An Emerging Model of Mental Illness
Kevin Turnquist M.D.
November 2003
For several decades now
mental illness has been explained on the basis of “chemical imbalances”. This
model has been quite handy for psychiatrists and our colleagues, especially given
the fact that none of us can really say exactly what causes any particular
mental illness. We tell our patients that their chemicals are not balanced
properly, then explain that they will have to take pills to correct the
imbalance indefinitely. It is hard to find anyone with a severe mental illness
who hasn’t been told that their illness is somehow akin to diabetes, with the
same requirement for daily medications to keep those rogue chemicals in the
right balance. Of course our drug companies perpetuate this view of mental
illness too. Their job is to provide a never ending stream of new imbalance-
correcting medications, always at enormous cost to whoever ends up paying the
bills for these pills. This “chemical imbalance” model of mental illness has become
such a pervasive part of our culture that few mental health professionals even
begin to question it. There are, however, a few problems with this approach.
One obvious objection to the
idea that mental illnesses arise from imbalanced brain chemicals is that so far
we can’t say exactly what chemicals are out of balance in any particular mental
illness. Our original ideas about the roles of neurotransmitters such as
serotonin and dopamine have proven to be simplistic and naïve. The idea that an
excess or deficiency of one neurotransmitter would be at the root of a major
mental illness may have intuitive appeal for the masses but it would be hard to
find a serious neuroscientist who believes this anymore. Humans are turning out
to be far more complicated than that.
Then there is the matter of
how people respond to the attempts to correct these “imbalances”. It is
extremely rare to see anyone truly recover from a mental illness as a result of
taking medications, even in the dizzying combinations that we now prescribe
them in. Many patients stop taking these medications at the first opportunity.
The fact that all of our major mental illnesses are now frequently
treated with the same combinations of antidepressants, major tranquilizers, and
mood stabilizers further weakens the ‘one neurotransmitter imbalance - one
mental illness- one corrective medication’ model of psychiatric treatment.
Ultimately, the biggest
problem with the chemical imbalance model of mental illness is not simply that
it is wrong. Our models of mental illness will always contain inaccuracies and
will never stop evolving. In the last analysis any model must be judged by its
usefulness. These explanations of mental illness shape all of our interactions
with mentally ill people, from our direct experiences with individuals to the
programs that our society sets up to help them. Our models of the human mind
influence our very beliefs about how a life should be conducted and what it
means to be human. As we look around at the way people with serious mental
illnesses live in our society it would be hard to argue that our current models
of mental illnesses have translated into better lives for the people that
suffer from them. Depression and the use of antidepressant medications are
expanding dramatically in our society. We have far more severely mentally ill
people in homeless shelters and prisons than we do in psychiatric hospitals.
And the incidence of mental illness in our children is skyrocketing.
Any new model of mental
illness should be consistent with the many advances in the neurosciences that
have taken place over the last decade. There has been an increased awareness
of problems in the structural
development of some key areas of the human brain. Factors influencing the
migration and hook-up of neurons in the developing brain have been identified.
The role of childhood experiences in shaping adult brain structure and
functioning is becoming better appreciated. We have learned a great deal about
the things that adult brains need to have a chance of working well. Taken
together, the implications of these discoveries about the human brain are
enormous. Our social programs for the mentally ill, the role of medications,
and the ways that we bring up our children will all be influenced by the model
of mental illness that is now emerging.
The Brain and Its Tasks
Human brains contain
somewhere on the order of one hundred billion neurons. Far from being inanimate
wiring, each of these nerve cells is alive and has a set of jobs to do. It is
strange to consider the fact that our neurons have some sort of awareness of
their own. In one ingenious experiment a researcher trained human neurons to
fire their electrical discharges at different rates by rewarding them with
little squirts of dopamine when they discharged at the rate he wanted. The job
of some neurons is to carry information to other cells. Others are helper
cells, tending to the needs of those involved in the information processing.
These neurons talk to each other in a variety of ways. The release of chemical
neurotransmitters across synapses is the one that receives the most attention.
We have long assumed that our medications act by increasing or decreasing the
actions of one of these neurotransmitters but the happenings at the synapse are
turning out to be just a small part of the communication between cells. When a
neurotransmitter crosses the synapse a whole cascade of chemical reactions
occurs in the next cell. Ultimately, a gene is turned on or off, influencing
the production of yet other chemical messengers.
Many of us have been a tad
dismayed by the findings of the human genome project. We have far fewer genes
than we had anticipated, probably around 35,000. To make matters worse, we
share about 97% of those genes with chimpanzees and our other primate
relatives. This all seems impossible until one thinks of genes as part of a
dynamic system of communication. If we think of a piano with 35,000 keys the
amazing possibilities become more apparent. And this system certainly does seem
to be dynamic. Our brains build new synaptic connections between nerve cells
all of the time. If we’re exposed to a stimulus for ninety minutes or so we
have already built new synapses to adjust to it. We are constantly shaping and
reshaping our brain, strengthening or diminishing connections between our brain
cells to meet the changing demands of our realities.
Our neurons communicate in a
variety of ways besides the release of neurotransmitters. Hormones provide a
mechanism to communicate with larger groups of neurons. Some communication
between cells occurs as a result of the release of nitrous oxide. There are
undoubtedly channels of communication that we’ve not yet discovered. But it’s
easy to get lost in the details of how neurons speak to each other at the
expense of what it is that they’re talking about.
Each of our billions of
neurons is a complex little world onto itself, constructed of a vast array of
molecules. Each of these molecules is, in turn, made up of atoms of the various
elements. The atoms that make us up are no different than those constructing
everything else in our world. Trees, bridges, amoebas, wall to wall carpeting,
and humans are all made up of the same stuff. Molecules within us one day may
be part of a plant the next, and vice versa.
These atoms are made up of
all sorts of strange sub-atomic particles. At least sixty have been identified
so far. These particles are in a constant dance, changing from moment to moment
into other types of particles. If one could take the mass of all of these
countless trillions of particles that make up the hundred billion neurons of
our brains, all of those particles could fit nicely on the head of a pin. At
their most basic level the particles that we’re constructed of are made of
energy.
We humans are, like all
creatures, awash in a sea of energy. Light, heat, gravity, motion, and
electrical energies are just a few of the forces that constantly impinge on our
nervous systems and bid for our attention. All organisms must select from the
types of energies that they can perceive to construct an inner model of “what’s out there”. These inner
representations of external reality will vary from species to species depending
upon the types of energy receptors that each species possesses. All organisms
have basic tasks that must be attended to as they interact with external
reality. Feeding, defense, and mating are given priority when decisions are
made about what energies to attend to at any given moment.
The process of organizing
sensory input into a coherent picture of external reality is enormously
complex. Fascinating and informative things take place when problems occur at
the basic levels of perception. Experiments have shown that kittens who were
raised from birth in a visual world artificially composed of only vertical
stripes were blind when transferred to an environment of horizontal stripes.
The raw neurological symbols for “horizontal” had not been developed through
experience. Similarly, frogs will starve to death if the only food available is
freshly killed flies. The frog nervous system can’t recognize its favorite food
as food unless it is moving. Human examples abound. One involves a man
who had brain surgery in an attempt to tame uncontrollable seizures. He had had
no unusual sexual interests prior to the operation but afterwards he could only
become sexually aroused by the presence of a safety pin. A short circuit had
developed in parts of his brain involved with assigning emotional responses to
his picture of external reality.
While only about three
percent of our genes are different from those of chimps, intuition and pride
tell us that those three percent must be mighty important. It is probably safe
to assume that most of this difference must be involved with how our brains are
structured. Humans are different from all other animals in a few key areas of
brain structure and function. These are primarily involved with creating,
storing, responding to, and manipulating complex symbols. It is the differences
in what our brains do with symbols that, ultimately, make mental illness a
uniquely human phenomenon.
