevant notion of function.

The medical model is often regarded as being based on the assumption that diseases / disorders are due to a malfunction in a system of the body. Pathogens can invade (and lead to malfunction), functions can break down (heart failure) etc etc. You can probably come up with different kinds of malfunction better than me.

If we apply the medical model to psychiatry (seeing as psychiatry is supposed to be a field within medicine and all) then it seems that mental illness is thought to be due to a malfunction in a system of the body. More specifically, empirical investigation has shown the brain to be the relevant system (and not the heart, for example). But the function of the brain is to... Um... Not sure really.

There are different ways in which systems can be described. You can talk about the circulatory system as a system, or you can break it down into sub-systems (the heart etc), or you can break it down into the level of the cell, or whatever. The brain also seems to be a system that can be described in certain ways. You can talk about structural components like the amygdala, you can talk about functional components like the visual processing system, you can talk about functional pathways, you can talk about individual neurones or groups of neurones, you can talk about transmission etc etc.

So the notion is that mental illness (the behaviours that lead us to regard a person as mentally ill) is due to malfunction of an inner system (together with a normative assessment that the behaviour that results from that malfunction is harmful). But what counts as a malfunction?

Consider schizophrenia. Someone might well need to correct my statistics here... I thought... That the upshot of the Icelandic genome project was that they found a three locus gene (or a three gene locus) relevant to schizophrenia. What do I mean by relevant? I mean that something like 7% of people with schziophrenia had similar values on that three gene locus and... around 14% of people without schzophrenia had those similar values on that three gene locus. As such, the three gene locus can't be THE cause of schizophrenia because you can have the gene locus without having sczhophrenia and you can have sczhophrenia without having the three gene locus. At best it is one causal factor. But it isn't even that really because more people without sczhizophrenia have it than people who do. And some individuals without sczhophrenia don't have it at all. But perhaps future research will unveil the genetic malfunction that causes schizophrenia?

The trouble with that line is that concordance rates for identical twins are something like 48%. That means that if you have a genetically identical twin who has schizophrenia you are more likely to not have sczhizophrenia than to have schizophrenia. (Don't you just love the way you can interpret statistics). The concordance rates show us that whatever the genetic basis of schizophrenia is it is not the cause of schizophrenia. It would seem that environmental factors are more relevant than genetic. So... Is schizophrenia the result of genetic malfunction? What grounds do we have for considering a genotype to be malfunctioning when it is more likely to result in your not having schizophrenia than having schizophrenia?

The basis by which we judge people to be mentally ill appears to be something about their behaviour. The medical model plugs into our PRIOR judgement and has us ASSUME that there is some inner malfunction. When we discover inner factors we take to be causally relevant to the problematic behaviours we regard the inner mechanisms to be 'malfunctioning'. The DSM allows that the 'malfunction' can be purely behavioural but Wakefield appeals to an inner / outer distinction in the attempt to retain a 'mental disorder' / 'problems in living' distinction. Etiology does appear to be important... Causal mechanisms are relevant for science.

There are a lot of different things that can be meant by 'socially constructed'. I gave one definition in a previous post (to attempt to capture the distinction between social constructionists about mental disorder and realists / objectivists). One way in which you can be a social constructionist would be to say that social causal mechanisms are fundamental for all (or some) mental disorders.

Why is anorexia nervosa more prevalent in developed western nations than in other nations? I'm fairly confident social causal mechanisms will be fundamental with respect to answering that question. What level of analysis is fundamental (genetic, neurological, cognitive, behavioural, sociological) depends on which questions we ask. If it comes to treatment, on the other hand... Finding out which level is fundamental doesn't help us particularly. Lets just assume (for the sake of argument) that OCD symptoms are caused by the 'OCD pathway' being activated in a certain way (so that neurological explanation is fundamental). This doesn't entail that psychosurgery or psychoactive drugs are the best way of altering the OCD circuit. There is evidence that mindfulness meditation training and therapy can alter the neurology comperable to psychoactive drugs. Similarly, to know that OCD is caused by the 'OCD pathway' being activated in a certain way doesn't tell us anything at all about how the OCD pathway got to be that certain special way. It might be that a particular genotype results in the OCD pathway fairly much in spite of environmental / social causes, or it might be that certain environmental / social causes results in the OCD pathway fairly much in spite of genetic variation. As such... There is a sense in which OCD (even if we grant that it is neurological) could turn out to be 'socially constructed'. It could be socially constructed in the sense that social mechanisms are the relevant cause, or in the sense that social interventions are the most effective intervention even if neurology was the proximate cause...

(What I'm trying to do is to refocus the discussion from 'inner malfunction' to 'relevant causal mechanisms that can be inner or outer'. the fundamental level of explanation depends on what causes seem most robust / invarient. The sciences (genetics, neuroscience, cognitive science, sociology) all seem relevant here (and i need to learn more about developmental processes). It is an empirical question which level the fundamental (most robust) causal explanation is located at. It might be inner or it might be outer. It might be a function. It might be a malfunction. I think this is an empirical matter. We can retain the intuition that causes / etiology is important without committing ourselves from the armchair to inner malfunction).

By the way... I wouldn't go so far as to say I'm just repeating Murphy's points... But I will put in a plug for this guy as something that I've been heavily influenced by:

Murphy, Dominic (2006) 'Psychiatry in the Scientific Image' MIT Press

 

[Chewbacca Jung]

I agree about there being inner and outer mechanisms of disease, but I’ve also been thinking about inner and outer mechanism of brain function—for a while now. Though, i believe separating the two, creates a false dichotomy. I've mostly thought about a phylogenic (or comparative anatomy/physiology) model of brain development as being useful to understand the “purpose” of function of the brain, and the relationship between inner and outer functions—particularly for those who take a biological deterministic stance—or at least probabilistic deterministic one…

The most primitive nervous system occurs in sponges. It basically allows the “animal” to react to touch from another animal by reflexively contracting its entire body full of myocyte-like (muscle cells) tissues-- this then supposedly causes a startle response in the offending organism, and increases the chances that the animal will flee, as opposed to eating the sponge. Thus in the most ancient nervous systems the proposed purpose of the “brain” is to sense the environment, respond to the environment in order to modify the environment. The development of the brain as you ascend the phylogenic tree is only an elaboration of this purpose. Later jelly fish develop optical sensors that help them orient themselves upright, and the eye begins to develop, along with the necessary supportive cerebral structures—then cephalization develops as the newly developing sense organs polarize in the body. The nervous system gradually specializes and gives certain advantages in finding food, attacking food, fleeing from preditors, and modifying the environment. If you jump ahead to lizards and early mammals you notice a development of the archaic brain- the amygdala—the beginnings of emotional processing. It is highly associated with olfaction—which aids in the detection of viable food, viable mates, and predators. When higher primates began to eat fruit, the neo cortex evolved to deal with the issues of remembering where the right trees are, when they are ripe. This is highly dependant on visual-spatial skills. Additionally this allows for recognizing social groups/preditors based on sight and allows for meaningful communication…

This is obviously an oversimplification, but it proposes that the primary function of the brain is to interact with the environment. To dichotomize inner and outer mechanisms is highly artificial—because by isolating the “internal” mechanisms, you sever the brain from it’s actual function. By isolating the “outer” you downplay the brains reaction to it. I think you have to deal with them as a dynamic coordinated processes, not as static elements.

 

[swanny]

The discussion above is great! Psychiatry is on the cutting edge of this philosophical/scientific issue, which nonetheless affects all of medicine. I'd like to provide a reference that might be helpful...

http://ajp.psychiatryonline.org/cgi/reprint/158/7/989

 

[maranatha]

The discussion above is great! Psychiatry is on the cutting edge of this philosophical/scientific issue, which nonetheless affects all of medicine. I'd like to provide a reference that might be helpful...

http://ajp.psychiatryonline.org/cgi/reprint/158/7/989

Thanks, swanny, for the great reference. It is an excellent review on the subject!

 

[worriedwell]

thanks swanny for the article, interesting read.

