The concept of mental illness in the West is largely shaped by the DSM diagnostic model. The DSM categorization of psychiatric disorders has been useful in driving research, and psychiatric neuroscience has made enormous strides in identifying some of the brain-based factors that contribute to mental disorders such as autism, schizophrenia, and bipolar disorder, as well as suggesting possible drug therapies. Continue reading
An untidy stack of new books on psychiatry has sprouted in my office since our last conference on cultural and biological contexts of psychiatric disorder in January 2010. At the top is a slim volume by Harvard clinical psychologist, experimental psychopathologist, and DSM-IV (PTSD and specific phobia) committee member Richard McNally entitled What is Mental Illness? (Belknap Press, 2011) that promises to cut through “both professional jargon and polemical hot air, to describe the intense political and intellectual struggles over what counts as a ‘real’ disorder, and what goes into the DSM.” (McNally is also advisor to the DSM-V Anxiety Disorders Sub-Workgroup.) The book, which was written for an academic/trade audience and can be read through in a single evening, is an impressive synthesis of research and scholarship interwoven with insights.
Like Arthur Kleinman’s Rethinking Psychiatry: From Cultural Category to Personal Experience (save for another evening), the titles of McNally’s chapters are phrased in the form of questions: “An Epidemic of Mental Illness?”; “Are We Pathologizing Everyday Life?”; “Can Evolutionary Psychology Make Sense of Mental Disorder?”; “Psychopathology as Adaptation?”; “Does Society Create (Some) Mental Disorders?”; Is It in Our Genes?”; “Do Mental Disorders Differ by Kind or Degree?”; “So What is Mental Illness Anyway?” The “gift” of this book is McNally’s ability to survey and evaluate a broad swath of psychiatric, evolutionary, philosophical, anthropological, historical, and neuroscientific literature, with the biological, classificatory, pharmacological, social, and narrative aspects of mental illness given equal play.
Although nearly half of all Americans suffer from some form of mental illness according to a recent study, McNally argues that we shouldn’t be surprised at the high rates. Just as “physical illness runs from the common cold to cancer,” he writes, so mental illnesses can range from mild phobias to severe psychoses. The real problem according to McNally, one that his book attempts to address, is in distinguishing the concept of “mental disorder,” and all that that classification entails, from the differing degrees of “mental distress” in response to the emotional tangles, ruptures, or situational predicaments of everyday life.
McNally believes that some forms of psychopathology “are likely natural kinds discovered by observant clinicians across cultures and throughout history.” These include mania, melancholia, panic disorder, obsessive-compulsive disorder, and alcoholism. (Although McNally describes schizophrenia as a biological disorder of recent vintage, he doesn’t consider it a “natural kind” because there are likely distinct phenotypes.) He recognizes other illness, like multiple personality disorder, as instantiations of one of Ian Hacking’s (1999) “interactive kinds” whereby psychiatric classification has a feedback effect on the behavior of the people being classified, as well as beliefs, institutions, and practices.  Still other illnesses may reflect what he considers an encroachment of psychiatry on “normal suffering” as a result of life’s “inevitable disappointments and limitations,” e.g., sexual dysfunction, social anxiety disorder, eating disorders, and PTSD – disorders that are tied to particular contexts, motives, and practices. (McNally, who is the author of a previous, terrific book, Remembering Trauma, is particularly critical of our capacity for “conceptual bracket creep in the definition of trauma.” )
He concludes that mental illnesses can never be defined on the basis of any single approach (or explanatory level) “because the questions asked by the stakeholders may require different kinds of answers.” The various definitions are based on the contexts in which disorders occur.
New books challenging our assumptions about psychopathology by McNally, Ethan Watters (Crazy Like Us), Irving Kirsch (The Emperor’s New Drugs), Jonathan Metzl (The Protest Psychosis), Daniel Carlat (Unhinged), Robert Whitaker (Anatomy of an Epidemic) and Gary Greenberg (Manufacturing Depression) are kicking up dust clouds all over biological psychiatry (see NYRB for a recent, 2-part essay review on the Kirsch, Whitaker, and Carlat books). Public debate matters because there are multiple stakeholders, a slew of treatments (some dubious), overmedicalization, unmet need, and an ethical decision to be made on whether or how to intervene in the face of psychological suffering. Psychiatrists, researchers, and the nearly fifty percent of us whom anthropologist Emily Martin refers to as living under the description of a psychiatric disorder will find McNally’s even-handed approach to the DSM’s validity issue of immense value.
