Monthly Archives: March 2013

Biological Psychiatry, Psychodynamic Psychiatry, and a New Approach to Understanding Mental Illness

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In Psychiatric Times, Dr. James Knoll IV writes in “The Humanities and Psychiatry: The Rebirth of Mind“:

What place do the humanities have in psychiatry? One might as well ask: What place does the mind have in the brain? What place does clinical experience have in medicine? What is the utility of the empty space within the vessel?…  In this article, I focus on the importance of the humanities to psychiatry, via the perennial conflict between biological psychiatry and psychodynamically oriented psychiatry. I hope to use a humanist approach to show that these “two cultures” depend on each other for balanced progress in the field…

Biological psychiatry has made truly impressive progress, yet it remains the case in 2013 that “biological psychiatrists do not hold the panacea for serious mental disorders,”particularly when standing on the lone pillar of science. The art of medicine remains a critical foundational structure in psychiatry, and both pillars are necessary for the stability of the field. One might say that the humanities and/or psychoanalytic thought helps provide science with the relevant questions on which to focus its “piecemeal work.”Put another way: the humanities provide the wonder, which science then illuminates.

It is sometimes the case that older theories are not proved false—rather, the very progress they contributed to now shows their limits.

In Mind, Modernity, Madness: The Impact of Culture on Human Experience, Liah Greenfeld writes:

Today we know an awful lot about schizophrenia and manic-depressive illness. An enormous amount of information has been collected about the psychological and biological expressions of these diseases — about the personal experience and outward behaviors corresponding to them, the anatomical abnormalities which show themselves in certain groups of patients and neurochemical dynamics characteristic of others — about patterns of their transmission in families and certain genetic elements involved. But this information refuses to combine into a “case” — an explanatory argument based on the available evidence: there are gaping lacunae where pieces of the puzzle are supposed to dovetail; and none of the things we know can be said to constitute the smoking gun. We still do not know what causes these diseases and thus cannot either understand their nature or cure them. After two hundred years neither of the two approaches — the biological and the psychodynamic — in which psychiatry put its hopes brought these understanding and cure any closer. Therefore, I feel justified to offer a new – radically different — approach that has never been tried.

The historical recency, the timing of the spread in different societies, and the increase in the rates of mental disease of unknown etiology indicates that it cannot be understood in terms of any universal, biological or psychological, propensity of human nature, or explained by the characteristics of the individual human organism or personality as such. The observable trends (however incredible) pertain to and distinguish between specific societies and historical periods, and therefore must be accounted for historically. …

My intention is not to prove either the biological or the psychodynamic approach to mental disease wrong, but to complement them, adding to psychiatry a necessary element which has been heretofore missing. All the findings of the biological research, specifically, should be consistent with the approach I propose and, in cases they are not, the fault would lie with the approach rather than the findings. Culture, personality, and biology are different, but not mutually exclusive realities, and for this reason cultural, psychological, and biological arguments should not be mutually exclusive.

Francesco Duina on Mind, Modernity, Madness

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“I like to call this a ‘fundamental’ book: a work that is grounded in a particular and comprehensive theory of modernity, according to which much of what happens in our societies can be understood in reference to a few key premises and principles. We live, as Greenfeld says, in the reality of nationalism. And nationalism is the cradle in which much of what we know – the sciences, the universe, our bodies, our economic system, our passions and pleasures, and ultimately ourselves – is produced. Therein lies the key to the emergence of madness. Nationalism implies equality, and this generates enormous pressures for self-definition for every one of us. The pressures can be intolerable, and millions of us experience madness as a result.

Though it took me a while to really understand the argument – specifically, to appreciate the nature of nationalism as Greenfeld describes it – over time I have come to appreciate it a great deal. It has informed my teaching as a sociology professor, and it has enabled me to put other theories of nationalism, modernity, and madness in perspective. Ultimately, I inevitably turn again and again to Greenfeld’s arguments, and find them the most compelling and complete. Greenfeld has therefore written, in my mind, a classic. It is as much a work of sociology as it is of political theory or anthropology or psychology or biology. It crosses, forcefully, disciplinary boundaries. It is ambitious and inspiring. In short, it is an indispensable work that is bound to keep people talking for a very long time.”

