Friday, November 28, 2014

What is a mental "disorder" (part 2): two viewpoints on mental health problems

Largely, there are two conflicting views of mental health problems. Others might be listed, but these perspectives provide two images that are difficult to merge. Yet they may depict the same phenomenon. 

The first sees mental health problems from the viewpoint overlooking those very seriously affected. This group has lives in tatters due to their problems. They may be intellectually disabeled, suffer major psychotic disorders, paralyzing mood or anxiety problems or drink in a perfectly obsessive way to an early death. 

Noone has any difficulty saying that these persons are ill, nor that abnormal brain functioning is involved. General movements and posture are affected. It is debated whether this kind of mental illness is on the rise or remains constant across cultures and time, but anyway, prevalences are counted in single-digit percents. Proponenets of this perspective are often psychiatrists or nurses.

The other sees mental health problems from the viewpoint of total population epidemiology. This is a different sight. Problems are now present in tens of percents of the population, are gradual rather than categorical, change over time, often into new diagnoses or no diagnosis at all. Instead of disease-like conditions, diagnoses may be worded as liabilities or traits, and understood rather as extremes in the normal variation than as pathologies.

The problem is that psychiatry, in the era of criteria-based diagnoses, has put very little effort into studying how these two views relate to eachother. Instead, both have been voiced as if they were one and the same seamsless psychiatric truth. There is vast clinical experience to validate the first, in addition to it being common-sensical. There is more and better scientific data to validate the second.

Problems arise when knowledge from the first group is applied to large swaths of the population. Substance abuse is one example. Psychiatrists are eager to promote a medical model based on the very severe cases, but this conflicts with population-based data showing that most cases remit spontaneously, even without treatment. Maybe the same problem is present in our understanding of depression, hyperactivity, autism spectrum disorders, behaviour disorders and even psychoses?

This would explain why findings of brain abnormalities, genes and treatment effects in case-control studies tend to disappear when tested in population-based studies. And how 80% of the liability for a certain condition may be statistically referred to genetic effects, while the gene variants actually found only have very small effects. It also means that the severe cases may not be fully understood from the general population viewpoint, and that, if a clinical group with schizophrenia or autism have a certain sign in their genome or brain scans, it cannot be interpreted as a characteristic for the type of problem in the population.

It is tempting to propose that the general population liability for mental health problems expresses genetic polymorphisms, while the severe cases are due to mutations. In some very crude way this may be true, for example in autism, where mutations have been found in subgroups of cases who often also have mental retardation. And as polymorphisms are defined as being more prevalent than mutations, it would seem a safe bet. But as a general explanation, I think such analogies between genome and mental phenotypes over-simplify the complex causation of mental health problems. They also overlook how mental processes may be free, random, self-generating and the result of interactions with the environment.

In a forensic or moral context, the obvious existence of persons who have had their mental capacities for insight and action control destroyed by severe mental or neurological disorders should not be interpreted as a general lack of accountability in people with mental health problems. As health care staff, our aim should be to restitute health and responsibility. By stating generally that people with e.g. substance dependence or ADHD have no responsibility for their behaviour, we disserve large numbers of persons who deserve both praise and criticism for their acts.

Elegant plaidoyers of the first vs the second view are proposed by Allen Frances in "Saving normal" and by Jonathan Rottenberg in "The Depths". Both books are heartily recommended.

Friday, November 21, 2014

Mental disorder is a cause of crime: what is a "disorder" in this context? Part 1

Psychiatry is not only vague in defining the "psyche" (a.k.a. the mind, the spirit) but also in how to name its pathological states. In the DSM-IV-TR, we read that “each of the mental disorders is conceptualized as a clinically significant behavioural or psychological syndrome or pattern that occurs in an individual” (APA, 2000, p. xxxi). 

Numerous other terms, more or less synonymous with “mental disorder”, have been suggested, e.g. “illness” or “condition”.

"Clinically significant" may mean that the condition hampers the ability to "work and love" (Freud), i.e. to have meaningful occupation and relations, but also that the condition produces considerable suffering. Various definitions of mental (un)health have been proposed, but none is generally accepted. 