There are three main areas of
the human brain that are strikingly larger and more highly developed in humans
than would be predicted based on comparisons with other creatures’ brains: The
frontal cortex, the hippocampus, and the cerebellum. It is reasonable to assume
that the roots of mental illness are somehow related to problems in the ways
that these important structures are built and how they are connected with each
other. Within the past decade neuroscientists have, indeed, discovered that one
or more of these three key areas are abnormal in each of our major mental
illnesses. The understanding of mental illness is now shifting from a focus on
neurotransmitters to changes in the structure and interrelationships of brain
areas involved in creating our own personal versions of reality.
Some general findings about
the structure and functioning of these brain areas are summarized below. This
is a relatively new area of study and conflicting reports emerge but the idea
that there are abnormalities in these areas - changes in structure, activity,
biochemical concentrations, cellular architecture, and symmetry - in the major
mental illnesses now seem pretty certain.
Hippocampus Amygdala Frontal lobes
Cerebellum
Schizophrenia: -decreased
volume -decreased -hypoactive -asymmetry
-decreased activity volume on left -loss of gray
?enlarged
-altered shape matter
-decreased activation
during memory tests
Bipolar Illness -Left > Right? -increased size -white matter ? increased
?neuronal loss
lesions volume
-? decreased
gray
matter
Borderline -decreased volume -decreased volume -decreased L
Personality
orbital-frontal
Disorder
Depression -decreased volume -abnormal
blood flow
-increased activity
Moving symbols instead
of muscles
Perhaps it is our large
frontal lobes that are most responsible for the differences in brainpower
between we humans and all of the other creatures. During the period between
fifteen and twenty weeks of fetal development this area produces an astounding
250,000 new brain cells per minute, causing it to overgrow everything
around it. It is helpful to think of these frontal lobes as an outgrowth or
expansion of the brain’s motor system, and that does seem to be the case anatomically.
Other animals basically move their muscles and limbs in response to changes in
their environments. Because of this extension of our motor system, however,
humans have the ability to move symbols as well as muscles. When
confronted with changes in our external world we can use our frontal lobes to
create a variety of potential options and choose among them, rather than being
limited to a few stereotyped behavioral responses.
Ultimately, this newfound
ability to create a separate world of symbols and manipulate them on our “inner
screens” underlies every talent and achievement that makes us different from
other animals. Thinking, planning, and problem solving are all manifestations
of this human capacity for creating an inner symbolic reality that stands quite
apart from consensual external reality. We even have the unique ability to
attend to two realities at once, as when we drive our automobiles while
simultaneously thinking about our plans for the evening.
From an evolutionary
standpoint this talent for moving symbols is brand new. It has allowed humans
to have an unprecedented impact on our planet. Communication, transportation,
and creativity have been elevated to levels that no other organisms could ever
approach. But when brain functions are so new and different there are a lot of
things that can go wrong with the structures responsible for them. The study of
mental illness is, ultimately, an exercise in understanding the huge list of
things that can go awry in these new domains of brain structure and
functioning.
The Process of Reality
Construction
Let’s consider a simple
illustration. Imagine that you have parked your car in a ramp at a local
shopping mall. The lighting is dim and you’re alone. When leaving your vehicle
you see a stranger approaching. As he comes closer he says something that you
can’t quite make out, then reaches into his pocket and tosses something towards
you from about ten feet away. During the brief moment that the object is in the
air your nervous system accomplishes a number of tasks at an amazing speed. It
gauges the speed and trajectory of the unknown object, easily anticipating
where it will be in space when it nears you. To perform these basic
calculations with a paper and pencil would require a knowledge of physics and
mathematics that few of us possess. And as the object approaches the brain
makes a host of more impressive determinations.
As light that reflects off
from the object reaches you an electrochemical reaction takes place in the
retinas of your eyes. The resulting nerve impulses race to the back of the
brain via four main bundles of fibers, two of which cross near the pituitary
gland. These pulses of electrical energy reach the primary vision centers and
begin to be processed but so far the incoming data is not in useable form. It
must be further processed in a sequence of two visual association areas,
comparing the input to stored symbols of things that the eyes have seen before.
Once the visual information has been properly buffed up it is immediately transmitted
down into the limbic system, the evolutionarily ancient part of the brain that
is heavily involved with memory and emotion. The limbic system then must
exchange information with the frontal lobes. The incoming stimuli are compared
with existing symbols held in the long term memory banks. Your brain must then
address a number of important questions about the approaching object: What have
you seen like this before? Is the object alive? Is it sharp. Is it heavy? Is it
dangerous? Is it something you want?
Once your brain has made its
best-guess determination of what is approaching out there in external reality
there is still a lot of work to do. It must assign appropriate emotional
responses to the situation that it believes is developing. Should you be
terrified, amused, excited, or angry? What intensity should be given to the
emotional response? Should you be a little bit frightened or fear for your very
life? Mildly irritated by the stranger’s intrusion or enraged to the point of
attack? You might have a different response from one day to the next, depending
on other things going on in your life at the time. Obviously, other people
would emotionally respond to the same situation in very different ways.
The number of factors
influencing the emotional reality that you happen to create in the parking lot
that day is almost limitless. A person approaching at two a.m. will likely
elicit a different reaction than someone at two p.m. A female’s approach may
bring up different emotions than a male. The age, race, and size of the
stranger may all impact on your reactions. Your personal history will also
influence your assessment of the situation. People who have been subjected to
cruelty or abuse will be more likely to react to innocent settings as though they
were dangerous. We can only construct our picture of the world with the symbols
that are neurologically available to us at any given moment.
After the brain has made its
best effort at determining what is out there and what emotions to activate it
must still choose from an array of possible behavioral responses to the
unfolding situation. What should you do in response to the approaching
stranger? Run? Jump back into the car and lock the doors? Throw up your arms in
self-defense? Scream? Attack? Or simply extend your right hand to catch the
roll of hundred dollar bills that a wealthy philanthropist had decided to
donate to the first shopper he met at the mall that day?
This exercise illustrates
some important points. Most crucial is the fact that our nervous system must
actively create a moment to moment representation of external reality
-of what is “out there”. The fact that all of these many tasks seem to occur
instantaneously camouflages the sequence of actions and decisions that are
actually taking place as we construct our complex versions of reality. It is
easy to forget that even though the gap between an external event and our
perception of it might only be a few microseconds, that is still an enormously
important gap. For particles moving near the speed of light a microsecond might
seem like a very long time.
The difficulty that we face
is in getting past the conviction that we are just experiencing reality as it
exists, as though it is always the same for everyone. The only reality that
anyone can know is the neurological representation of it that is created in
one’s head. Once that fact is truly appreciated it is easy to understand some
of the things that can go wrong with the process of reality construction. And
mental illness can start to make sense.
Balanced Brain Systems
A basic principle found
throughout our nervous system is that there are two opposing systems that are
set up in a dynamic balance. The system controlling the movement of our muscles
is a good example. Flexors move our limbs in one direction, extensors in the
other. Maintaining normal posture or
moving our limbs smoothly requires an ongoing balance in the brain
systems controlling these muscle groups. Imbalances can result in jerky
movements, tremors, or spasticity. Brain systems involved with creating a representation
of external reality, and with assigning proper emotional responses to it, must
be balanced in a similar way although these systems are much more complex and
difficult to understand.
Most people are now aware
that the brain is constructed of two large hemispheres. The idea that each of
these hemispheres sees reality in somewhat different ways is also generally
understood, but the implications of all this are not as clear. Below is a
summary of some of the differences in the ways that our hemispheres commonly
perceive the world.
Left Hemisphere
Right Hemisphere
Logical
Intuitive
Sequential Non-linear
Time oriented
Timeless
More cheerful More
depressive
Detail oriented Big
picture
Verbal focus
Non-verbal communication
Abstract Concrete
Our tendency is to think of
specific brain functions as being located in one hemisphere or the other.