Francesco Duina is Professor of Sociology at Bates College.

Shakespeare and Mental Illness

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Alan A. Stone, Touroff-Glueck Professor of Law and Psychiatry in the faculty of law and the faculty of medicine at Harvard University, in Psychiatric Times, March 12, 2013:

The ancient Greek dramas of Aeschylus, Sophocles, and Euripides gave Western civilization its foundational myths: Prometheus, Oedipus, Antigone, and the Oresteia. Two thousand years passed until Shakespeare arrived and, according to literary critics, achieved something perhaps more important: he “invented the human!”1 I think of this invention as the secular conception of the human condition. Yes secular! it is a vision of the moral adventure of life constrained by no religious orthodoxy.

Scholars debate whether Shakespeare was Catholic or Protestant. He often draws on both the Old and New Testaments of the Bible and the Book of Common Prayer, but God is missing from his greatest plays. Nonetheless, to paraphrase Simon Russell Beale, the great British actor, to perform in those plays is to experience “redemption and transcendence.” Shakespeare’s understanding of the human condition miraculously transcends his culture, time, and place…     Continue reading →

Schizophrenia and Manic-Depressive Illness: What do We Know about Biological Causes?

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By David Phillipi

While the technological advancements of recent decades allow us to map the human genome and look at the brain on the molecular level, the enormous amount of data that has been amassed is virtually useless for psychiatrists trying to diagnose their sick patients because the assumed biological causes of schizophrenia and manic-depressive illness have not been found. No brain abnormalities that are specific to either illness or present in all cases have been identified. Nevertheless, the experts who study and treat schizophrenia and manic-depressive illness (MDI) keep the faith (quite literally) that a breakthrough is just around the corner.

For years, genetic research has appeared to be the most promising of the recently opened avenues, but the excitement seems unwarranted by the findings. The relatively large number of chromosomal regions which may be implicated in susceptibility for bipolar disorder means that hope of finding a specific bipolar gene or even a small number of genes must be given up. Some researchers think the way to go is to narrow the search by looking for genes associated with specific aspects of the disease. Of course, this further refinement is only possible because of the huge variation in symptoms and experiences of those who fall under the MDI/bipolar umbrella, and we are once again reminded of the difficulty of defining what this illness or group of illnesses even is. Furthermore, even the distinction between schizophrenia and MDI seems to collapse in light of the genetic linkage data. In Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression (2nd Edition), Drs. Frederick Goodwin and Kay Redfield Jamison write:

While the search for predisposing genes had traditionally tended to proceed under the assumption that schizophrenia and bipolar disorder are separate disease entities with different underlying etiologies, emerging findings from many fields of psychiatric research do not fit well with this model. Most notably, the pattern of findings emerging from genetic studies shows increasing evidence for an overlap in genetic susceptibility across the traditional classification categories. (49)

Genetic studies in the schizophrenia research community lead to pretty much the same hypothesis as with bipolar: genetic susceptibility is most likely polygenic, meaning dependent on the total number of certain genes which may contribute to vulnerability. It must be noted that genetic vulnerability is a condition, not a cause of schizophrenia and bipolar – something else must be acting on this vulnerability. In one way or another, this fact is usually noted in the literature that deals with genetic data, but it is often obscured by a tone of confidence which suggests the information may be more meaningful and explanatory than it truly is.

Even when a specific gene has been well studied across illnesses, its usefulness in understanding genetic susceptibility may be extremely limited. Some studies in both schizophrenia and MDI have found an increased risk of illness for those who possess the short form of the serotonin transporter promoter gene 5-HTT. The thing is, each of us has two copies of this gene, and over two-thirds of us have one long and one short form, meaning that having the normal variant of the gene is the risk factor! If most of us possess a gene which puts us at risk for an illness which only a small minority of people have, then this particular trait is obviously not much of a causal explanation.

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