I agree to a large extent with chewbacca jungs last post about the inherent difficulty with separating brain from inner and outer function.

regarding the example of OCD being potentially socially derived, well...there are some dogs who lick or chew their paws to the point that they start to get sores on their paws and their skin starts to break down...they obsessively chew their paws and cannot readily stop. if you give them prozac, they stop. while you might be implying that dogs attribute some external importance to the meaning of chewing your paw, fine. the same way that the societal importance of keeping your hands clean can become a prominent portion of the life of someone (like a doctor or nurse) who's brain has a vulnerability to be OCD, then they become obsessive handwashers. but who's to say if they didn't do that and lived in a different society, then they wouldn't do some other behavior that was out of the norm and caused them morbidity. in fact if you observe people, they have certain obsessive tendencies that manifest themselves different ways and if you stifle one way, then another one manifests. but its the people who are biologically predisposed and who probably have other "insults" to the system in their life, who then manifest as the full blown disease (due to the morbidity that it causes).

anorexia is a western phenomenon because of the "image" issues in western society especially for white girls like those images seen on the cover of vogue. if that same girl grew up in another culture (which we could possibly replicate with twin studies) like a 3rd world country, then my feeling is she would be strongly predisposed to having some illness which has control issues etc. However, even twin studies might fail because I consider the illness to be mediated by how, where, and with who that exact girl grew up.

in neurology, multiple sclerosis is more common in white women who grew up until a certain age a certain distance from the equator. living near the equator is somehow protective. the mechanisms of this are postulated, but not known. it has to do with a biological predisposition AND an environmental insult.

in psychiatry, the environment in which you live predisposes you to manifest certain symptoms but only if you are vulnerable to have those symptoms.

in ptsd for example, most people who experience significant trauma never develop ptsd. the uniqueness of those who do is that they have some biologic vulnerability. it is the diathesis-stress model.

one liver may be more vulnerable to cirrhosis than another but neither one will get cirrhosis in a vacuum. the other insulting environmental agents are required to manifest the disease. this isn't the case for all medical diseases that are too strongly genetically decided (ie, a few livers will get cirrhosis in a vaccuum), but again it states that there is no difference between alot of "physical" medicine that clearly is defined as disease and with the diseases (which are still being ironed out) that exist in psychiatry.

its just that it is so much more complex and fascinating to figure it out in the brain (the final frontier of medicine) due to the profoundly important topics that are being raised here that are more existential and about human identity. the philosophical implications are certainly huge and it does affect the way humanity thinks of itself. but that changes as well, the way that we have come a long way embracing science over time as humans. is it flawed to feel that science should rule the day when it comes to all of "mind"? perhaps, and by no means do i think i know the answer. but as it pertains to morbidity and mortality (medicine), it must rule the day. (and by the way science can be applied to psychotherapy too, so i'm not just advocating for biological interventions. but i've made it clear that all of medicine could benefit from psychosocial interventions, its just that society doesn't give them as much of a hard time as it does psychiatry and that is due to stigma. so in many ways, the rest of medicine could take a page from mental health and employ more professionals that work on the behavioral aspects contributing to physical illness (read psychologists and social workers). although obesity and all of its related diseases are getting more and more pressure for societal psychosocial interventions.

psychiatry is a discipline of how behavior affects the brain and vice versa but inherent in that is that its focus is primarily on the brain. for example, one doesn't use the criteria for eating cheeseburgers to be what defines peripheral artery disease. but we do currently define the illnesses in psychiatry by descriptors because of our limitations. medicine used to do this with other physical illness. for example AIDS used to be GRIDS or gay related immunodeficiency syndrome until more science took hold but originally it was defined by a behavioral descriptor.

in the example of peripheral artery disease (bear with me for taking some liberties in the following), we do however note the symptom of not being able to walk far because their legs hurt (claudication) to be related to the disease. however, the interventions are aimed not at something inherently defining about the behavior of eating lots of cheeseburgers (which contributes/causes the disease) but at changing the arteries to improve how far somebody can walk. in having the goal of improving how far you can walk, one of the interventions one can use is to stop eating cheeseburgers. another is to take a medicine which thins your blood and another is doing surgery on the artery to get rid of the clot.

in "attacking" the behavior of stopping to eat cheeseburgers, a psychoanalyst would try to get somebody to have insight into the meaning cheeseburgers so that then hopefully that insight would change the behavior for the better. cognitive therapists and behavioral therapists do things differently but with the same goal of stopping the maladaptive thoughts about cheeseburgers and thus stopping eating the cheeseburger. interestingly, almost all of medicine could take the approach of psychiatry and use all these other resources to help people with their medical illnesses because they all have behavioral components. but instead, they look for pills to treat them all because behaviors are too hard and costly to treat and produce mixed results (at least as we currently know how to treat them).

the brain malfunction in much of psychiatry is just not yet readily apparent and the pills we use are very blunt instruments. plus you can't just cut out the bad parts of the brain. i guess overall what i'm advocating for is psychiatry to involve itself with "the mind" in so far as if the knowledge of brain provides answers to how to increase productivity or longevity for individuals in that society. of course, the notion of the person "wanting" that help which may be measured by them asking or by them "showing" signs of distress (like catatonia, mania, or psychosis). when we talk about involuntary treatment, it does open a slippery can of worms in regards to what "showing" distress means. but it doesn't invalidate the bonafide illnesses that are taking descriptive shape in psychiatry. now the next generation must take further empirical steps to better identify the "markers" for disease as much as that is possible. the importance of identifying these markers is to identify treatment options.

 

[toby jones]

Thanks very much for the link, I haven't seen that before.

(I haven't had the chance to read through it all as yet, but my attention was drawn to this bit at the end):

> I continue to feel that functionalism makes sense if you think about computers and artificial intelligence, but when you deal with brains like we do, I have my doubts. But as I said, this is still the most popular theory about the mind-body problem among philosophers.

Hmm. Functionalism (with token identity) is fairly much the view that cognitive psychologists have of the brain. Cognitive psychologists describe tasks that people can do like recognising faces, tensing verbs, identifying objects etc. Then they attempt to decompose the task down into sub-tasks. People with prosopagnosia can't identify faces of people who are familiar to them. They have a heightened SGR to faces of people who are familiar to them, however (which is normal), and they can say they are familiar (which is normal), but they can't say who it is or where they know the person from. People with the Capgras delusion (as it arises in response to cerebral injury) deny that their wife (for example) is their wife. They say it looks just like their wife, but they then conclude that their wife has been replaced by some kind of duplicate (a robot or alien or whatever). It has been found that people with the Capgras delusion have an absence of the usual heightened SGR to faces that are familiar to them.

Cognitive psychologists thus posited that there were two functionally distinct modules involved in identifying faces. There is an affective pathway that is responsible for generating the heightened SGR to faces that are familiar. There is a perceptual pathway that is responsible for matching the percept of the face to a name / context stored in memory. To succeed in identifying a familiar face both pathways need to process information appropriately. In prosopagnosia the perceptual pathway is malfunctioning but the affective pathway remains intact, in the Capgras delusion the affective pathway is malfunctioning but the perceptual pathway remains intact.

Then what we want to know is 'how are these functional modules realized in the neurological hardware?' This involves looking at the location of the acquired cerebral injury in the brain. Capgras seems to occur in response to right hemisphere dysfunction and not in response to left hemisphere dysfunction.

I'm thinking that there might be some support for the notion that delusions that arise from cerebral injury (and maybe all delusions) are best thought of as problems with AFFECTIVE rather than PERCEPTUAL or RATIONAL processes. That is controversial, however...

There has been some stuff written on how psychiatry needs to take the functional (cognitive psychological) level of explanation more seriously. Cognitive psychologists go with functional modules. Cognitive neuropsychologists attempt to describe neurological anatomy in ways that they are dividing the brain up into different functional structures. There are an indefinate number of ways we could divide the brain up. We would rather divide it up into different functional components than dividing it up arbitrarily, however... Different parts might look distinct but that doesn't mean they are functionally distinct. Different functions might be performed by parts that look the same. We seem to need a back and forth process between functional (cognitive) and structural (neurological) levels of description.

I'm a little unclear on how cognitive psychology and psychodynamic theory relate... Is one more low level than another? I'm thinking cognitive might be a little lower than psychodynamic but I'm not sure about this. Need to learn more...

(Christopher Frith has done some good work on schizophrenia and delusions of alien control that is back and forth between neurological and cognitive psychological. I've also recently discovered Schore who has done some good work interweaving a neurological and psychdynamic account of the role of attachment in infant development, later personality traits / disorders, and other mental disorders)

 

[solumanculver]

thanks swanny for the article, interesting read.