 Although McNally refers specifically to “interactive kinds,” Hacking (2007) has since dispensed with the term: “Interactions among classifications, people, institutions, knowledge and experts are essential to the explanation of the looping effect and making up people, but there is no well-defined type of classification of people worth calling interactive or human kinds. Interaction, yes, but interactive kinds as a distinct class, no” (2007, p. 293, fn. 21).
Greenberg, G. (2010). Manufacturing depression: The secret history of a modern disease. New York: Simon & Schuster.
Hacking, I. (1999). The social construction of what? Cambridge, MA: Harvard University Press.
Hacking, I. (2007). Kinds of people: Moving targets. Proceedings of the British Academy, 151, 285–318.
Kirsch, I. (2010). The emperor’s new drugs: Exploding the antidepressent myth. New York: Basic Books.
McNally, R. (2003). Remembering trauma. Cambridge, MA: Belknap Press.
McNally, R. (2010). What is mental illness? Cambridge, MA: Belknap Press.
Metzl, J. (2010). The protest psychosis: How schizophrenia became a black disease. Boston: Beacon Press.
Watters, E. (2010). Crazy like us: The globalization of the American psyche. New York: Free Press.
Whitaker, R. (2010). Anatomy of an epidemic: Magic bullets, psychiatric drugs, and the astonishing rise of mental illness in America. New York: Crown.
We will be periodically posting summaries of the 4th interdisciplinary conference on brain, mind, and culture (“Cultural and Biological Contexts of Psychiatric Disorder”) sponsored by the Foundation for Psychocultural Research and UCLA, which took place at UCLA on Jan 22-24, 2010. Below is the summary for our session on bipolar illness.
One innovative aspect of the FPR-UCLA conference was the inclusion of transdisciplinary and experiential reflections on mental health and illness. Saturday morning’s session on bipolar illness (BPI), chaired by UCLA anthropologist Douglas Hollan, focused on white matter tract abnormalities and the possibility of using this neuroimaging finding as a biomarker to differentiate BPI from unipolar depression, as well as to identify persons at risk. Cutting-edge neuroscience was combined with insights from individuals “living under the description of bipolar disorder” (in the words of conference participant Emily Martin). As another conference participant (cultural psychiatrist Laurence Kirmayer) put it, these commentaries “provided grounding and reflection on the limits and promise of current psychiatric theory and practice.”
Neuroscientist Mary Phillips of University of Pittsburg discussed the clinical implications of brain imaging studies detecting abnormalities in neural systems for emotion regulation in BPI. BPI is one of the ten most debilitating illnesses worldwide, with a high (15%) suicide rate. At the same time, BPI is frequently misdiagnosed as unipolar depression (UD). A 2003 study by Hirschfeld and colleagues indicates that only 20% of people living with BPI received a correct diagnosis within the year of first consultation, while 35% did not receive a correct diagnosis for 10 years or more, primarily due to overlap of BPI symptoms with those of other psychiatric disorders. The goal of Phillips’s research is to improve diagnosis by identifying biological markers (e.g., abnormal amygdala activation) that can distinguish BPI from other disorders, including UD, and to identify asymptomatic young persons who may be genetically at risk for developing BPI.
Brain imaging research has identified specific brain circuits by testing voluntary and involuntary emotional regulation in response to facial expressions. Involuntary emotional response processing occurs largely in communication between the amygdala, which detects emotionally salient stimuli, and the orbitomedial prefrontal cortex OMPFC, which regulates emotional responses. Voluntary emotional response processing involves the above areas, as well as the dorsolateral (DLPFC) and ventrolateral (VLPFC) prefrontal cortices.