People may ask questions like "which side is mathematics located
in?", as though their difficulty with the subject must be a result of one
hemisphere's failings. The fact that each of these hemispheres forms its own
representation of reality, complete with its own emotional responses, talents,
and areas of difficulty, is harder for us to picture. The idea that we
simultaneously form a second world view that includes different political
opinions, different morals, and different ideas about ourselves seems almost
preposterous. But experiments in which the two hemispheres are separated via
surgical or chemical means tell us that this is indeed the case.
One thing that seems clear is
that we should not be aware that we have two distinct views of reality going on
in our consciousness at the same time. This could get a little distracting.
When our brains are working properly the two realities should be nicely
balanced into a seamless whole. In the chapter on schizophrenia we'll look at
some of the problems that can take place when the input from these two
hemispheres is not balanced properly. Hallucinations and delusions such as
believing that outside forces are monitoring one's thoughts or controlling
one's behavior are common results.
There are other brain systems
that must be kept in a reasonable balance if we are to remain mentally healthy.
One appealing theory holds that we have within us two distinct "reality
generators" (that are not the same as the realities created by the two
hemispheres). One generator forms a pretty exact reproduction of "objective"
external reality as we experience it during clear consciousness. The other
forms the "subjective" reality that we experience in pure form during
our dreams. The idea is that these two "reality generators" must be
kept in a proper balance as well. When there is too much input from the
"objective" generator consensual reality looks the way that it should
except that it is "flat" in terms of the emotional component. The
person does not attach the proper motivations, emotions, and creativity to his
world view. When the balance is shifted towards the "subjective"
generator there is lots of emotion and personal input into the view of reality
but the world can be experienced in strange ways. Dream like intrusions into
the picture of reality can occur. In fact "dreaming while one is
awake" may be the simplest and most accurate way to conceptualize many
psychotic experiences.
The fact that we actively
construct our own views of the world is certainly not easy to grasp. The idea
that these constructions are the result of an interplay between opposing
systems that are inclined to see things differently requires even greater
reach. But so far we have been looking only at the process of creating a
picture of external reality and responding to it emotionally. As complex and
puzzling as this is, it only touches on the enormity of the brain's constant
task. For we not only react to the ever-changing world around us. We must also
attend to our inner world of thoughts and imagination.
Our uniquely human problem is
that we must deal with realities that might happen, in addition to those
that are happening. We attach emotions to thoughts about things that may
or may not take place tomorrow. In addition, memories and possible
interpretations of past events compete for our attention and emotional
responses. We can replay the events of yesterday in our heads for weeks, coming
to different conclusions about what the meanings of those occurrences might be
and feeling different emotions in response to what we believe took place.
Imagine that you were in a
meeting last week with ten coworkers and your boss. You said something
impulsively. Some people might have thought that it was a bit outlandish or
politically incorrect. Perhaps it will influence your standing in the company.
Maybe it was really insignificant and no one even remembers. It is possible for
you to replay that event in your mind thousands of times, with a multitude of
emotional responses. To complicate things further, you can replay the event
from the perspective of each of the other people in that room, imagining how
every one of them might have reacted to your possible faux pas. Different
emotions arise within you depending on what you conclude that each of the
coworkers thought of you. Your employer’s possible reaction is given even more
emotional weight. What did he think of your comment? Was he angry or amused?
Does he value your fresh approach to things or think that you're brash and
immature. We humans run these sorts of possibilities through our minds all of
the time. To make things more complex, we can perform these mental gymnastics
while we're doing other things at the same time. It is possible for humans to
attend to two separate realities at once. How many of us pay complete and total
attention to current external reality when we're sitting through lengthy
Powerpoint presentations?
This separate inner world of
thoughts, memories, and imagination is almost always taking place while we try
to attend to the demands of the present. Thinking is the most important and
pervasive of our brain's symbol- manipulating activities. From the moment we
wake up until we finally drop off to sleep the process of thinking dominates
our consciousness. We talk to ourselves constantly, and our own lives are the
main topic of conversation. Many of us are only jolted out of our world of
thoughts on the rare occasions when something crops up in external reality to
demand our attention for a moment. We then return to our thinking as quickly as
possible and continue until another irritating intrusion occurs. And emotions
can be attached to every one of those thoughts.
How does a nervous system
decide what emotions should be activated at any given moment? How does a brain
strike a balance between emotional reactions to the world of thoughts and
emotions arising in response to external reality? This is all so new in
evolutionary terms. It comes as no surprise that we'd have trouble balancing
all of these competing demands. Estimates suggest that as many as twenty
percent of humans have enough problems with these basic processes to warrant a
diagnosis of mental illness. But this job of balancing thought, emotion, and
the experience of external reality is so amazingly complex that each of us is
bound to have problems with it at some time. The list of things that can go
wrong in the formation of the brain structures responsible for these tasks, and
in the resulting formation of our realities, is so long that it seems endless.
That fact that these brain systems are ever in some semblance of balance
is a miraculous human achievement.
A Dual Emotional
Processor Hypothesis
One of the most exciting
areas of neuroscience research in the past decade has been the growing
awareness that the hippocampus appears to be abnormal in all of the major
mental disorders. Scientists have also been amazed to learn that the
hippocampus is one of two known brain structures ( the olfactory cortex being
the other) that manufactures new brain cells each day. It is quite likely that
this process of generating new brain cells may be essential for the formation
of new memories. The idea that nerve cells that are created today are somehow
related to the memories that are made of today has tremendous intuitive
appeal. But this is clearly an area in which the findings coming out of laboratories
are far ahead of the theories available to explain them.
Research has found that the
hippocampus is often small and misshapen in schizophrenia. Its volume may also
be reduced by as much as 20% or so in major depression. Antidepressant
medications and electroconvulsive therapy ( ECT) may actually exert their
antidepressant effects by stimulating the birth of new brain cells in the
hippocampus. Childhood trauma and abuse, as is so frequently seen in borderline
personality disorder, also can result in smaller hippocampal volumes. Bipolar
disorder has been found to be associated with enlargement of the amygdala, a
structure that abuts the hippocampus. So there does seem to be an association
between structural brain changes in this key brain area and the emergence of
mental illness. But how can we understand this connection?
The hippocampus is heavily
involved in two major brain functions: the maintenance of a decent mood and the
formation of new memories. Its activity appears to be inversely related to that
of its neighboring amygdala. When the hippocampus becomes less active the
amygdala’s activity increases. A number of other connecting brain structures
are also intimately involved in the processes of forming memories and moods but
for the sake of this simple model let’s imagine that there are two basic
emotional processors. Let’s call these processors “Hippocampus”
and “Amygdala” after the two key structures that seem central to
their functioning. In this model the bold italic versions will refer to the
processing systems while regular typeface will simply refer to the structures
themselves.
As the constant flood of
highly processed incoming stimuli from our sense organs arrives in the limbic
system it appears that we have two broad ways of sorting it all out. “Amygdala”
primarily assesses the stimuli based on emotional symbols and
memories. When this system asks “ what is out there?” the first thing that it
wants to know is if there is anything that is an immediate threat to our
survival. Other basic instincts like sexual drive, feeding, and strivings for
social dominance also get high priority here. “Amygdala” is
highly connected to parts of the autonomic nervous system that control our
“fight or flight” reactions. In the example of the stranger approaching in the
parking lot, most of us would experience sudden increases in pulse, blood
pressure, respiration, and adrenaline as “Amygdala” sized up the
situation and prepared us to do battle or run for our lives. This is a system
that must be capable of responding quickly and decisively. It is likely to
attach particular emotions such as hostility, fearfulness, desire, and anxiety
to our experiences. Desires are experienced as powerful and immediate. When the
balance is shifted towards excessive input from “Amygdala” depression, anxiety, impulsivity,
irritability, and the abuse of mood altering substances all become more likely.