I agree to a large extent with chewbacca jungs last post about the inherent difficulty with separating brain from inner and outer function.

regarding the example of OCD being potentially socially derived, well...there are some dogs who lick or chew their paws to the point that they start to get sores on their paws and their skin starts to break down...they obsessively chew their paws and cannot readily stop. if you give them prozac, they stop. while you might be implying that dogs attribute some external importance to the meaning of chewing your paw, fine. the same way that the societal importance of keeping your hands clean can become a prominent portion of the life of someone (like a doctor or nurse) who's brain has a vulnerability to be OCD, then they become obsessive handwashers. but who's to say if they didn't do that and lived in a different society, then they wouldn't do some other behavior that was out of the norm and caused them morbidity. in fact if you observe people, they have certain obsessive tendencies that manifest themselves different ways and if you stifle one way, then another one manifests. but its the people who are biologically predisposed and who probably have other "insults" to the system in their life, who then manifest as the full blown disease (due to the morbidity that it causes).

anorexia is a western phenomenon because of the "image" issues in western society especially for white girls like those images seen on the cover of vogue. if that same girl grew up in another culture (which we could possibly replicate with twin studies) like a 3rd world country, then my feeling is she would be strongly predisposed to having some illness which has control issues etc. However, even twin studies might fail because I consider the illness to be mediated by how, where, and with who that exact girl grew up.

in neurology, multiple sclerosis is more common in white women who grew up until a certain age a certain distance from the equator. living near the equator is somehow protective. the mechanisms of this are postulated, but not known. it has to do with a biological predisposition AND an environmental insult.

in psychiatry, the environment in which you live predisposes you to manifest certain symptoms but only if you are vulnerable to have those symptoms.

in ptsd for example, most people who experience significant trauma never develop ptsd. the uniqueness of those who do is that they have some biologic vulnerability. it is the diathesis-stress model.

one liver may be more vulnerable to cirrhosis than another but neither one will get cirrhosis in a vacuum. the other insulting environmental agents are required to manifest the disease. this isn't the case for all medical diseases that are too strongly genetically decided (ie, a few livers will get cirrhosis in a vaccuum), but again it states that there is no difference between alot of "physical" medicine that clearly is defined as disease and with the diseases (which are still being ironed out) that exist in psychiatry.

its just that it is so much more complex and fascinating to figure it out in the brain (the final frontier of medicine) due to the profoundly important topics that are being raised here that are more existential and about human identity. the philosophical implications are certainly huge and it does affect the way humanity thinks of itself. but that changes as well, the way that we have come a long way embracing science over time as humans. is it flawed to feel that science should rule the day when it comes to all of "mind"? perhaps, and by no means do i think i know the answer. but as it pertains to morbidity and mortality (medicine), it must rule the day. (and by the way science can be applied to psychotherapy too, so i'm not just advocating for biological interventions. but i've made it clear that all of medicine could benefit from psychosocial interventions, its just that society doesn't give them as much of a hard time as it does psychiatry and that is due to stigma. so in many ways, the rest of medicine could take a page from mental health and employ more professionals that work on the behavioral aspects contributing to physical illness (read psychologists and social workers). although obesity and all of its related diseases are getting more and more pressure for societal psychosocial interventions.

psychiatry is a discipline of how behavior affects the brain and vice versa but inherent in that is that its focus is primarily on the brain. for example, one doesn't use the criteria for eating cheeseburgers to be what defines peripheral artery disease. but we do currently define the illnesses in psychiatry by descriptors because of our limitations. medicine used to do this with other physical illness. for example AIDS used to be GRIDS or gay related immunodeficiency syndrome until more science took hold but originally it was defined by a behavioral descriptor.

in the example of peripheral artery disease (bear with me for taking some liberties in the following), we do however note the symptom of not being able to walk far because their legs hurt (claudication) to be related to the disease. however, the interventions are aimed not at something inherently defining about the behavior of eating lots of cheeseburgers (which contributes/causes the disease) but at changing the arteries to improve how far somebody can walk. in having the goal of improving how far you can walk, one of the interventions one can use is to stop eating cheeseburgers. another is to take a medicine which thins your blood and another is doing surgery on the artery to get rid of the clot.

in "attacking" the behavior of stopping to eat cheeseburgers, a psychoanalyst would try to get somebody to have insight into the meaning cheeseburgers so that then hopefully that insight would change the behavior for the better. cognitive therapists and behavioral therapists do things differently but with the same goal of stopping the maladaptive thoughts about cheeseburgers and thus stopping eating the cheeseburger. interestingly, almost all of medicine could take the approach of psychiatry and use all these other resources to help people with their medical illnesses because they all have behavioral components. but instead, they look for pills to treat them all because behaviors are too hard and costly to treat and produce mixed results (at least as we currently know how to treat them).

the brain malfunction in much of psychiatry is just not yet readily apparent and the pills we use are very blunt instruments. plus you can't just cut out the bad parts of the brain. i guess overall what i'm advocating for is psychiatry to involve itself with "the mind" in so far as if the knowledge of brain provides answers to how to increase productivity or longevity for individuals in that society. of course, the notion of the person "wanting" that help which may be measured by them asking or by them "showing" signs of distress (like catatonia, mania, or psychosis). when we talk about involuntary treatment, it does open a slippery can of worms in regards to what "showing" distress means. but it doesn't invalidate the bonafide illnesses that are taking descriptive shape in psychiatry. now the next generation must take further empirical steps to better identify the "markers" for disease as much as that is possible. the importance of identifying these markers is to identify treatment options.

Great Post, lots of good points.

 

[Chewbacca Jung]

I like what TJ is saying about different layers of the psych/cognitive/neurological. The concept of emergent properties, as described by the Kendler piece are very important to understanding the relationship between those various levels.


And, I still don’t think we’ve defined what the mind actually is, or proposed at least what it could be. This contributes to the dissidence of our discussion. So to revel in the state of Kendler’s “existential vertigo”, I like to think of an example from the Orson Scott Card book “speaker for the dead” (part of the Enders Game series)—where an ultra intelligent being accidentally comes into existence because of the resonance waves generated by an internet-like interplanetary communication network. (I hope this makes sense—if not, I highly recommend the series, whether you are sci-fi fans or not (I’m generally not)). At any rate, for those of you who can conjecture what I’m talking about, The mind, then, (if this case holds) has little resemblance to its components—in fact it is an accident of the components, although, it was initially entirely derived by the interaction of it’s components. (some may say sum-- perhaps the product, or factorial, or complicated matrix…—some kind of mathematical relationship may apply). I think the concept of “emergent properties” as described in the essay, explains this phenomenon.

Another example is nuclear fusion, where you need a critical mass for a reaction to occur. When the reaction occurs all material components are converted to energy. I.e. there is a change between the nature of the substrate and the product. I hope these examples are helpful to the discussion. I’m trying to show how, using logic and scientific (in the case of fusion) congruent ideas to discuss how the mind and the brain can be completely different and yet relevant to each other.

WW-regarding the example of OCD being potentially socially derived, well...there are some dogs who lick or chew their paws to the point that they start to get sores on their paws and their skin starts to break down...they obsessively chew their paws and cannot readily stop. if you give them prozac, they stop. while you might be implying that dogs attribute some external importance to the meaning of chewing your paw, fine. the same way that the societal importance of keeping your hands clean can become a prominent portion of the life of someone (like a doctor or nurse) who's brain has a vulnerability to be OCD, then they become obsessive handwashers. but who's to say if they didn't do that and lived in a different society, then they wouldn't do some other behavior that was out of the norm and caused them morbidity. in fact if you observe people, they have certain obsessive tendencies that manifest themselves different ways and if you stifle one way, then another one manifests. but its the people who are biologically predisposed and who probably have other "insults" to the system in their life, who then manifest as the full blown disease (due to the morbidity that it causes).

The example of ocd dogs breaks down, with the anthropomorphization of canines. There is no evidence that dogs have a mind. What a dog experiences and what a human experience are several orders of magnitude in difference. SSRI’s may be able to treat what a dog has when you create a reductionalistic model of OCD, but there is an entire “mind” component to Human OCD that a SSRI may or may not be able to affect—we don’t know, because rct trials on ocd fail to address factors of the mind as a dependent variables.

WW- anorexia is a western phenomenon because of the "image" issues in western society especially for white girls like those images seen on the cover of vogue. if that same girl grew up in another culture (which we could possibly replicate with twin studies) like a 3rd world country, then my feeling is she would be strongly predisposed to having some illness which has control issues etc. However, even twin studies might fail because I consider the illness to be mediated by how, where, and with who that exact girl grew up.

The argument of anorexia being biologically derived requires the discovery (or creation) of an “illness which has control issues” to which both parties would be “strongly predisposed to having” to have merit.

WW-in psychiatry, the environment in which you live predisposes you to manifest certain symptoms but only if you are vulnerable to have those symptoms.