A key white-matter tract linking the amygdala to the OMPFC is the uncinate fasciculus. (White matter refers to the white myelin that covers the axons of neurons.) In individuals with BPI, a 2008 study from Phillips’s group using diffusing tensor imaging (DTI), which measures the diffusion of water in white matter tracts, showed abnormal left and right fiber alignment in these circuits. With respect to healthy controls, individuals with UD display abnormal left-side connectivity. However, individuals with BPI display both abnormal left (more streamlined) and right (more diffused) connectivity. In response to happy and sad faces, individuals with BPI show particular discrepancies in left and right connectivity between the OMPFC and the amygdala. The OMPFC’s regulatory effect (“the brake”) on the amygdala is diminished in BPI individuals’ responses to happy faces, particularly on the left, whereas connectivity between these two structures is enhanced in the same individuals’ responses to sad faces, particularly on the right. A further whole-brain study by Phillips and colleagues recruited two groups of currently depressed individuals: those diagnosed with BPI and those with UD, as well as a group of healthy controls. They found significant differences in the right uncinate fasciculus between individuals with BPI, those with UD, and healthy controls. In terms of bidirectional connectivity (using the happy faces paradigm) Phillips’s group found evidence indicating a significant discrepancy between individuals with BPI and those with UD in response to happy faces. Whereas UD individuals displayed greater inhibitory (left OMPFC to amygdala) effective connectivity relative to controls, BPI individuals displayed less with respect to controls, as well as less right bottom-up (amygdala-OMPFC) connectivity than controls.
The structural, functional, and white matter differences in UD and BPI (particularly the “disconnectivity” in BPI vs. the greater inhibitory connectivity in UD) suggest distinct physiological processes underlying the two disorders, which are difficult to distinguish clinically. Phillips’s work presents the serious possibility of one day using objective biological markers for BPI in children who are genetically at risk as well as adults living with the illness, which could eliminate much human suffering due to misdiagnosis, but with all the ethical, social, legal, and mental health policy implications that such an advance would entail.
Kay Redfield Jamison, professor of psychiatry at Johns Hopkins University and author of An Unquiet Mind: A Memoir of Moods and Madness, spoke eloquently and movingly about the personal experience of living with bipolar illness (BPI). Jamison described BPI as a chronic relapsing illness involving “cyclic upheavals” of mania and depression, which she first experienced at age 17. BPI presents a special dilemma since moods are essential to a sense of self, which affects the willingness or motivation to seek treatment (“it’s very hard to tell an 18-year-old, who’s feeling better than he’s ever felt in his entire life that he’s sick”), to stay on medication, and to stay alive. Mild elated states pose a particular set of clinical, theoretical, and scientific problems. She described these states as addictive, at the biological as well as psychological level. Like depression, the manic states (or more generally positive affective states) can be ranged along a continuum, she said, with positive implications for learning, creativity, exploration, and risk taking. (She addressed “the fiery aspects of thought and feeling” in a previous book, Touched with Fire: Manic-Depressive Illness and the Artistic Temperament.) On the other hand, the pain of severe depression and severe mania “are not comprehensible to people who have not experienced them,” a gap she began to address as a young clinician and researcher at UCLA, when she wrote a series of anonymous accounts of her own illness experience for the benefit of the residents and the psychology trainees in the affective disorders clinic.
Jamison movingly described what it was like to have BPI, which she characterized as “recurrent cycles of pain, elation, loneliness, and terror.” She described her unwillingness to accept her illness and take lithium on a regular basis, until repeated psychosis and a nearly lethal suicide attempt convinced “even the slowest of learners.” Although her form of BPI (Bipolar 1 with psychotic features) is well stabilized with medication, she said the illness has a “ghostlike presence,” not only because it can recur but because it can be entwined with a hyperthymic (or “hail-fellow-well-met”) temperament. Psychotherapy may be particularly effective in addressing the erratic flow of experience. Like Elyn Saks, Jamison believes that “psychotherapy has been underestimated in its importance in the psychotic illnesses” and that “it can keep people alive.” Psychotherapy “makes some sense of the confusion, reigns in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all. Pills cannot and do not ease one back into reality.”