“ Hippocampus” is the more modern system. In evolutionary terms one
could say that it is still an experimental system as well. This system appears
to separate us from the “Amygdala” based system of responding to
our environments that all other animals must rely on.
“Hippocampus” is the limbic system’s gateway to the frontal lobes’
memory banks and their capacity for imagination. It is interesting to consider
that memory and imagination are so intimately related. Imagination is the
creative combination of symbols already stored in memory. These symbols are the
very stuff that our representations of external reality are made up of as well.
“Hippocampus” is situated in a way that allows it to not only
ultimately decide what events are to be stored in memory, but to later access those memories in our
efforts to decide “ what is out there”. This is the system that allows us to
creatively move symbols and representations rather than just our limbs.
When confronted with a
challenging situation humans can ask “what have I seen like this before?” and
“what are the possible meanings of this situation?”. A human with a well
functioning “Hippocampus” system could easily generate a list of
dozens of possible reasons why a stranger might be approaching him in a parking
lot, then prioritize them from most to least likely based on experience and
intuition. We could also generate a list of possible responses to the
situation. But problems can develop. We can become so preoccupied with moving
symbols on our inner screens that we become incapable of fully participating in
external reality. Sometimes we’re so lost in our thoughts that a wad of money could
land at our feet without even registering in our attention.
What Does “Hippocampus”
Need To Thrive?
If one accepts that our
brains have these two basic emotional processors- regardless of the terms that
are applied to them- then some important questions naturally follow. What
factors influence the neurodevelopment of these important brain areas? What is
the role of early experience in shaping them? And what can we do as adults to
maximize the functioning of these systems?
Over the past several years a
significant amount of information has accumulated about the workings of the
hippocampus. A number of factors appear to impact on the volume of this
structure ( or more properly structures - each side of our brain has one).
Physical exercise is important for the formation of new brain cells.
Environments that provide sufficient stimulation are essential. The role of
sleep is becoming clearer. It looks like a gene called zif 268 is involved in
the formation of new neurons in the hippocampus. Adequate sleep may be
necessary for this gene to be turned on properly. Novelty, or new experiences
also are emerging as important for hippocampus health. This makes good
intuitive sense. Why would we devote a lot of energy to maintaining an active
hippocampus if we aren’t having any new or different experiences to remember?
Similarly, challenges for the memory apparatus such as trivia games, crossword
puzzles, etc. may have important benefits in maintaining both healthy memory
and mood systems.
People familiar with our
mental health systems will immediately recognize a problem here. As a rule,
stimulating environments, novel experiences, new things to remember, and
adequate sleep are in short supply
throughout our mental health systems. Rather than trying to provide our chronic
mentally ill people with enriched environments we have spent our resources
primarily on providing expensive medications that are supposed to correct
chemical imbalances. And the role of environmental factors in maintaining
mental health goes far beyond providing those important factors necessary for a
healthy “Hippocampus”. The importance of stress is becoming
increasing clear as well.
The Toxic “Hippocampus”
A number of factors have been
identified that interfere with the workings of the “Hippocampus”
system. Excessive alcohol use and the abuse of opiates are known examples, each
can lead to the memory and mood problems that would be anticipated.
The negative effect of stress
hormones is probably an even more important and pervasive factor.
Glucocorticoid hormones, the messengers of the stress response, are known to
inhibit neuronal growth in “Hippocampus”. Prolonged exposure to
stress can clearly lead to anxiety, depression, and impaired mental
functioning. Our views of ourselves and our realities are different when we’re
stressed and brain changes are undoubtedly a major part of this.
The catch is that we humans
differ dramatically in terms of what we’ll experience as stressful. Some people
will drive across the country to ride a new roller coaster. Others would react
to the ride as though death were imminent. Our beliefs about ourselves, our
past experiences, our support systems, and the current state of our brain all
contribute to our perceptions of stress and dangerousness. Feeling like one has
some degree of control over what is about to happen is an enormously important
determinant of what we’ll experience as upsetting.
For humans, our perceived place in our social hierarchies has a
major role in how we feel about ourselves and the resultant realities that we
live in. We have new brain mechanisms capable of all sorts of amazing feats.
But the advanced processors that are able to remember, imagine, plan, and
create are still basically wired up to emotional systems not too different than
those of our primate ancestors. We continue to be driven by the same instincts.
It is as though we have a super-fast computer hooked up to a chimpanzee emotional
system, as much as we would like to deny this about ourselves.
We humans are still basically
troop animals. Where we stand relative to other humans around us is
critically important to us. We spend inordinate amounts of time and energy
trying to convince ourselves that we are superior to other humans. Obtaining
expensive cars, fancy homes, attractive clothing, and large bank accounts
motivate us in ways that we only dimly understand. Our species is obsessed with
sexuality. It occupies much of our mental life and is a constant subject in our
entertainment media. We are driven to see ourselves as attractive mates, even
when there is no evidence in the environment to support this notion. And anyone
who has experienced the American freeway system knows firsthand that we are
still territorial animals. Many of us believe that we own the rights to the
left hand lane. Everyone reacts emotionally as though the stretch of road in
front of them and immediately behind them is theirs and theirs alone. Many of
us would try to pass other drivers if we were on the way to our own execution
by torture. Watching the behaviors of Americans as they try to assert dominance
over other drivers calls to mind that of chimps as they fight over who will get
the choicest bananas or be able to sit on the sunny rock. This is just part of
our competitive nature. We are constructed to be extremely self centered and to
strive for the highest social position available to us.
Problems come about when our
efforts to see ourselves as occupying an important position on our social
ladder are unsuccessful. When humans experience social rejection we respond by
activating the same parts of the brain that we do when we experience actual
physical pain. Threats to our self image and our perceived place among other
humans are stressors of enormous importance. The chemicals involved in these
stressful emotions can be toxic to “Hippocampus”. And we humans
do not even need anything in our environments to activate these chemical
cascades of stress hormones. We can drive ourselves crazy anywhere. Even a hike
through beautiful wilderness can be marked by anxious thoughts about the
opinions of people hundreds of miles away. And those people whose opinions
we’re concerned about are probably thinking the same sorts of thoughts about
what other people think of them.
So this business of attaching
emotions and motivations to our experience is tremendously complex.
Difficulties can occur when the brain structures involved are not built
properly or when the balance between them is disrupted. The actual content of
our beliefs and thoughts can result in chemical stresses to the very structures
responsible for adding the emotions. A host of problems can develop.
Connections between the
frontal lobes and the emotional centers can become too tight. Things
that we think about or imagine can result in emotional responses that are too
powerful or intense. Again, this occurs most commonly when issues of self
esteem are involved. Some of us know what it is like to lay in bed before sleep
and recall stupid things that we did or said during the day. The painful
feelings that accompany these memories can be so strong that they’re
experienced as a physical feeling in the belly, almost like a blow to the solar
plexus. This is probably even more common in the serious mental disorders.
Psychotic people often believe that everything revolves around them. They may
feel that their actions are so important that the very fate of the world
depends on them. The self loathing that some mentally ill people must deal with
can be extreme. The resultant stressful emotions can be disabling in the short
term, and the hormonal responses to the stress can cause long term disruption
to these circuits. Many mentally ill people have had periods of time in which
their emotional system has been in overdrive for prolonged spells. There are
now suggestions that in schizophrenia some of the important brain pathways are
permanently damaged by excitotoxicity - stimulation in excess of what
the neurons are able to handle.
The connections between
thought, imagination and emotion can be too loose. Things that we think
about may result in an emotional response that barely registers. Patients with
“Negative Symptoms” of schizophrenia have enormous difficulty in mounting
adequate emotional responses to experience. Problems with will and motivation
can be so severe that the person becomes essentially non-reactive to his world.