It is currently impossible to predict who will develop PTSD given a certain stressor. So I don’t think this statement has data to back it up—for or against. Even with MDD, which you may argue that risk factors—such as family history—the best that you could argue is that given current knowledge some biological factors may predispose some individuals to depression. Anything else is an over-extrapolation of data.

WW-but as it pertains to morbidity and mortality (medicine), it must rule the day.

And why morbidity and mortaliy? I can understand morbidity to some extent—as no-one likes to suffer. But in the case of involuntary-ness, who is to decide what is the lesser of two evils—suffering because of a mental d/o with no insight, or suffering because of involuntary administration of medications. Who are we to say, it’s better for you in the long run. The only way to prevent morbidity is to cause morbidity.

Also, who wants to live while suffering? Is death then never a viable option for refractory chronic mental illness?


Sorry, WW, I'm not trying to pick on you. I'm just trying to push you a little to go deeper than scratching the surface. I appreciate your answers and comments.

 

[maranatha]

I'm almost afraid of getting dragged into this discussion....

While I admit that the idea of emergent properties that Chewy suggests is appealing, it is not without some problems.

CJ--Another example is nuclear fusion, where you need a critical mass for a reaction to occur. When the reaction occurs all material components are converted to energy. I.e. there is a change between the nature of the substrate and the product. I hope these examples are helpful to the discussion. I'm trying to show how, using logic and scientific (in the case of fusion) congruent ideas to discuss how the mind and the brain can be completely different and yet relevant to each other.

The problem with relating this to mind or consciousness is that in the case of nuclear reactions, one form of energy is simply being transferred into another form--no new energy is emerging. As you know, mass and energy ultimately exist on a continuum. While it is correct that a distinct set of conditions must be present for the reaction to occur, it should be noted that the reaction does not violate any laws of nature and no new matter or property arises. The problem with relating an example like this, or any event found in nature such as the H20 example, is that one can not find any event or process in the natural world that directly correlates with mental phenomena such as experience, hope, faith, or any other subjective mental process. While we can observe a nuclear reaction or the molecules of H20 increasingly gather to define our experience of "wetness", we cannot observe experience emerge from the brain. Nor, for that matter, can we observe any process that can directly correlate to experiential phenomenon. My thought is that the only way your nuclear reaction example would make sense is if you stated that there is something intrinsic in matter that would allow for the emergence of consciousness--some sort of property of matter that would allow for the perceived emergence of mind/consciousness from the brain. An idea suggested by some more radical thinkers...

 

[Chewbacca Jung]

I'm almost afraid of getting dragged into this discussion....

While I admit that the idea of emergent properties that Chewy suggests is appealing, it is not without some problems.

CJ--Another example is nuclear fusion, where you need a critical mass for a reaction to occur. When the reaction occurs all material components are converted to energy. I.e. there is a change between the nature of the substrate and the product. I hope these examples are helpful to the discussion. I’m trying to show how, using logic and scientific (in the case of fusion) congruent ideas to discuss how the mind and the brain can be completely different and yet relevant to each other.

The problem with relating this to mind or consciousness is that in the case of nuclear reactions, one form of energy is simply being transferred into another form--no new energy is emerging. As you know, mass and energy ultimately exist on a continuum. While it is correct that a distinct set of conditions must be present for the reaction to occur, it should be noted that the reaction does not violate any laws of nature and no new matter or property arises. The problem with relating an example like this, or any event found in nature such as the H20 example, is that one can not find any event or process in the natural world that directly correlates with mental phenomena such as experience, hope, faith, or any other subjective mental process. While we can observe a nuclear reaction or the molecules of H20 increasingly gather to define our experience of "wetness", we cannot observe experience emerge from the brain. Nor, for that matter, can we observe any process that can directly correlate to experiential phenomenon. My thought is that the only way your nuclear reaction example would make sense is if you stated that there is something intrinsic in matter that would allow for the emergence of consciousness--some sort of property of matter that would allow for the perceived emergence of mind/consciousness from the brain.

No, you probably have a point, my main driving point was to talk about a critical mass and a transition. The transition between brain and mind abides more in emergent properties than in a continuum or in causal terms, as you point nuclear fusion would imply. Although, you could argue that the natural history of radioactive materal is not to explode, but to decay at a rate consistent with it's half life. Nuclear fusion is a result of an artificial enrichment process. I.e the software determining the manner in which the energy is released is in the processing (naturally or artificially) or in other words, the context. Also you could possibly view the brain and mind on an energy contimuum as well-- e.g. the energy it takes to think about this hurts my brain. So although this example doesn't explain the interaction between the mind and brain in its entirety (not to mention in its bidirectionality) and the fact that uranium ultimately has no choice in it's own destiny, I think the example holds for what it's worth.

 

[Chewbacca Jung]

Radical thinkers?

wow, i can imagine it. Nuclear philosphical psychiatry. If not already begun, lets start a movement.

 

[toby jones]

Skinner once said (on the inner / outer distinction) 'the skin isn't all that important a boundary'. There has been philosophical work done on 'embodied cognition' which also questions the inner / outer distinction. See, for example, Andy Clarke: http://www.philosophy.ed.ac.uk/staff/clark/publications.html#language

> In the most ancient nervous systems the proposed purpose of the “brain” is to sense the environment, respond to the environment in order to modify the environment. The development of the brain as you ascend the phylogenic tree is only an elaboration of this purpose.

Yes, I hear what you are saying here. I think that you are grasping the intuitive appeal of evolutionary accounts of functions. There has been quite a lot of work done in evolutionary psychology on function. They make a number of assumptions that are highly questionable, however. For example:

- Mental functions are thought to have been fixed at some point in our evolutionary pasts. Can't remember when... The mechanisms that subserve langauage don't have the evolutionary function of subserving language, for example. They evolved for some other function and enabling reading was some kind of beneficial side-effect. As such reading disorders aren't problems of evolutionary function. Reading could be a spandrel (a side-effect of the evolutionary proper function) or an exaptation (an evolutionary function that has acquired a different current function). Either way reading disorders don't count as malfunctions if the relevant functions are evolutionary. Evolutionary functions are hence insufficient to account for mental disorder.

Murphy says that the malfunction assumption can do for psychiatry what the adaptationist assumption does for biology. That is to say that sometimes the assumption is false (not all salient traits are adaptations and not all mental mechanisms that we are interested in have evolutionary functions). Sometimes we do not know whether the assumption is true or false but that does not impugn diagnosis. He thinks it can still be a heuristic that is useful for getting the inquiry up off the ground. I'm not sure what to make of the biology case, but in the psychiatry case I disagree: You don't need to say that psychiatry is about discovering the mental malfunctions. Instead you can say that psychiatry is about discovering the causal mechanisms (both inner and outer) for problematic behaviour. Whether behaviour is problematic or not does seem to have a normative aspect to it... Though axis V seems to be doing precisely that...

Daniel Dennett has a book 'kinds of minds' where he talks about the evolutionary development of (surprise surprise) kinds of minds. Kim Sterelny has a book 'thought in a hostile world' where he talks about the evolutionary development of 'decoupled representations' (roughly - beliefs).

I agree you need to study the brain as a dynamic, inter-related process. This is one of the insights of the literature on 'embodied cognition'. The notion is that you can study thought abstractly. One way of doing this would be to study 'inferential role semantics', for example. That is studying what kinds of inferences are and are not lisenced by the semantic content of the thought / sentence and norms of rational inference. One could develop a model of this and attempt to develop a computer model of it. A computer that was programed with syntax (if this is possible) and obeyed the norms of reasoning would have thought according to this conception of thought. If we are more interested in how people are able to behave intelligently in the world, however, then this gives us a slightly different conception of thought.

Kim Sterelny talks about the 'wiring and connection facts'. Those are the facts about how the internal neurology is wired into pathways etc, and how these internal states are connected to the internal and external world in various ways. There might not be a hard and fast distinction between the wiring facts and the connection facts. What he is interested in is how the folk psychological facts (facts about what someone believes and desires and hopes and intends and feels) relate to the wiring and connection facts. That is the mind-body problem, I guess.

Dave Chalmers talks about the 'easy' and the 'hard' problems of consciousness. The 'hard' problem is the problem of phenomenology and I really don't think that psychiatrists need to worry about the hard problem. The 'easy' problem is more relevant. There is still a lot of controversy... But we have a fairly clear view on the easy problem and on how to go about answering the easy problem. Looking for the NCC's, for example (neural correlates of consciousness). Where by 'consciousness' what is meant is 'verbal report' or something operationalised enough to be studied by existing scientific methods.