Mainstream psychiatric texts use the term “mental disorder” as a compromise. The stated advantages are that the term is unspecific about non-physical entities, such as the soul, and about the aetiology of problems, such as in illness. 

“Disorder” is a broadly defined term. It indicates a lack of some sort of order but does not specify what that order is. 

Is a mentally disordered person someone who in some mental aspect lies outside the variation contained in the central standard deviations of the normal curve? Or does (s)he fail to live up to an ideal, ordered, state of mind? Or does (s)he present symptoms that are qualitatively different from what is experienced by healthy persons (such as hallucinations, delusions, tics, or compulsions)? 

All three definitions are open to justified criticism. Symptoms such as hallucinations are not limited to persons exhibiting other features of mental disorder (van Os, Hansson, Bijl & Ravelli, 2000). Dysfunction and suffering depend to a considerable degree on the environmental demands made on an individual, and deviance from the average may be both advantageous and disadvantageous (Baron-Cohen, 2000). The statistical approaches invariably include measurement problems.

Of course, this vagueness becomes most problematic when definitions of mental disorder are applied in courts of law, but they also haunt psychiatric research. We will therefore continue to go through definitional pit-falls and different systems of validating disorders in a few more posts. Next week, the two different views on mental disorders as illnesses in the medical sense vs. extremes of the normal distribution will be discussed.

This blog post is partly excerpted from the paper "Mental disorder is a cause of crime" I co-authored with Susanna Radovic, Christer Svennerlind, Pontus Höglund and Filip Radovic in 2009. 

Friday, November 14, 2014

The mind and the body in (forensic) psychiatry

Throughout the history of human thought, few other distinctions have evoked so much controversy as the one between the mind and the body. In the DSM-IV-TR, it was regretted that the term “mental disorder” emphasizes mental as something distinct from physical, which is regarded as an “anachronism of mind/body dualism” (APA, 2000, p. xxx).

Causation is key to understand the relation between the mind and the body. The body influences the mind (most clearly shown by drug effects), but the jury is still out on whether the mind can influence the body. 

Material determinists deny that it can, mainly based on the lack of a reasonable mechanistic explanation. 

Bi-, or rather multi-directional causation body>mind>body>mind etc, is, however, indicated by e.g. real-life experiences of acts of will, the placebo effect and the influence of expectations on health.

This conflict partly stems from epistemology. The mind is considered in terms of “experience”, “knowledge”, and “being” that are distinct from how the brain and its physiological processes are conceived of. Different types of knowledge are difficult to join in a common model, even if the clinical psychiatrist approaches a person who happens to have a body and a mind.

And different ways of aquiring knowledge do not exclude that information refer to the same underlying phenomenon. 

Just as a notion of beauty may be applied to the same body that is scientifically examined as an organism, and perhaps to some extent even be causally determined by it (correlations between notions of beauty and physiological processes may be assumed), it is obvious that notions of beauty and of physiology operate according to different epistemological premises. The means by which we decide upon aesthetical matters are not the same as those we use in the natural sciences, nor are the concepts used in the different contexts inter-translatable in a straight-forward sense. The use of a plurality of concepts and methods does not in itself imply a plurality of real world items.

In order to meet medical or legal definitions, mental disorder are thought to refer to the form (processes, abilities) rather than the content (subjective experiences, as defined by Jaspers). The form is intuitively thought of as being more "brain-based" than the content. 

This remains an attractive idea. It is a common assumption in psychiatry that there are "real" mental disorders rooted in cerebral malfunctioning, and other, less severe conditions, which are more related to the person and her choices, life-style and experiences. 

But from the perspective of neuroscience, it makes little reason to think that one mental problem should be less "brain-related" than another. The body and the mind are intrinsically linked, mysteriously even.

The epistemological framework of psychiatry does not produce the concepts or the data that can give an answer to what is freely willed, morally good or bad. Science studies regularities, and acts of free will are unpredictable. Therefore, notions that presuppose freedom (such as evil) escape scientific explanations. Needless to say, this does not prevent the consequences of mental processes, e.g. behaviours, to be objectively good or bad.

As long as we do not know how the body and the mind interact to create a human person, nor whether determinism is true or there is a causal effect of free choices, scientific expertise for courts should be carefully worded to express what we know and what we don't know, and to refer to the findings of assessments rather than to legal or moral definitions that presume free will.