Interestingly, patients with Negative Symptoms of schizophrenia often show
pronounced abnormalities of their emotional centers when MRI scans or other
sophisticated brain images are obtained. Despite the growing awareness that
these Negative Symptoms are a function of how the brain is structured, people
often react to those who suffer from these symptoms as though they reflect
laziness or dependency.
Sometimes the “wrong”
emotions are attached to thoughts and experiences. In fact this “inappropriate
affect” is one of the cardinal features of schizophrenia. The most morbid
thoughts can elicit hilarious laughter. Innocuous experiences can result in
terrifying, life or death emotional responses. People can react with rage to
kind hearted attempts to help them. Powerful emotions can be attached to everyday
objects. People can be afraid of their furniture or believe that they are being
stalked by fishing lures. The ability of “Hippocampus” to reflect
on the emotions and use them as sources of information can be lost entirely.
Emotional responses can escape
normal feedback mechanisms. Some people cannot become just a little upset or
irritated. Once the angry emotions are triggered the feelings continue to build
until rage is released through impulsive verbal or physical behaviors. Anxious
or sad emotions can similarly escape control, although the results are usually
not as visible. For some people it can seem like the emotional apparatus has no
brakes. Strangely enough, positive feelings can escape their normal controls as
well. In mania the rewarding feelings of creativity and increased energy can
run amok. Grandiose versions of the self, usually kept out of conscious
awareness, begin to surface. Thoughts come too quickly and eventually begin to
disorganize. Euphoria can turn to irritability as the brain is forced to go
without sleep for extended periods of time. Lines between wish and reality can
become blurry. While mania can have many causes, the consequences of this
mismatch between experience and emotion are usually devastating for the
individual.
Anxiety disorders may be the
easiest to intuitively understand. In these conditions an excessive amount of
emotional weight is given to representations of things that could
happen. The brain overreacts
to these potential realities, as though they were actually occurring in the
present.
One of the anxiety disorders,
Obsessive Compulsive Disorder, demonstrates another important factor that can
go wrong when short circuits develop in these brain systems. In this disorder
the thoughts can demonstrate characteristics of the muscle movement disorders
that they are related to. The equivalent of “mental tics” can develop, with the
same thoughts being repeated over and over. Stereotyped behaviors like hand
washing, checking, and counting may occur, again without any sense of volition
from the individual. These anxiety disorders emphasize the importance of being
able to coordinate one’s thinking. The ability to smoothly shift from one
thought to the next, to stop a train of thought when it has gone on for too
long, and even to stop thinking altogether for a while are essential talents if
one is to remain mentally healthy. But in Obsessive Compulsive Disorder there
are changes in the basal ganglia region of the brain, an area normally
concerned with maintaining smooth muscle movements. Asking an obsessive person
to stop ruminating may be akin to asking a person to stop a tremor.
Our emotions can be
influenced by rhythms and cycles that we are only dimly aware of. The
biological tendency towards inactivity as winter sets in or to become more
energetic with the sunny days of spring can go awry. Many people become
depressed in the fall, as day lengths shorten. The increased incidence of mania
in the springtime is a well recognized phenomenon. There are so many factors
that impact on our moods that we’re usually unaware of them. Moods are prevailing tendencies towards
particular emotional interpretations of experience. They save us the trouble of
having to create totally new emotional reactions to everything that happens to
us.
Below is an attempt to
summarize the growing body of research about the two very different ways that
our brains have of connecting emotions to thought, imagination, and perception.
“Amygdala” System
The “default” processor
Emphasis is on emotional memory
Highly connected to “flight
or fight” responses
Activity increases in
depression and addictions
Not as amenable to
self-observation
Bias towards fear,
irritability, hostility, impulsivity
Less creativity / flexibility
of responses
Very involved in chemical
reward systems, especially dopamine
Takes over in times of
stress, whether danger is real or imagined
“Hippocampus” System
Allows for a stable,
satisfying mood
Able to use memories and
symbols to reflect on the self
Can create and examine
options for behavioral responses
Emotions are available for
use as signals
Birth of new neurons
essential for its healthy functioning
Activity is boosted by
antidepressants, ECT, probably by
psychotherapy
A modern system. A lot can go
wrong:
-Requires active support to function well
-Needs intact wiring and the proper genes
-Empathic caregivers during childhood necessary for optimal
development
-Needs physical exercise and adequate sleep
-Requires relative safety/ freedom from stress. Stress hormones
are toxic
-Novelty and new challenges are necessary for good functioning
-Stimulating, enriched environment needed
-Sensitive to toxic effects of alcohol, opiates, probably
stimulants
-Falling estrogen levels can be deleterious to its functioning in
women
Dual Pleasure Systems
One of the most peculiar
things about humans is that we can attach varying degrees of pleasure to our
experiences, and even our emotions. Some people can even find physical pain or
emotional degradation pleasurable in the right settings. The whole business of
pleasure is one that has received little attention in psychiatric circles. Our
focus has been on the elimination of various symptoms of mental disorders. The
capacity to experience pleasure is not something that we’re prone to thinking
about. But for individuals the capacity for pleasure is, of course, enormously
important.
As with other brain systems,
it’s looking like pleasure involves two different systems that require
balancing to work properly. Researchers call them the Consummatory and the
Appetitive pleasure systems.
The pleasure brought about by
the Consummatory system has been termed
“ the pleasure of the feast”. It is the sort of pleasure that we experience
after a satisfying meal or having sex. The chemicals responsible for
Consummatory pleasure are the endorphins. The drugs that mimic this pleasure
system are the opiates.
Consummatory pleasure,
whether brought on naturally by a big meal or from outside by pills like
Oxycontin or Percodan, is an inactivating pleasure. After people eat
Thanksgiving dinner the tendency to lay on the couch can be irresistible.
Opiate addicts don’t move around much after a heroin injection. Just sitting in
one place, even in terrible surroundings, is pleasurable enough.
The Appetitive pleasure
system is very different. It is an activating pleasure system. Its pleasure has
been called “the pleasure of the hunt”. The neurotransmitter involved with
Appetitive pleasure is dopamine. The drugs that mimic this pleasure system are
the stimulants, especially cocaine. When this system is turned on the
individual is active and alert. It is hard to sit still. Physical and mental
movement feels essential.
The idea is that these two
pleasure systems should be held in an optimal balance. As a simple example,
think of our hunter-gatherer ancestors. As the time since the last meal
increased they became progressively hungry. The activity of their Appetitive
pleasure systems increased. They were stimulated to explore their environment
searching for food. When they found food and feasted their Consummatory
pleasure system kicked in. A period of inactivity followed until hunger started
to set in again.
Most people with mental
illness appear to have relatively intact Consummatory pleasure systems. They
are still driven to eat, drink, and smoke -often to excess- because consuming
these things brings about pleasure. The Appetitive system can be much more
problematic however.
When the Appetitive pleasure
system is turned up for too long a time, either through mental illnesses or the
abuse of stimulant drugs, strange things start to happen to people. They become
increasingly irritable and suspicious, sleep poorly, and lose their appetite.
If the Appetitive system remains activated long enough people start to show
paranoia and delusional thinking. The clinical condition brought about by the
prolonged use of stimulants may be indistinguishable from Paranoid
Schizophrenia.
It seems likely that many
people with mental illnesses have something wrong with this balance between
their two pleasure systems. Perhaps a sensitivity to the stimulating effects of
dopamine is involved.
Dopamine is a neurotransmitter
that gets a lot of emphasis from pharmaceutical companies. All of our major
tranquilizers, or antipsychotic medications,
are designed to inhibit
dopamine flow. But once again the commonly held notion of a primary chemical
imbalance causing a mental illness, and the idea that decreased dopamine equals
decreased psychosis breaks down under scrutiny.