 

[toby jones]

three notions of function:

1) Wright function

Wright came up with a fairly simple account of function:

The function of X is Z means
(a) X is there because it does Z
(b) Z is a consequence (or result) of X's being there

Here is a counter-example (which shows the above account to be inadequate)

Boorse says consider a small rock holding up a larger rock in a fast-moving stream. If the small rock didn't hold up the larger rock then it would be washed away. Holding up the big rock is the thing the small rock does and it explains why it is there. So on Wright's analysis this is the function of the small rock.

Wright's account appears to be too general.

2) Evolutionary function

In response to Boorse's counter-example (and others) Millikan suggested that we restrict the entities to which functions are ascribed to those which exist within lineages defined by relations of reproduction or replication. Very roughly, the function is whatever past instances of that reproductively defined type did that explains the presence of the present instances.

A counter-example to the above account would be Dretske's work on representation. Dretske says an inner state C can have the function of indicating an external condition F if C has been recruited as a cause of some motion M because it indicates F. This is okay on Boorse's view but not on Millikan's. (The problem is that individual development is a bit different to evolutionary function. We might want to say neural pruning and / or Hebbian learning is akin to natural selection but it isn't an EVOLUTIONARY process in the way that Millikan defined evolutionary processes.

3) Cummins function

Are to do with the contribution that a mechanism plays in some greater system.

'The difference is in the type of explanation. So if it is claimed, for instance, that the function of the mylin sheaths round some brain cells is to make possible the efficient conduction of signals over long distances, it may not be obvious which explanatory project is involved. This may be intended as an explanation of why the myelin is there (Wright / Millikan), or it could be part of an explanation of how the brain manages to perform certain complex tasks (Cummins)'.

(Above is derived from Godfrey-Smith, Peter (1993) 'Functions: Consensus Without Unity', Pacific Philosophical Quarterly 74, 196-208

If we ask 'is this inner brain state an instance of function or malfunction' then the answer will be highly dependent on what we take to fix the function of that brain state. There is controversy over how we fix the relevant functions. That is a conceptual issue. Different conceptions of function give us different answers to the question 'function or malfunction?' when we have plugged in the empirical data.

I really think that we don't want to stipulate (from the armchair) that mental illnesses are caused by malfunction.

As Murphy says 'the current literature on the concept of mental disorder is an impediment to research'. All we need is the notion that cause (whether inner or outer) is important. We can be neutral on whether the cause is a function or malfunction. Who cares? Not me. One could write several theses over on how we should understand the concept of function. What we seem to be doing is deciding this in intuitive grounds anyway. Whether or not we have an adequate account of function seems to be determined by whether the theory gives us the verdict we intuitively find to be correct. That isn't a scientific project. As such... To get too hung up on it... Is to let conceptual analysis impede the scientific project of discovery of causes (either inner or outer).

On with the science ho.

(There are some philosophers out there who consider themselves to be 'naturalised' or 'naturalistic' who are fairly hostile to people making bold claims about the way the world is from their armchair. Saying that mental disorders are caused by inner malfunctions is IMHO one such overstepping of bounds. The relevant notion of malfunction is such that whatever the cause turns out to be it will be dubbed a malfunction. Not on any independent grounds. Just as a matter of stipulation)

 

[worriedwell]

Another example is nuclear fusion, where you need a critical mass for a reaction to occur. When the reaction occurs all material components are converted to energy. I.e. there is a change between the nature of the substrate and the product. I hope these examples are helpful to the discussion. I’m trying to show how, using logic and scientific (in the case of fusion) congruent ideas to discuss how the mind and the brain can be completely different and yet relevant to each other.

I get it, the whole is greater than the sum of its parts, but you are now talking about things like the soul, the meaning of life, existence and religion to some degree. As above stated, mind is just different when you are talking about it on that front and not comparable to anything else. while fun to sit around in the coffee shop with the hipsters (and I do it with certain people) and wax poetic about stuff like that, I think its starting to stray from my initial rebuttal to the original concept about mental illness having fundamental differences in how they are defined as illness in society. I'm talking about illness primarily and how it is defined more than I'm dissecting definitions of mind. And I'm essentially saying that the "mental" part is the way we measure dysfunction in the brain. Thus, we deal with different functional components of the brain than neurologists do, but the plasticity and the "learning" that takes place both in the realm of physical neurology and mental neurology can imply that relearning can be used as treatment both for peripheral and central nerve diseases (although it takes a lot of hard work-for example in physical rehab from spinal injury and in mental rehab in psychotherapy). I don't think its as simple as needing a body system to clearly be "malfunctioning" either. I think that it is more complicated in all of medicine save for the obvious things like the heart stopped pumping etc. But what caused the heart to stop pumping is highly multifactorial and even though the insult is very readily apparent in seeing a clot...the interplay of a thousand things led to the disease state of heart disease. Thus its a bit pompous for psychologists to discount all of the rest of so called physical illnesses as clearly reducible to organ malfunction in some "pure" way.

There is no evidence that dogs have a mind. What a dog experiences and what a human experience are several orders of magnitude in difference.

Really, you must not have a dog then. my dog has emotions, motivations, memory and desires. he gets affectionate, frustrated, angry, jealous. what the heck is mind if not some component of those things? I'm not saying we are the same as dogs, but I don't think that dogs don't have a mind.

but there is an entire “mind” component to Human OCD that a SSRI may or may not be able to affect—we don’t know, because rct trials on ocd fail to address factors of the mind as a dependent variables.

How do you propose to test the "mind" component in randomized controlled trials? Have you ever asked a person with ocd if they've felt better after you've treated them with high dose ssri? because most of them say "yes". and i realize that isn't a randomized controlled trial, but symptom scores are the best we can do, unless you have another testable mind variable.

The argument of anorexia being biologically derived requires the discovery (or creation) of an “illness which has control issues” to which both parties would be “strongly predisposed to having” to have merit.

agreed...I never said I did a study on it, and maybe its not true. hopefully one day we will know.

It is currently impossible to predict who will develop PTSD given a certain stressor. So I don’t think this statement has data to back it up—for or against. Even with MDD, which you may argue that risk factors—such as family history—the best that you could argue is that given current knowledge some biological factors may predispose some individuals to depression. Anything else is an over-extrapolation of data.

I'm not saying there is data, yet, to back up my claims. There are definitely strong hippocampal imaging data suggesting post PTSD changes in the brain. But the fact is that if 100 people share the same traumatic event, only a small percentage will get ptsd from it. I attribute that to a "vulnerability" to get the disease in those people. And there is data indicating other comorbidities that are sky high in PTSD which suggest some sort of biological mechanism at play. Maybe that is an over extrapolation, maybe not.

The only way to prevent morbidity is to cause morbidity.

Its relevant to all of medicine. You give chemotherapy to treat cancer. That causes a heck of a lot of morbidity in the short run.

Also, who wants to live while suffering? Is death then never a viable option for refractory chronic mental illness?

Palliative care is a field of medicine. And euthanasia is debated in all of medicine, so again, not unique to psychiatry.

Sorry, WW, I'm not trying to pick on you. I'm just trying to push you a little to go deeper than scratching the surface. I appreciate your answers and comments.

I could do without the condescension. But thanks for the "push".

 

[sunlioness]

I'm not saying there is data, yet, to back up my claims. There are definitely strong hippocampal imaging data suggesting post PTSD changes in the brain. But the fact is that if 100 people share the same traumatic event, only a small percentage will get ptsd from it. I attribute that to a "vulnerability" to get the disease in those people. And there is data indicating other comorbidities that are sky high in PTSD which suggest some sort of biological mechanism at play. Maybe that is an over extrapolation, maybe not.

That's one explanation. Another is that those who develop PTSD in response to a traumatic event have a history of earlier traumatic events, which may not be recognized as such. Someone who has been traumatized already is more vulnerable to develop PTSD from a new trauma than someone who has not. Also one could argue that the comorbidity seen in PTSD is a function of dissociation and thus is because of the trauma and not an indicator of increased biological vulnerability. A really cool book is The Body Bears the Burden by Babette Rothchild (sp?) in it she postulates that panic attacks are a form of a flashback in which you replay the somatic manifestations of the traumatic event SOB, fear, helplessness, etc. Robert Scaer, MD's books are really cool too.

 

[Chewbacca Jung]

WW-I could do without the condescension. But thanks for the "push".

sorry about that, not my intent. How about ...'just trying to push a little deeper'...