Saks acknowledged that some experts espouse neither psychodynamic nor psychoanalytic therapy for schizophrenia, but said, “I’m here to tell you that it is (effective) for some people.” Stress is bad for all illness, in particular mental illness, she said, and it is important to understand triggers and learn to cope with or avoid them.
Refusing medication is resistance that arises from the narcissistic injury of having that illness, she said, and working through those feelings of “damage and defectiveness is really important” for recovery. For her, a safe place to bring frightening thoughts (and, as a result, not express them in the workplace) was very valuable. “Interpretations can detoxify symptoms, but not always,” she elaborated. Some believe psychotic symptoms are just random firings of neurons and others think they’re meaningful, Saks acknowledged, but when the person is experiencing them interpretations do not always help.
Having someone accept you not only for the good, the bad, and the ugly is “enormously empowering,” she said. Schizophrenics are people, too, she said, “we have relationship issues and work issues that can be addressed through psychotherapy.” Therapy improves quality of life, she said, “so on lots of different vectors it could be a very helpful compliment to medication.” Although early studies did not involve medication, Saks suggested that future studies explore the efficacy of both psychotropic medication and good, intensive therapy.
Kandel then noted that both women are highly intelligent, which is a sign of ego strength, and asked them to elaborate on their experiences. Jamison responded that intelligence is not always an advantage. Some literature suggests that early on the highly intelligent commit suicide because of their keen awareness of their unraveling and its implications for their future. She also emphasized that refusing medication is a psychological issue, but has enormous medical implications and the patient’s relationship with his or her doctor is “hugely important.” For Saks, working, thinking, and writing are important. “Whatever intelligence I have has helped me navigate having this illness,” she said.
A member of the audience thanked Saks and Jamison for their courage. He then inquired about the tension between recognizing a biological process that might mediate aspects of disorder with the contrasting notion that willpower can overcome that discomfort. Saks responded, “I don’t believe this has anything to do with willpower. Mine is not the story of willpower, but of one who had enormous treatment resources–great psychopharmacology, a supportive family and friends. It’s not will power, it’s help.”
Robert Lemelson, UCLA anthropologist and documentary filmmaker, added that in Indonesia there is one psychoanalyst for 200 million people who mostly treats foreigners. Pak Kereta (the main character in Lemelson’s documentary, Shadows and Illuminations, which is one of a three-part series) has schizophrenia, according to some models. But only during the last cut did Lemelson begin to view Kereta as having “something like schizophrenia.” His outcome, by most measures, is quite good, Lemelson said, because he is married, has children, and works, despite horrific experiences and major stressors in his life and without the kind of western biomedical interventions being discussed. “One of the points we make in the film is that he’s not labeled . . . we show that people, while they consider it odd, don’t consider it insanity, or madness, or mental illness, so he’s protected by the lack of a biomedical label.”
In another film in Lemelson’s series (Afflictions: Culture and Mental Illness in Indonesia), a woman with Tourrette’s Syndrome also escapes labeling, but those in her midst do see her as mad and she has a very poor outcome because her social world is quite toxic. Some of the factors Lemelson mentioned that effect positive and negative outcomes in rural Indonesia include: labeling and social stigma (or lack thereof), supportive family environments, environmental toxins, and the lack of drug abuse. “So several factors, none of which is specifically psychiatric or biomedical, shape outcomes of severe mental illness,” he concluded.
Finally, Marvin Karno, Professor Emeritus, of the Department of Psychiatry and Biobehavioral Sciences at UCLA, emphasized the importance of “a strong sense of tenacity, resilience under incredible stress,” traits that are “not ordinary,” as very important to positive outcomes. Having worked for many years with persons with schizophrenia and bipolar disorder, he has observed that those with good outcomes possess such traits. “They’re essential to fighting any terrible disease,” he said. He described a five-year survivor of pancreatic cancer who was also a triathelete. “She was just determined that that cancer wasn’t going to kill her and it didn’t.” He suggested that the trait of resilience ought to be further explored.