It turns out that there a
variety of subtypes of dopamine. The Dopamine 2, or D2 receptor, appears to be
most heavily involved in the response to antipsychotic medications. It seems to
be involved in chemical reward systems in the brain, as well as playing a role
in linking brain areas involved with thought, imagination, and emotion. But
this particular receptor can exist in two different states. In its activated,
“high affinity” state it is hungry for dopamine and very responsive to it. And
too much dopamine flow can be associated with psychosis.
These dopamine receptors can
also exist in a low affinity state in which they aren’t so responsive to dopamine
flow and are less likely to cause psychotic symptoms. It is suspected that
environmental variables, as well as our self image, can have a lot to do with
the state that these crucial dopamine receptors will be in at a given time.
Dopamine and the Environment
When we see ourselves as
being in danger, whether the threat is to our safety or our self esteem, we’re
likely to activate those dopamine receptors. It seems likely that our current
practice of housing mentally ill people in cramped, crowded conditions, usually
in undesirable or frightening neighborhoods, is ultimately causing activation
in these very dopamine systems that they have so much trouble regulating. The
need for dopamine blocking chemicals increases.
In the section on Evidence
Based Treatment we’ll look at some of the reasons why the clinical evidence
obtained from medication experiments done in research hospitals doesn’t seem to
carry out into common psychiatric practice. One thing about the current
American system of psychiatric care that is usually overlooked is the way
people respond to psychiatric hospitalizations. The average length of stay in
an acute care psychiatric hospital runs significantly short of a week these
days, regardless of what disorder you suffer from or what part of the country
you live in. And people commonly improve during their hospitalizations, leaving
the hospital feeling at least somewhat better than when they came in. Most of
them have some changes made in their combination of psychotropic medications and
we usually attribute the clinical improvement to the changes in the drugs. But
the medications that are given all require longer than a week to work. People
are routinely getting better before the medication changes are taking
effect. The effects of the changes in their environment- having a safe
place to sleep, some decent nutrition, and caring attention from other humans-
results in brain changes and clinical improvement.
A recent study with monkeys
further strengthens the idea that the Appetitive pleasure systems in our brains
change in response to changes in the environment. Researchers housed a number
of monkeys in individual cages and studied their Dopamine 2 receptors using
sophisticated PET scanners. There were no observable differences between the monkeys.
Then the monkeys were put into group cages and restudied. The monkeys of higher
social ranking - the “dominant” monkeys - changed their dopamine systems. An
increase in Dopamine 2 receptors was observed, probably reflecting an increased
manufacture of dopamine. The non-dominant monkeys did not make this change in
their dopamine systems. All of the monkeys were then given intravenous
solutions. They could choose to push a button that would give them saline
solution- salt water- or one that would administer intravenous cocaine. The
dominant monkeys didn’t show any preference for the cocaine at all. The
non-dominant monkeys couldn’t push the button to get cocaine fast enough.
That experiment demonstrates
several things. Changes in our environment can result in changes in our brain’s
pleasure systems. Being grouped with other humans, especially not of our
choosing, can be enormously stressful. Perhaps most importantly, our perception
of our status or ranking in our social groups has a tremendous impact on how we
respond to our environment and how our very brains are structured.
The dopamine story is even
more complex and important than we’ve seen so far though. We have learned about
how flexible and adaptive these brain systems really are. When we try to treat
people with mental illnesses with our powerful dopamine blocking medications
the brain responds with changes of its own. Block dopamine receptors and the
brain builds more dopamine receptors in response. There are suggestions that
this phenomenon may be changing the way mental illnesses affect human beings.
Psychiatrists working on
inpatient treatment units will routinely report that the single most common
reason for psychotic decompensation and hospitalization is the client’s
decision to stop taking antipsychotic medications. There is a long list of why
people stop taking their medications. Anosognosia, the neurologically
based inability to tell that one is actually ill, is probably the most common
one. If your brain cannot carry on the complex comparisons of representations
of the self- before and after illness, on and off medications- then it is very
hard to truly conclude that you’re ill. The only reality that we can know is
the one that our nervous system puts before us. Without awareness of illness
-and about 70% of people with schizophrenia have this problem with anosognosia
- psychiatric treatment may be experienced as something inflicted on
you for problems that you don’t really have to begin with.
Regardless of why medications
are stopped, the brain can be left in a very different state when this occurs.
It has built up more dopamine receptors in an attempt to get around the
dopamine blocking drugs. A dramatic increase in dopamine flow can result when
the medications leave the system and dopamine hits that enhanced dopamine
receptor system.
Sometimes patients
decompensate into agitated psychosis rapidly. And everyone’s conviction that
all of those dopamine blocking drugs were necessary is further strengthened.
Several studies done by the
World Health Organization have found that a person with schizophrenia actually
has a better chance of recovering from the illness if they live in
undeveloped countries where antipsychotic medications are not available. This
is very troubling. Certainly some of the improvement that people with
schizophrenia show in the Third World may be related to environmental variables
such as tighter family groupings and fewer of the stressors typical of urban
life. But we cannot discount the possibility that our medications may be
causing long term brain changes that make recovery from schizophrenia less
likely.
Advocating for the
abolishment of antipsychotic medications is an extreme, and many of us believe,
irresponsible position. The vast majority of psychiatrists would want our
children to take antipsychotic medications if they developed schizophrenia. But
we probably would not want our own children to be treated in the way that most
people with schizophrenia are currently treated in our society. We would want
our loved ones to live in environments that give their brains the best possible
chance of working adequately ( in the section on Housing we’ll develop some
ideas about what optimal living environments for mentally ill people might look
like in the future). Most of us would not want our children to be treated with
dosages or combinations of medications that weren’t absolutely necessary. We
certainly would not want them to have to receive large amounts of several
antipyschotic medications at once just to feel calm enough to survive in
environments that would make any sane person nervous. We wouldn’t want our
children’s illness to be conceptualized as the result of something as simple as
a “chemical imbalance”.
Does the Cerebellum
Balance Opposing Brain Systems?
As it becomes increasingly
clear that brain systems set up in a balance are responsible for our views of
reality and the emotions that we attach to them a good question becomes “what
does the balancing?”. The cerebellum is becoming the prime candidate. Remember
that the cerebellum, along with our frontal lobes and hippocampus, is
considerably larger in humans than our size would predict. In fact this
mysterious structure contains over half of the brain’s neurons. The commonly
recognized function of the cerebellum is the coordination and balance of muscle
movements. Our talents in this area certainly would not explain the need for
enlarged cerebellums.
To understand this we need to
revisit the idea that our frontal lobes are essentially an outgrowth of our
motor systems. Humans must balance all of those symbol-moving capacities in
addition to the muscle movements. The role of the cerebellum in mental illness
is not yet well understood but it is now clear that it is involved in many of them.
The balancing of opposing brain systems seems like the most logical
contribution of the cerebellum. The smooth coordination of inputs from each of
the cerebral hemispheres and the balancing of “Hippocampus” and “Amygdala”
are likely cerebellar functions. Keeping our Subjective and Objective “reality
generators” in proper balance, and
coordination of the inputs of our dual pleasure systems are other tasks
that the cerebellum may be responsible for. Even the smooth flow of our
thoughts might be mediated here.
Implications of the
Emerging Model
The wealth of information
available about the workings of these brain structures in mental illness is
more than one human can comprehend. Even a casual Internet search can lead us
in all sorts of different directions, with references to proteins, genes,
neurotransmitters, and even brain structures that will be new to almost all of
us- and quickly forgotten if they aren’t used regularly. It’s very easy to get
lost in the details.
If we are to accept the basic
tenants of this emerging model of mental illness, we see problems that result
from basic changes in the way key areas of our brains are developed and
structured. Chemical imbalances reflect not the “cause” of the mental illnesses
but a reflection of aberrant communications between malformed brain structures
as they try to accomplish the business of reality construction. In the section
on schizophrenia we’ll look at the evidence that schizophrenia, and probably
most of the major mental illnesses, can result from changes in the migration of
neurons during the first two trimesters of fetal development. On first glance
the idea that mental illness results from problems in the way our brains are
built can seem pretty discouraging. One might even long for the days when
invoking those “chemical imbalances” was explanation enough.