 

[Chewbacca Jung]

I think I've come to the conclusion that schizophrenia is not biologically determined. I think that genetics can give a strong disposition towards schizophrenia (50%) and other events can put you at risk (i.e. obstetric complications), and biology may serve as a good model of how it unfolds, i.e the best example of pathological changes/ functionality, and it may be a good way to intervene once the disease develops (i.e. DA blockers), but I think that what determines whether biological predisposition actually transforms into schizophrenia may be something other than biological. This is the only way I can reconcile the 50% concordance rate, and yet the strong response to anti-psychotics.

PTSD may be a better example of this--as, even if there is a predisposition, the disease cannot occur unless trauma ensues. Sunlioness cautions that a predisposition may not even be the case.

any way, what do think, in the context of this thread?

 

[worriedwell]

i think that anything that has a 50% concordance rate has a HUGE biological component compared to 99% of all diseases in all of medicine across all disciplines. Heart disease, for example, has strong family "ties" but you never know who is going to get a heart attack. Although, risk factors can up the ante, but you still don't know. Same with breast cancer. so your point is well taken, but essentially you are saying that schizophrenia is like every other disease on the planet except for a handful (Huntingtons comes to mind) that have 100% penetrance and always outwardly fatal or disabling. There are recent studies showing family members of people with schizophrenia who have delayed visual processing which may have promise in further identifying biological "risk factors" for schizophrenia.

 

[toby jones]

I agree that schizophrenia isn't biologically determined but that Huntington's seems to be. I mean the penetrance isn't perfect (the person might die before they get the 'opportunity' to develop the disorder) but I think it is fair to say that had they lived they would have got it. Not so with schizophrenia, however. Or bi-polar. Or any other mental disorder you care to name.

What that shows us is that while genetics is clearly going to be PART of the story there is no way that genetics is going to be ALL of the story. Other causal factors must be relevant. Perhaps even (shock horror) some social causal mechanisms ;-)

Given that penetrance is less than 50% for identical twins (I hope I got that terminology correct) what grounds do we have for saying that there is a genetic malfunction? IMHO we don't have grounds and there are significant ethical issues around altering peoples genes when more likely than not they will be okay.

I think that the behavioural symptoms of schizophrenia are caused (more proximally) by neurology (hence the anti-psychotics tend to help with positive symptoms). But neural development is partly due to genes and partly due to environmental (including social environmental) factors.

I find the three WHO studies that showed that around two thirds of people in developed nations to be chronic and around one third of people in developing nations to be chronic (still talking about schizophrenia). The people in the developing nations would have had less access to psychiatrists, medications, stigma etc. And probably more access to family and social supports. I think this shows us something about intervention as altering the environment (including the social environment) results in changes to neurology.

There has also been some work done on how the genetic basis for schizophrenia might have been selected for in virtue of enhanced creativity (in people below the threshold for 'mental disorder'):

> Highly creative "normals" also tend towards over inclusive or "allusive" thinking and, as pointed out by Albert Rothenberg [20], demonstrate a capacity to conceive and utilize two or more opposite or contradictory ideas or concepts simultaneously, without being disturbed by this simultaneity of opposition, as is also the case with schizophrenics. It seems that creative individuals, like schizophrenics, are subject to a widening of selective attention, which makes them more aware of and receptive to experience, with more intensive sampling of environmental stimuli [9, 19]. In fact ideational fluency and a preference for complex and asymmetrical designs, two of the main factors contributing to creativity, could derive from higher levels of arousal and faster stimulation of discrete cerebral areas. Schizophrenic thought processes tend to allow unusual associations which result in over inclusive thinking, with many irrelevant elements being included in reasoning: this peculiar style of thought is assumed to derive from a failure in the filtering of stimuli by dysfunctional gating systems [3, 18]. Creative individuals, conversely, may gain advantage from higher levels of associative thinking, since they are capable of effectively processing these increased inputs without the risk of cognitive overload. Since to create consists essentially of the making of new combinations of associative elements [3], any ability which serves to bring together otherwise remote ideas will facilitate a creative solution [9, 17]. The favouring of associations implies an extended knowledge of the argument under study (memory of ideas to be associated) and a restriction of inhibitory influences on stimulation of remote cerebral areas. The more associations evoked by an element, the more likely it is that another element will be combined with it in a manageable form. Since inhibition or suppression (by anxiety or other more powerful competitory stimuli) would limit awareness and openness to both internal and external stimuli, freedom from these forces would favour associative thinking, and so creativity.

also:

http://cogprints.org/2009/

 

[OldPsychDoc]

I agree that schizophrenia isn't biologically determined but that Huntington's seems to be.

You're confusing "biologically determined" with genetically determined.
The environmental factors, whatever they may be in schizophrenia, are still acting to alter the biology of the brain.

Thank you.

 

[solumanculver]

I think I've come to the conclusion that schizophrenia is not biologically determined. I think that genetics can give a strong disposition towards schizophrenia (50%) and other events can put you at risk (i.e. obstetric complications), and biology may serve as a good model of how it unfolds, i.e the best example of pathological changes/ functionality, and it may be a good way to intervene once the disease develops (i.e. DA blockers), but I think that what determines whether biological predisposition actually transforms into schizophrenia may be something other than biological.

Hey, I sometimes have difficulties following this kind of thread. I think that there is some very ambiguous talking going on here. When you say that schizophrenia is not biologically determined, are you implying that a person who has schizophrenia, if they could go back in time, could have exactly the same biological events occur within their body the second time around and yet not end up schizophrenic again? That is what lack of biological determination means to me, and I don't think that it's possible.

It seems like you might be differentiating between social causes and biological causes, yet social causes can only be perceived by us inasmuch as they cause some biological effect. A social event that does not precipitate some biological change is by definition an event that nobody noticed, and I don't think that unnoticed events can play a significant role in schizophrenia.

This is the only way I can reconcile the 50% concordance rate, and yet the strong response to anti-psychotics.

It really seems like you might mean to say that schizophrenia is not genetically determined, rather than that it's not biologically determined. I think that in order for non-biological mental illness to be possible there has to be a much stronger dualism than most people would be willing to accept, something along the lines of vitalism, and I'm actually something of a dualist myself... Evidence definitely does show that it can't be completely genetically determined, but it seems like there is a genetic component and an epigenetic component, which together probably explain everything.

There's also the point that I think Toby Jones has made, that supposing that mental illness supervenes entirely on pathological neural states, and that its etiology is completely describable in terms of genetic and epigenetic factors, it still may not be most usefully described in this way. Kind of like how all organic chemistry is based upon quantum mechanics, yet we have developed a shorthand for talking about the reactions that doesn't even make reference to quantum mechanics. Grignards and Aldehydes make primary alcohols, for instance. It could be that the causes leading up to schizophrenia, even though they are fully explained on a given level in terms of genes and proteins and whatnot, are also describable in terms of a higher-lever phenomenon like "too many spankings", or "having a transvestite uncle" or something.

 

[Chewbacca Jung]

I'm trying to get at root cause analysis. There is a difference between schizophrenia being "biologically determined" and "we can observe biological mechanisms mediating changes, or plays a vital role in the transformation to schizophrenia", and it's more than just semantic.

Even though we can observe grey matter changes, diminished blood flow to the prefrontal lobes with cognitive challenge with fMRI, and decreased ability to perform anti-saccades; and even with changes in the peripheral leukocyte d3/4 receptors I can envision these biological changes as merely a probabilistic predetermined response to outside stimuli. The brain, on its most simple level, is a contraption (using decartian terms on purpose) which senses the environment and respond to the environment. It can also adapt to a constant environment over time—just like any other tissue in the body.

Input, self modification, output.

Genes are the determining factor in how the whole thing is programmed to adapt and respond to the environment, thus genes are the only way something can be biologically determined (this includes genetic mutations). Everything else requires some sort of insult to the system, i.e. toxins, metabolites, ionization, infectious agent, trauma, etc,…. It is possible that the transition to schizophrenia is a stochastic event,--a true flip of the coin-- given the genetic predisposition, but I doubt there is a precedent for this concept.

It seems that as solumanculver points out, that biology is the lingua franca, everything must be translated into biologic terms in order for us to conceptualize it as actually occurring. But that doesn't mean that biology is the best language to describe these events., or that biology can even describe the dynamic events that are actually occurring. I think a lot is lost in the translation.

Schizophrenia may be biologically mediated, but not caused

I think the best example to prove my point is that of a desktop toy—the one with the linear 5-steel-balls-suspended-by-string thing, that when you drop one and hit the row of steel balls and it causes the last one to fly up and then they go back and forth… Well,

1)the initial input is the cause of the chain of events
2) the ones in the middle (that barely move) they are the mediators of the event, and
3) the final ball is the end product.

