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