Medical conditions can preclude free choice and insight, but medicine cannot say that a specific act was done freely. This does not mean that a judge can't.    

This blog post is partly excerpted from the paper "Mental disorder is a cause of crime" co-authored with Susanna Radovic, Christer Svennerlind, Pontus Höglund and Filip Radovic in 2009. 

Friday, November 7, 2014

Mental disorder is a cause of crime: what is "mental" in "mental disorder"?

Numerous definitions of “mental” have been attempted over the years, but consensus on its definition remains to be established (just as its two sibling words, "psyche" and "spirit", but let us focus on mental here). This is noteworthy, as it is a core definition not only in sciences on the mind and its disorders, but also in legislation and cultural references. "Mental disorder" is a key phrase for forensic psychiatry in many legislations, and it is important that we strive to be as clear as possible about how we use and what we mean with the term. After a brief foray into the body-mind problem next week, we will return to "disorder" in a fortnight. But let's focus on the "mental" part of "mental disorder" for now. 

In forensic psychiatry, as clincians, we will probably have to do with some examples of what mental can, and cannot, be. The task of further definitions belongs rather to philosophers, or the field of jurisprudence, or even to philology. It is interesting to try to grasp how the Greek and Latin words for mind, soul and spirit have evolved in the European languages, and often have come to refer to differnt or overlapping concepts in different contexts. 

Psychiatry has also used several words, such as mind, psyche or senses, without clear definitions and without too much worries over distinctions. Historically, it has tended towards mind and mental in the Anglo-Saxon culture, and towards psyche, soul or senses in continental European or Scandianvian cultures (but these are merely tendencies, just as psychiatrist means "doctor of the soul" in English, references to "mental" are common in French, German or Swedish).  

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association (APA) described mental as: a) inner experiences, relating to mood, thought content, or sensory experiences, b) behavioural patterns, and c) cognitive functions such as learning, social understanding and reality assessment.

As these descriptions refer to different ways of conceiving the human, let us refer to them as aspects of the mental. 

The first aspect, inner (subjective) experiences, denotes the inner life that a subject can be aware of. Mental representations are not limited to sequences of language but may be “iconic” or non-symbolic, merging sensory input with memories and emotions.

Subjective experiences are made the object of science by methods that are basically hermeneutic in a wide sense and dependent on the clinical encounter. The requirement that scientific knowledge should be possible to generalize to persons other than those under direct observation is as important for assessments of inner experiences as for behaviour observations or tests of abilities.

Cognitive processes represent knowledge of the world and the self and are thus intrinsically linked to learning and structured by language. Learning, and the ability to learn, are more accessible for quantification than inner experiences, and may, in part, be evaluated by tests.

The behavioural manifestations of the mental were once proclaimed by behaviourist philosophers and psychologists to be the only aspect accessible for scientific exploration. Behaviours do indeed lend themselves to quantification by various forms of assessments based on their observability (self-rate, collateral, or clinician-rated), but it may be misleading to refer to "mental" aspects if behavioural manifestations are all that have been studied. 

Generally, these descriptions of mental aspects complement each other, and together form an ideal for clinical work. In the forensic context, however, test-retest reliability, transparency, and objectivity become more important than comprehensiveness. Behaviour assessments and cognitive tests may therefore be more acceptable and useful than hermeneutic assessments of inner experiences.


In forensic psychiatry, the concept of "mental" may thus be limited to include only such law-bound patterns of behaviours and faculties that are possible to describe by replicable metods.

This blog post is partly excerpted from the paper "Mental disorder is a cause of crime" co-authored with Susanna Radovic, Christer Svennerlind, Pontus Höglund and Filip Radovic in 2009. 

Tuesday, November 4, 2014

"Hypermodern times" by Gilles Lipovetsky and psychiatry

In his 2005 book Hypermodern Times, the French philosopher Gilles Lipovetsky refers to the new millennium as “hypermodernity,” that is, something as paradoxical as a “modernist renaissance” characterized by hyperconsumerism, new individualism, narcissism, and a desperate need for control that remains impossible to satisfy in the absence of a belief system.