Schizophrenia is the entire chain of events.
1) The initial ball is currently unknown (or atleast not well understood),
2)biology (genes, brain structure and function) is the middle balls- the mediator, and
3) the final ball is the behavioral deregulation and disharmony with society caused by schizophrenia.

Biology (2), in this example, is necessary, but yet not sufficient to cause schizophrenia (in the natural environment, at any rate —you could possibly move any combination of the three balls in the middle, forgoing the first ball, and still get the final ball to move—but, that would be a manipulation, and therefore not schizophrenia (as defined above))

Intervention to stop the movement of the final ball can occur at any stage.
1) prevention of initiating event(s)?, social support to those at risk?…
2) pharmacologic intervention, psychotherapy
3) hospitalization, restraints, IM haldol prn….
Each step has its associated cost and efficacy. Anyway, I think it's a fun model to think about—and even a little hypnotic if you have an overactive imagination like me… It's obviously a reductionalistic model compared to the possibly multi-dimensional factors that go into the making of schizophrenia-- and biology is much more complicated than a passive transducer of energy through a system. But it illustrates my point how biology can be important to the pathogenesis and treatment of schizophrenia, but yet not be the cause.

To answer your questions solumaculver, If a schizophrenic goes back in time developmentally, and the environmental insult that occured that caused transformation to schizophrenia does not occur the second time around then 1) the patient will not develop schizophrenia 2) the structural/ functional brain changes that are directly associated with production of psychosis will not occur 3) other brain changes that are more proximal to genetic code and less dependent on environmental changes (i.e. endophenotypes such as anti-saccades-- which appear in non-symptomatic family members of schizophrenics--) may continue to appear 4) behaviors which fit into the spectrum of schizophrenia may be manifest.

Finally, as for dualism or plurism, I think that these concepts help to conceptualize the various components of mentation. But I doubt the reality of static descriptions of separate systems that interact only at specific points. The production of schizophrenia is the interaction of a myriad of dynamic elements that play off of each other at all levels, with feedback and synergy. I'm using the category of "biology" in an attempt to disprove its use as an isolated phenomenon that creates schizophrenia . I'm trying to re-describe biology as a moving player in a dynamic landscape, and I'm trying to be specific in how biology reacts to and affects that landscape.

I don't think any one answer can really be an answer for anything—it's complicated. I think this is more in the realm of anti-monism than any form of pluralism.

 

[solumanculver]

I’m trying to get at root cause analysis. There is a difference between schizophrenia being “biologically determined” and “we can observe biological mechanisms mediating changes, or plays a vital role in the transformation to schizophrenia”, and it’s more than just semantic.

Hi, I have to admit that I'm still pretty confused as to what you're getting at. As far as I can see it there can be no debate that schizophrenia is, as a matter of definition, a pathological biological state. As long as we acknowledge that brain controls behavior, and we define Schizophrenia as a set of pathological behaviors, it must follow that schizophrenia is also describable as a set of pathological brain states. The only way around this is to deny that brain controls behavior, which requires an interactionist dualism which is very difficult to defend.

I can envision these biological changes as merely a probabilistic predetermined response to outside stimuli.

I'm not sure what you mean by "probabilistic predetermined". It seems like probabilistic is the opposite of predetermined.

Genes are the determining factor in how the whole thing is programmed to adapt and respond to the environment, thus genes are the only way something can be biologically determined (this includes genetic mutations). Everything else requires some sort of insult to the system, i.e. toxins, metabolites, ionization, infectious agent, trauma, etc,….

Apart from remaining a little bit confused on your use of "determined", I think that you have a good point here. Non-genetic factors are definitely involved, toxins and metabolites and everything. In my mind, however, these things still remain firmly under the heading of biology.

It is possible that the transition to schizophrenia is a stochastic event,--a true flip of the coin-- given the genetic predisposition, but I doubt there is a precedent for this concept.

Yeah, there is plenty of philosophical precedent for the concept, it's called indeterminism. The only scientifically proven indeterminism occurs on the quantum level, though, so it doesn't seem like it could result in a person coming down with schizophrenia or not.

It seems that as solumanculver points out, that biology is the lingua franca, everything must be translated into biologic terms in order for us to conceptualize it as actually occurring. But that doesn’t mean that biology is the best language to describe these events., or that biology can even describe the dynamic events that are actually occurring. I think a lot is lost in the translation.

Hey, that's a pretty good summary of what I said, except for your caveat that biology might not be able to describe the dynamic events that are actually occurring. I think that biology must be able to describe all states of a persons body and behavior.

 

[worriedwell]

To answer your questions solumaculver, If a schizophrenic goes back in time developmentally, and the environmental insult that occured that caused transformation to schizophrenia does not occur the second time around then 1) the patient will not develop schizophrenia 2) the structural/ functional brain changes that are directly associated with production of psychosis will not occur 3) other brain changes that are more proximal to genetic code and less dependent on environmental changes (i.e. endophenotypes such as anti-saccades-- which appear in non-symptomatic family members of schizophrenics--) may continue to appear 4) behaviors which fit into the spectrum of schizophrenia may be manifest.

I feel it my obligation as the antagonist in this thread to point out (as goodnaturedly as possible) a couple things:

1. Everything in this last post is completely the way psychiatric research and treatment are currently thought of and practiced. Thus, it is not particularly profound and definitely not a unique way of conceptualizing disease.

2. This is EXACTLY how other medical models work. By posting this, you are essentially reinforcing the diathesis stress model of disease, and accepting that this illness is a "medical illness" which I believe Toby Jones disagrees with and the original reason this thread was started. For example, we have a predisposition genetically for colon cancer, we eat a "Western Diet" high in free radicals, we are at higher risk for getting colon cancer. We can intervene/screen at multiple stages for colon cancer. And the good news with colon cancer is that we can cut out the diseased part of the colon and then prevent or cure the illness. But the disease was never completely determined by ones genes. The steps from baseline risk from birth to disease are slightly better understood but not completely. Unfortunately for schizophrenia, the mediating steps and insults are not well understood (but they aren't for a ton of physical illnesses too).

As for Toby Jones post, which if I'm reading it right seems to suggest that Schizophrenia may just be an extension of being "creative" because someone is just more "sensitive" to stimuli...well I recognize that there is a rich history of troubled individuals who tend to be some of the most profound artists. And I think there is something to say about "viewing the world differently and not being bound by conformity" (this is getting into social control again, which I see is part of why your spirit resists defining someone as "mentally ill"). However, the difference between creativity and schizophrenia is that a schizophrenic cannot volitionally "turn off" their creativity. There are so many other cognitive, motor, and emotional symptoms. It engulfs them and causes them severe distress. Should we not try to help them? If somebody who is a great artist is suicidal and hates the thoughts in their head, should we let them spiral out of control and kill themselves just so we can get them to do some pretty paintings and then call them a genius?. It is possible that people can be creative AND mentally ill. But you are implying that we as a society hold creative up as a virtue, and therefore anybody with a "unique way of looking at the world" should not be called ill.

I think that is an oversimplication of the features of psychotic illnesses. having Schizophrenia is more than just having a unique way of viewing the world. But the social elements are always in play, and it is a difficult balance. Again though this only practically is an issue if someone is being involuntarily treated, and this is a different conversation about the role of psychiatrists to "police" the mentally ill from hurting themselves or others and assuming a certain predictive ability to do so. That is truly debatable, and I readily question that role of psychiatrists.

 

[solumanculver]

To answer your questions solumaculver, If a schizophrenic goes back in time developmentally, and the environmental insult that occured that caused transformation to schizophrenia does not occur the second time around then 1) the patient will not develop schizophrenia 2) the structural/ functional brain changes that are directly associated with production of psychosis will not occur 3) other brain changes that are more proximal to genetic code and less dependent on environmental changes (i.e. endophenotypes such as anti-saccades-- which appear in non-symptomatic family members of schizophrenics--) may continue to appear 4) behaviors which fit into the spectrum of schizophrenia may be manifest.

Hey, thanks. This helps a lot. I think that what you call indeterminism is identical to what I call determinism. To me, in order for something to be undetermined it's required to show that given the exact same circumstances more than one thing could possibly happen. Your example of the case in which different conditions lead to a different result is also what I believe in, which does not argue either for or against biological determinism. As I said before, I don't think that it's possible to disprove biological determinism, as I have conceived it, without recourse to some interactionist dualism and agent causation kind of stuff, which has become philosophically very difficult to defend.