Ultimately, however, the new
model of mental illness brings with it more realistic hope than has existed
before. The understanding that brain research is providing increases the
likelihood that we’ll be able optimize the functioning, and even the very
structure, of the parts of the brain that don’t function well in the mental
disorders. Learning about what these brain areas need to develop and function
well will replace the search for some magic pill that will correct the
imbalanced chemicals once and for all.
The things that we are
learning about fetal brain development may affect the way we care for pregnant
mothers. Emotional trauma, toxins, infections, and changes in the intrauterine
hormonal environment during childbearing can all affect the way the brain
develops, and the likelihood that the child will become mentally ill at a later
time. We can anticipate that more enlightened societies of future humans will
pay much more attention to the chemical environment that is provided in the
womb as its babies develop.
The role of early childhood
experience in brain development will become increasingly recognized and
respected. We already know that traumatic experiences during childhood can have
dramatic effects on brain structure. The critically important role of empathy
on brain development will undoubtedly become clearer in the coming years. A
close, consistent, empathic relationship with a loving caregiver may be one of
the most important variables in how a child comes to view himself, construct
his world, and react to these representations emotionally.
Newborn humans come into the
world with raw nervous systems that are not capable of modulating emotions
well. Our emotional systems are not differentiated to a point where shades or
nuances of feeling can be experienced. When we are upset we must count on our
caregivers to sense this and to do whatever is necessary to comfort us,
whether it be feeding, changing diapers, or providing proper amounts of
stimulation. Without an attentive caregiver who is attuned to our emotional
states infants can experience mounting distress, to a point where the emotional
system essentially shuts down to protect itself from over stimulation. The effects of this sort of early brain
trauma on the developing nervous system are likely to be substantial,
especially if the baby is exposed to it repeatedly. Babies that are not soothed
from outside may never acquire the capacity to soothe themselves as adults.
Early conceptions of the self and others that are being laid down in symbolic
form are also bound to be affected.
Older children must also
count on their caretakers to provide them with an external world that is both
safe and sufficiently stimulating. There is no way a child can do this for
himself. One of the interesting things about childhood trauma is the fact that
some children can be exposed to horrendous episodes of abuse and come through
them seemingly unscathed while others become almost crippled in terms of their
emotional worlds. These differences in resiliency are undoubtedly related to
the way that their nervous systems are structured during fetal development in
some cases. But it is logical to suspect that differences in the presence and
consistency of loving, empathic caretakers may also play a role in the
development of emotional systems that are stress and trauma resistant.
Some of us believe that the
increasing incidence of mental illnesses in our children must certainly be
related to the way that we currently raise kids in our society. In addition to
relative freedom from stressors, the developing child’s brain needs all sorts
of stimulation. Physical touch and awareness of the body are important.
Children require environments that support their creativity and sense of
curiosity. They need to know that they can explore their little worlds, safe in
the knowledge that their caretaker will be there to welcome them when they
return. Acquiring a basic trust in others depends on these early relationships.
Estimates suggest that only
about 30% of American children are now raised at homes by a parent that stays
with them. This is a dramatic change from only a few decades ago. It seems
ludicrous to think that a social change of this magnitude would not be
reflected in the mental health of our children. Providing kids with only the
basic levels of food, shelter, stimulation, and attention could not routinely
result in their forming the same types of brains that they’d develop in more
enriched environments. And the increasing use of images moving on screens to
occupy our children, whether they be on television, computers, or video games,
must similarly have important effects on the developing brain. These devices
can capture and sustain attention but do not provide the physical and emotional
stimulation necessary for optimal brain development.
Whenever there are
suggestions that some mental malady in increasing in our society you can bet
that some psychiatrists will claim that the problems have been there all along
but we’re only now getting better at detecting them. This seems downright
silly. Are we to believe that we just didn’t notice our children’s problems
with attention and emotional regulation before? That millions of kids were
suffering from unrecognized bipolar disorder or attention deficit disorder, to
a degree that they needed powerful
stimulants, mood stabilizers, and tranquilizers like we give them now ? Why is
it so difficult to consider the possibility that the rapid and enormous changes
in our society would have results in the way humans structure their developing
brains?
Once people have an
established mental illness, whether it results from genetics, prenatal factors,
or problems in their early development we psychiatrists have, for some time
now, simply attributed them to chemical imbalances and prescribed medications.
As the saying goes, “when the only tool that you have is a hammer, every
problem starts to look like a nail”. Perhaps our attention should shift to
considering what variables in the environment can be manipulated that will give
those mal-developed brains the best chance of functioning well. Creating
specially designed, enriched environments for those with severe mental
illnesses would likely be more cost effective in the long run than relying on
medications alone. Meaningful work, privacy, security, good nutrition, and
decent relationships in which they are not stigmatized or looked down upon are
essential commodities that many of our patients will not be able to acquire
unless we help them.
When we design programs for
the mentally ill, we often neglect some of the things that make life worth living
for the rest of us. Laughter is enormously important in our mental health. The
beneficial physiological effects of laughing have now received some research
attention. Decreases in stress hormones, lowered blood pressure, and relaxation
of the muscles have all been documented. Dopamine based pleasure systems are
activated when we laugh. Many of the best natural therapists have the capacity
for adding a playful element to their relationships with mentally ill clients.
Meditation is another
wonderful natural therapy. Researchers have found that meditation can actually
change the balance between our cerebral hemispheres, moving more activity to
the left with a resultant improvement in mood and the capacity for logical
thought. Yoga, “Sensory Integration Therapy”, and other activities that can
change the relationship between mind and body will likely become recognized as
beneficial for mentally ill people as well. There is no reason to limit our
therapies to those that can be written on a prescription pad.
For humans, optimal
environments must allow us to feel that we have some degree of control
over what happens to us. Without this we are bound to experience anxiety and
discomfort. Our mentally ill do not routinely have access to this sense of
self-determination. Here in Minnesota, mentally ill people will no longer be
able to decide whether to smoke tobacco or not if they are on State property-
even if they are committed to living in hospitals against their will. Patients
can lose their housing or be kicked out of treatment programs for using alcohol
or marijuana - activities that would have few or no consequences if they were
not diagnosed with mental illness. The decision to try living without
medications is almost never supported, even if the person is deemed competent
to make other life decisions. Oftentimes we react as though going off
psychotropic medications is tantamount to a criminal offence. Social programs,
housing facilities, and even mental health clinics often treat the mentally ill
as though they do not really have the same rights as other people.
In truth, this is not a
situation where mentally ill people have something wrong with their nervous
systems while the rest of us have brains that are optimally configured. Just
about everybody has something wrong with their nervous system. They are just
too complex to get everything right all of the time. The fact that mentally ill
people have relatively more brain problems than the rest of us does not mean
that they should not enjoy the same rights - and responsibilities- as other
people whenever possible.
The Emerging Model and
Psychotherapy
One of the encouraging things
about the emerging model of mental illness is the way that it dovetails with
the findings of the psychotherapies. The chemical imbalance model has often
forced an arbitrary division between various mental health disciplines. Even
psychiatrists are divided into the “biological
psychiatrists” and a group made up of everybody else. Psychiatric
training programs have become increasingly “biological” over the past several
decades, to a point where some new doctors look upon psychotherapy with a smug
condescension.
The irony here is that the
focus on changing the brain chemistry of mentally ill people has allowed us to
change some things about humans relatively rapidly, without having to actually
understand anything about them as individuals. Psychotherapeutic models are
much better at understanding people as individuals but nowhere near as able to
effect sudden changes. In our society sudden changes will always win out over
gradual ones, even if the gradual ones are more effective and long-lasting in
the long run. The demand for instant gratification is an increasingly important
part of our national character.