Lipovetsky puts the new era in the context of modernism and postmodernism, and elegantly describes its many paradoxes. The hypermodern times actually began when the description of postmodernism became common knowledge in the last decades of the 20th century. The predominant emotional chord is described like this:

“The ambience of this civilization of ephemerality has changed the prevailing emotional tone. A sense of insecurity has invaded all minds; health has imposed itself as a mass obsession; terrorism, catastrophes and epidemics are regularly front-page news. /…/ The only real question now is that of protection, security and defense of social benefits, of urgent humanitarian aid and safeguarding the planet.” (p 39)

And about future: “The less one has a teleological vision of the future, the more that future lends itself to being manufactured in a hyperrealist way: science and technology in combination aspire to explore the infinitely great and the infinitely small, to reshape life, to manufacture mutants, to offer a semblance of immortality, to resurrect vanished species, to programme the genetic future.” (p 43)

Psychiatry is, and always has been, medicine's—and perhaps the modern era's—most daring enterprise. Here, man uses natural science to try to explain that thoughts, feelings—even consciousness—have material causes that are subject to the laws of nature and, therefore, are possible to manipulate and predict. Even the name is edgy: the Greek word “psyche” (which few psychologists or psychiatrists can define off the cuff) is the New Testament's word for life, the soul, that which previously was seen as the immortal, God-like, free essence of being human, which, through psychiatry, becomes a part of physiology and pathology.

Mental suffering has been referred to widely divergent conceptions of causes, such as sexual experiences in infancy, capitalist alienation from work, and the “schizococcus,” but from Freud's psychoanalysis to Marxist-influenced social psychiatry, to neuropsychiatry, the same modernist insistence that psychological phenomena can be traced back to sufficient causes has characterized the different schools of thought.

In the hypermodern culture, psychiatric knowledge and tools are suddenly indispensable for people who struggle to use their minds just as their bodies. The spell of the 1970ies anti-psychiatry is broken. As the body has taken on new iconic meaning as a provider of status and bliss, the same perspective is taken on our inner selves, with identity-shaping schemes to create the “dream-me”. Anxiety is controlled with the help of computer programs, visualization techniques, meditation, and other forms of “training.” We even map our genetic predispositions using saliva DNA kits purchased online, and use inventories and websites to match our procreation, love, relationship, friendship, and existential ideals to other people's.

Young people are increasingly seeking out psychopharmacological treatments, not only for impairing conditions but also as “enhancers” of everything from attention span to love or moral judgment. The lust for self-experimentation is striking. Forty years ago, treatment with psychopharmacological agents was widely considered nightmarish. Now, it is clearly mainstream.

With structural and functional imaging methods, epidemiological and molecular genetics, national databases, and broad psychopharmacology, does psychiatry finally have the technology to realize the 1930's modernist ideals of “healthier, clearer, cooler?”

Yet the need for security and predictability is ever-increasing. Instrument-based risk assessments are increasingly used to certify people in order to point out individuals who present some sort of risk. New hospitals use cutting-edge technologies to supervise patients. Do we see the beginning of a new culture wherein neuroscience truly can influence mankind's big questions of peace, happiness, financial security, and global health?

Or will there be a huge disappointment in hypermodernist solutions on the scale of that in the late 1960-early 1970ies? After all, there is very little evidence that psychiatry is improving either general mental health, well-being or the outcome for patients. On the contrary, mental health is getting steadily worse in the hypermodern culture, treatment results have not improved in any general sense and psychiatry itself is getting more repressive, with more involuntary care, forced pharmacotherapies and long-term monitoring. Is this an early sign that hypermodernism is not really all there is to our future?

In 2014, the confidence in the progress of psychiatry seems to have started to dwindle. Funding from the pharmacoceutical industry is drying up, and molecular genetic studies implicate extremes of normal variation rather than identifiable mutations in a large majority of research subjects with common conditions such as depression or even autism spectrum disorders. If mental health problems arise along a spectrum ranging from the normal variation into out-lying pathologies without clear demarcations between disorder-health or between different diagonses, easy technical solutions will be difficult to deliver. 

(Partly excerpted from this paper, available in full text, where changes in psychiatry from modernism to postmodern and hypermodern times are described)