This is EXACTLY how other medical models work. By posting this, you are essentially reinforcing the diathesis stress model of disease, and accepting that this illness is a "medical illness" which I believe Toby Jones disagrees with and the original reason this thread was started.

It seems to me that the argument as it's currently formed is unclear. It equivocates between mental illness not being medical disease at all to mental illness being a biological medical issue that happens to be best understood on a level above the biological, like the psychosocial or whatever.

The first argument is a lost cause, if behavior supervenes on neural processes then there is no room for odd behavior to not correspond to odd neural processes. Given that our rough definition of disease is "harmful dysfunction", and if we take it to be the case that there is some threshold at which mental illness becomes unequivocally harmful (somewhere below florid psychosis, probably), then all that must be shown is that this "harmful odd behavior", which supervenes by definition on "harmful odd neural states" is equivalent to "harmful dysfunctional neural states". In other words, if we can show that biological features which are both harmful and odd are by definition dysfunctional then that's all we need to say. I think that we can make that intuitive leap without too much spilled ink.

The second argument is valid, however. Some mental illnesses need to be treated on a level above the biological, like with CBT or something. This fact, however, has no bearing on the etiology of the illness itself. It's just like when you add aldehydes to grignards to make alcohols. Just because we can describe it with electron arrows and functional groups doesn't mean that it's not fundamentally a quantum mechanical process; both levels of explanations work, but some questions must be answered by going down to the quantum stuff while others can be addressed just fine by talking about carbonyls or whatever.

 

[Chewbacca Jung]

sorry, my philosophical prowess is probably a 2 out of 10. I'm trying to be concise with my language, but I am really not familiar with any of the terms.

I'm trying to downplay the role of biology. Even though its common to think of schizophrenia as a biologically derived disease, I think biology fails to capture all of the elements of the disease. Biology is only correlated with onset of symptoms, and some treatment response using biologic agents, there is no causal role established. Environmental insults could possibly be included in the grab bag of the biological, but most environmental insults are more determined by socio-cultural-political factors than biology (fast food restaurants, hygiene, seatbelt laws...). Biology, at the most, is mearly a bottleneck in the pathogenesis of schizophrenia. Behavioral output is also very dependent on the psycho-socio-cultural-political...-- (interestingly enough, at Colorado they have a big screen tv that has yet to have even a scratch on it--)

I do believe that there is something to all this biology I've been studying (meaning some amount of ultimate truth behind it). I think that the social construct comes into play, though, at every level of trying to understand what is really going on. The social affects which studies get funded, how those studies are carried out, how the results are compiled and interpreted, what conclusions are drawn, which studies are published, who believes those studies, which ones go into practice, which studies are repeated... and what we ultimately teach medical students to believe. I guess my language is not really percise in differentiating whether I mean the socially constructed biology and the actuality that biology is attempting to describe. I don't think I have the jargon to do it justice, and i'd get bogged down.

ww-I am emphasizing a form of stress diathesis model only for schizophrenia. Schizophrenia is not a "medical illness" if "medical illness" is defined only in terms of biology. I'm not sure I understand what "medical illness" means to you.

ww-and I'm not trying to revolutionize psychiatric thought via a quasi-anonymous online forum. I have a lot of thoughts and questions and I'm trying to understand and get some feedback. If there is some consensus to my musings, all the better. But i doubt that what I mean is completely in line with popular theory in research and treatment. Otherwise, why the outcry at the initial post stating that schizophrenia is not biologically determined?

s- by "probabilisticly determined" I mean that every thing in current biologic theory depends on concentrations and probabilities of interaction. Nothing is for sure. I think the term sets the stage for feedback/feedforwad at all levels of complexity.

s-the precedent I am referring to is a disease that is genetically determined but only has a 50% penetrance because of completely random assortment of downstream products which is not influenced by outside influences.

 

[sunlioness]

I can't brain well enough to contribute to this conversation today, but a good alternate view of schizophrenia can be found in Schizophrenia: Innovations in Diagnosis and Treatment by Colin A. Ross, MD. He addresses the concordance rates of MZG twins as well.

 

[toby jones]

Firstly, I’d just like to say that I’m trying to get people to think. I don’t think Schizophrenia is a natural kind of mental disorder, but I’ll grant that some people with Schizophrenia are mentally disordered if anybody is (they form exemplars of the ‘core’ cases of mental illness).

ØAs far as I can see it there can be no debate that schizophrenia is, as a matter of definition, a pathological biological state.

This is disputed (by Szasz, for example, and by others as well). The DSM maintains that in order to diagnose the mental disorder must be due to a malfunction, but it allows that the malfunction can be purely behavioural. If one meets criteria for a DSM disorder (and the behaviour results in harm to oneself and / or others) then one is mentally disordered. While the DSM ALLOWS the malfunction to be inner it certainly doesn’t require it.

ØAs long as we acknowledge that brain controls behavior, and we define Schizophrenia as a set of pathological behaviors, it must follow that schizophrenia is also describable as a set of pathological brain states.

I’m sorry but that does not follow. Does a software malfunction entail a hardware malfunction? No, it does not. I’ve provided an example before (and I’ll provide it again) of how there can be behavioural malfunction WITHOUT inner malfunction. Wakefield provides the example of the Y2K problem. The problem was that the system wasn’t designed to take the input ‘00’. The concern was that the input ‘00’ might have been interpreted as ‘1900’ instead of ‘2000’ and that would affect other programs. A payroll program that was designed to pay employees on a Thursday, for example, could have produced deviant output by virtue of the deviant input and yet the system had no inner malfunction. Wakefield also considers that a person who had levels of neurotransmitter at the high end of the normal range and receptors for that neurotransmitter at the high end of the normal range could have deviant behaviours even though the individual mechanisms are not malfunctioning. The assumption of cognitive therapy is that there is deviant input (being told you are worthless, for example) and normal processing of information so if you provide input within the designed range for the system outputs will become normal).

Murphy says: We do not need to say that mental disorders are caused by inner MALFUNCTION to respect the intuition that inner CAUSES are important (because the brain determines behaviour in either a strictly determinate or probabilistic fashion).

Whether the brain is malfunctioning or not should be an empirical matter for scientists to investigate and it most certainly should not be STIPULATED from the armchair that mental disorders must be caused by INNER malfunction. If one stipulates that mental disorders are necessarily caused by inner malfunction (as Wakefield does) then it could turn out (as a matter of empirical fact) that many of the suffering people who present to psychiatrists for treatment turn out not to have inner malfunction and hence not to be mentally disordered after all. That seems crazy and since it does seem obvious to most people that functions / malfunctions are a scientific matter and it similarly seems obvious to most people that paradigmatic cases of mentally ill people really are mentally ill it is exceedingly unwise to build inner malfunction in as part of our CONCEPT of mental disorder.

ØThere are so many other cognitive, motor, and emotional symptoms. It engulfs them and causes them severe distress. Should we not try to help them?

Don’t forget that there are many people with Schizophrenia who do NOT want to be hospitalised, who do NOT want to take their medication, who do NOT want ‘help’.

All I’m trying to draw people’s attention to is that we begin with these paradigmatic cases of ‘well that person is mentally ill for sure’ and ‘so is that one’ and so forth… Our concept is formed around those paradigmatic cases. Then scientists study the causes of those behaviours. It is an EMPIRICAL matter (and isn’t to be stipulated from the armchair) that mental disorders must be caused by inner MALFUNCTION (IMHO the function / malfunction controversy is a waste of time). Whether the causes are ‘functions’ or ‘malfunctions’ the point is to figure out the causal structure so that one can interveane in such a way that they aren’t a paradigmatic example of a person with a mental disorder.

But… Lets not kid ourselves… It all begins with a NORMATIVE assessment of behaviour. Some peoples behaviour is assessed as socially deviant such that we are justified in involountarily committing them and trying to intervene on their behaviour. It is clear that breaking just any social or moral norm (or convention) won’t do so it must be certain kinds of social or moral norms (or conventions) that are relevant. All I’m saying is: Forget about inner malfunction people and appreciate that there is a normative aspect here. I’m fairly sure that this normative aspect is what is meant (at times) by ‘mental illness is a social construct’. Whether people are mentally ill or not depends on societies values (in whether we judge there to be harm or not) and in whether we consider the behaviour sufficiently deviant / problematic so we can intervene. Seems that we also want to criticise past practices so that the Russian doctors who diagnosed political dissentors as suffering from sluggish schizophrenia were abusing their powers. Seems as though we might need to gesture towards a ‘final ethics’ instead of a ‘final science’ of malfunction.