The three main schools of
psychotherapy seem to fit very nicely with what we’ve learned about the brain
through neuroscience research. Cognitive Therapies focus on the
importance of beliefs and expectations in determining the realities that we
live in. Nothing could be more consistent with this developing model. Creating
pictures of reality through incoming sensory stimuli and via our world of
thoughts are both dependent upon the symbols that we have developed and stored
in our brains. These symbols, including basic ideas about ourselves, our self
worth, other humans, and the very meaning of existence are all organized
according to our beliefs. Beliefs are the filter through which we arrange our
worlds and respond to them emotionally. Changing belief systems allows us to
create a different reality, and to respond to it differently. This process of
changing the organization of the very symbols that we use to assemble our
realities may be slow but it must be just as rooted in actual brain changes as
any medication therapy. Our technology is only recently advancing to a point
where this is becoming obvious.
Ego Psychology deals with the ways that brains protect themselves
from unpleasant emotions. One of the curses of being human is the fact that we
are probably the only animals that are aware of our own mortality. The emotions
arising from this fact, along with those related to the many challenges to our
self-esteem that occur during everyday life, must be dealt with in some fashion
or we cannot function. “Defense Mechanisms” allow us to cope with the painful
emotions so that we can turn our attention to other things.
“Higher Level” defense
mechanisms leave the basic picture of reality intact. Mentally healthy humans
can laugh at their own foibles, channel energy into work or play, or simply
decide to put unpleasant thoughts out of their mind for the time being. When
the brain systems involved with attaching emotions to thoughts and experience
are not working optimally, one sees distortions in the representations of
reality or the image of the self. Basic facts can be denied completely.
Unacceptable feelings and aspects of the self may be perceived as originating
in the outside world rather than from within. Representations of other humans
can acquire inflexible, all-good or all-bad qualities. The excessive use of the
less healthy defense mechanisms carries the cost of disturbed relationships
with other people and many other areas of impaired functioning.
An important but often
overlooked facet of human behavior is our capacity for generating comforting
thoughts. From the first time that we learn to soothe ourselves with the
thought that “Mommy will come back” we utilize thoughts that are designed to
bring us hope and ease our anxieties. Each of us has our own repertoire of thoughts
and memories that we can turn to in an effort to feel better. Fantasies of
romantic conquests, wealth, being
admired, and of having a high rank in our social groups are common themes in
the thoughts that we rely upon to produce positive emotions. The problem is
that this unique human ability to generate thoughts that make us feel good is
reinforced by brain chemicals that have an addictive quality. The more we turn
to thoughts and memories to feel good, the stronger is our tendency to live in
our inner worlds. This tendency to keep attaching positive emotions to images
of ourselves also opens us up to despair. Humans cannot help but compare
current representations of ourselves to underlying idealized images of how good
we think we should be. The greater the disparity between the genuine
image of our self and the idealized version, the more severe are our feelings
of depression and existential pain.
Our relationships with other
humans are, ultimately, the most important factors that determine our mental
health. Object Relations is a branch of psychotherapy that focuses on
the development of the neurological symbols for the self and other people. Just
as those newborn kittens must develop symbols for things as basic as horizontal
and vertical through experience, we build symbols for self and other through
our interactions with our caretakers. Core relationship patterns involving
images of ourselves, important people in our lives, and the emotions that link
us are repeated over and over throughout our existence. The options are
limitless but common patterns involve feeling that we are small, under
appreciated, and that we must hide our true natures from more powerful “grown
-ups”. Anyone who has looked in his rear view mirror to see a police car knows
how powerful and deeply rooted are our feelings around authority figures. Our
process of socialization depends on the fear of disapproval and its
consequences. Even mature adults often show a tendency to respond to other
people as though they were important but withholding sources of potential love,
admiration, and support. Emotions of shame, resentment, and a desire to be
recognized as special are common emotional links between these images of self
and other. Freud’s concept of the repetition compulsion - our innate drive to recreate relationships based on
early patterns of interaction with our caregivers- is one of his theories that
has stood the test of time.
Many non- specific benefits
of psychotherapy take place regardless of the theoretical orientation of the
therapist. The increase in hope and the expectation that improvement will occur
are powerful contributors to any
therapy. Studies have found that patients often experience significant
improvements even when they’re on waiting lists to begin therapy. And being in
the presence of someone who can see us for who we really are - warts and all-
and still respect us allows us to become more tolerant of ourselves.
All of the psychotherapies
involve a process of becoming aware of the guiding beliefs that underlie our
moods and our more acute emotional responses. With time we can become better at
understanding where these emotions come from and in using them as sources of
information about ourselves. Some of the brain rewiring that occurs during
psychotherapy undoubtedly occurs in connections involving “Hippocampus” and
the frontal lobes as new symbols for self and other are laid down in the memory
banks. With increased self- reflection and understanding we become
neurologically more flexible in the ways that we can interpret our experiences.
Longstanding patterns of interacting with other humans become less rigid and
stereotyped. Our enormous sense of self-importance can occasionally give way to
genuine concerns about other people. We begin to have more conscious input into
how our lives are conducted.
Recognizing the legitimacy
and importance of psychotherapy does not mean that psychiatry should abandon
the gains that medications can sometimes produce. Some of the more structurally
based mental disorders, like schizophrenia, make the process of self-
reflection and understanding tremendously difficult. In many illnesses
medications may be essential for the brain to approximate some degree of normal
functioning. These drugs do not permanently repair the underlying structural
problems, nor do they truly correct some undefined “chemical imbalances”. At
best they restore a better equilibrium between the parts of the brain charged
with creating representations of the self and the world, and with those areas
involved in our emotional responses. They may slow down input from the senses
and thoughts enough that the brain can be less overwhelmed and disorganized.
Our medications may turn on genes responsible for making new brain cells in the
hippocampus and keeping that system healthy. They may temper the responses of
overly excitable neuronal systems in mania, regardless of its cause. Improved
sleep may be a common pathway through which many of our medication treatments
are mediated. But as yet we do not know for sure how or why any of our
psychotropic medications actually work.
To advocate for the
abolishment of psychotropic medications would be just as senseless as assuming
that medications are the answer to all human problems. Whenever any person or
organization assumes extreme positions of this nature some reality distorting
and the creation of an artificial sense of certainty must be involved. The
point is that psychiatry and our society seems to have swung too far in the
direction of demanding quick medication fixes for all problems of brain
development and structure. It would make better sense for us to provide
mentally ill individuals with all of the environmental factors that give their
nervous systems the best chance at decent functioning. Then to see what
sorts of medications are needed, and in what degree. Our current mental health
system frequently puts people in situations where their nervous systems cannot
possibly work well, then tries to correct the situation with massive doses of
medications. This may be good for the pharmaceutical companies but they’re the
only ones that are truly benefiting from this system of care.
Future generations will
certainly look back to view our present models of mental illness, including
this one, as naïve and simplistic. Our models of the mind are always evolving
and they can never offer more than a glimpse of something that is infinitely
more complex and wondrous than the mind itself can comprehend. All of our
current treatment efforts will probably look primitive in hindsight. Some will
even look barbaric. The ways that our society currently cares for its brain
disordered individuals will, hopefully, be recognized as misguided and
ineffective. And perhaps the contributions of mentally ill people to our
society will someday become respected.
People with mental illnesses
ultimately provide us with enormous amounts of information about what it means
to be a human being - information that might not otherwise become apparent.
They do this, of course, by demonstrating what happens when important brain
systems are malformed or malfunctioning. But they also show us a great deal
through the courage and dignity that so many bring to their struggle to create
a decent life for themselves. How we as a society understand and care for our mentally
ill citizens also sheds light on this central question of what it really means
to be human.
Kevin Turnquist M.D.
November, 2003