It hit me today: current psychiatry diagnostics is “brain-less” and empirical. An analogy between diseases of the heart and diseases of the mind will forward my argument: Cardiac chest pain is not a disease of the heart, nor is depression a disease of the mind; both are just symptoms. [def. Disease: a disorder of structure or function]. In fact, the diseased heart’s state is cardiovascular ischemia and myocardial tissue anoxia; the diseased brain’s state is neuronal network dysfunction.
Ischemia and depression are events, not entities.
Defining a whole person [or entity] by an event or even a series of events is inexact: to call someone depressed is wholly inexact, for that confounds nouns and a verbs; a person is an entity while depression is an event. To say a person has depression is likewise inexact, for an event is not something one has but something that happens to oneself. By analogy, a country at war is war torn but not the civil war itself, even as the strife arises from amongst the people. In all cases, events do not define entities; nor should depression define people.
It is a matter of lazy semantics, I think, to say you are depressed rather than that you are experiencing a state of depression. The distinction here is critical, for lazy semantics breed stigma through the equation of persons with diseases. One is not an emotional state or mood; one goes through it. Thus, it might seem better to say one has depression since it doesn’t equate a person with a disease, but it again overlooks the confounding of nouns and verbs–depression is an event not an entity. It implies you “possess” or “carry” or “are crushed by” a thing called depression. This rather dangerous mindset saddles one with an unnecessary burden, a bad thing, an albatross: Depression. It is more accurate (and healthy), I think, to say that one is experiencing depression. Alas, it is difficult to keep this distinction straight while in the middle of an psychiatric episode with an unimaginable end; yet, it is critical to try to identify oneself beyond prevailing events. Some depressive episodes seem to never pass, but that still doesn’t make them entities to have, just persisting or repeating states to get through. Seeing mental episodes as entities gives them more weight, and hides the fact that moods change all the time, and often moments of happiness occur and go unrecognized despite depression.
I would refer the reader to the The Problems of Philosophy by Bertrand Russell.
Turning back to psychiatry, we have Axis I disorders of state and Axis II disorders of trait. My argument pertains: if we define a person by a state–say an episode of mania–in order to give them, for example, a diagnosis of bipolar disorder, we have again confounded nouns and verbs, events and entities.
Therefore, I am beginning to doubt the wisdom of labelling someone as bipolar or depressed or anxious or schizophrenic or obsessive-compulsive, based on the tabulation of empirical events or actions. As I understand the modern push to define psychiatry by neuronal circuitry (e.g. the RDoC[Research Domain Criteria] ), the plan is to move away from labels and towards brain events. Before the reader protests: to define psychiatric phenomena by brain activity is not to reductively define people by their brains; remember–nouns and verbs–the brain’s neuronal events do not define a person, for brain states are events not entities. The argument that “brain-based nosology is reductive” is spurious. This is worth repeating: just because we are beginning to understand psychiatry on a molecular level doesn’t mean we are reducing people to neuronal events; people are entities not events. By analogy, “the cardiac patient” or “the psychiatric patient” are wholly inadequate conceptions: people have had cardiac and psychiatric events.
The RDoC allows for a molecular, anatomic, neurophysiological, and genetic levels understanding of psychiatric disorders. The system carefully defines mental illness in these terms. It is very attractive and precise. It is very convincing; yet, its semantics must be carefully watched. While it reduces behavior and subjective experience to definitive processes at any given moment, it does not tell you who the person is over time. I find this fabulous, but I find it perilous, too. If you have lazy semantics, you may erroneously conclude that a person is such and such genetic, molecular, anatomic, or neurophysiological disease. That is inexact: nouns and verbs, right. We are characterizing several layers of an active process as it occurs and changes.
This is the thought that struck me this afternoon and gave me pause: A brain can go into a particular state with reproducible, measurable anatomic and functional findings; it can exit it as well; it can enter a different state at some future point and exit that as well; the brain is profoundly complex; different states come and go and symptoms change each time. So, with all this change, how can you confine a brain to one state or empirical disorder? or a person as being one particular thing? Diagnoses change all the time: shouldn’t we abandon the whole effort of categorizing mental illness?
Perhaps the analogy of the weather can help us here. Brain states are mercurial and kaleidoscopic, so are weather patterns: You can’t define the weather by one storm; you can’t define the brain by one episode. In all cases, it may always be different tomorrow. Or it may be the same. Indeed, there may be common patterns that repeat, like repeated snowstorms in the Arctic. In fact, repeated weather patterns shape the landscape and make repeats more likely. Rain comes from rivers. Nevertheless, brains and climates both have variegated natures and are far more complex than any one event or state. They are constantly changing. The flow of a river through a canyon is determined by the underlying geography of the ravine; it shapes its path over time into something seemingly timeless. Yet, what seems the same is not, for a river’s turbulent properties vary with the temperature, ice pack, rainfall, etc.
Read about Complexity Theory if you are not convinced.
So, patterns repeat. With the weather, underlying geography interacts with atmospheric physics and chemistry to create a particular pattern. Similarly, with brain function, underlying anatomic and functional characteristics (i.e. RDoc) tend towards typical mental states, and certain states may persist or repeat; indeed, the state can shape the brain to make its persistence more likely. However, in my experience, no one depression is the same; examined closely, states do vary even as they bear a resemblance to past states. Hence, one might be fooled into thinking that the brain has a persisting thing, like a condition or disease, but actually, the brain’s ever changing function and nature means it is does not have a fixed entity like depression, it just repeats similar patterns. Thus, it implies the brain has the potential to change.
Read the Brains Heals Itself by Norman Doidge if you are dubious on this point.
The patterns change if the circumstances change. For example, certain places on Earth are inexactly labelled as rainy or humid or tropical or dry, etc., because people ignore the full breadth of that locale’s weather history–it’s ecology, if you will; similarly, certain brains are erroneously labelled as depressed when it’s full “ecological” history of emotional states is ignored. The key point is this: It is very stigmatizing to think of a person as having a disease or as being mentally ill; what they probably have are nonspecific, broadly defined brain-related characteristics that tend towards common mental patterns in particular situations. The implication is this: within a certain range, if you change the situation you can change the mental pattern– and the range is probably greater than you think and probably includes mental health. In conclusion, if you are able to manage your “ecology” well enough, you can probably change your mental patterns thus revealing the fallacy of labelling yourself depressed.
This is why I believe psychiatrists should pay attention to diet, exercise, social interventions, Cognitive therapy, economics, family dynamics, and general health.(ie. Engels Biopsychosocial Model), in addition to pharmacological manipulation of the brain.
I will leave for another day the discussion around using medications to directly alter mental patterns; it is kind of like creating or overriding a local weather pattern–might be useful–probably has ecological and geographic side effects.
In sum, Ecology may be the most apt paradigm to conceptualize the brain’s complex functioning–extremely complex dynamics to be observed and barely understood. If you are not convinced please read The Universe from Nothing by Lawrence Krauss. Our scientific understand of the universe is revealing less and less truth, more and more possibility, greater and greater complexity (e.g. the multiverse), less and less certainty , and fewer and fewer (if any) eternal laws; what emerges is the humbling scientific realization that we are probably just descriptive ecologists more than anything else.