Read an Excerpt

CHAPTER 1

Brain Disease, Mental Disease And The Limits To Biological Psychiatry

1-1. Introduction

There is an ancient and universal notion that there is something we can add to or subtract from the diet that will cure all sorts of mental woes. In a sense, this is what biological psychiatry is all about, because underlying this particular belief is the concept that, even if there is an immortal and immaterial human soul that separates us from the beasts of the field, it has a very touchy stomach. Ultimately, they say, a man is what he eats. Generations of grandmothers have believed that constipation causes an accumulation of toxins in the bloodstream, which in turn affect the mind, causing all sorts of niggly behavior — but only in children. While grandmothers may become niggly themselves, it is always for good reason.

The principle is simple. Whatever the mind is, it can get sick just like everything else on earth. Despite thousands of years of religious indoctrination, there has always been a fifth column of old women frightening children with the idea that the mind sickens if they can't produce a good bowel action each day. But in biological psychiatry, this notion is extended to cover the complete state of the body as the final determinant of the mental state.

Now this is not Descartes' concept of the mind immaterial and unextended, the ethereal mental captain of the physical ship, as it were, but it is a widespread and very powerful notion. In every culture, people take drugs to feel or think better or to arouse or still various passions. In this context, "drug" means any physical agent introduced to the human body with the purpose of inducing a change. Drugs are therefore not the same as talismans or spells, which effect changes by supernatural means. Folk medicine as practiced by grandmothers is very largely built upon the concepts underlying modern biological psychiatry. So what are they?

Unfortunately, and despite the vast sums of money being spent on the biological research program in psychiatry, I am not aware that the principles underlying biological psychiatry have ever been explicated by its practitioners. In the main, biological psychiatrists have accepted as true all the materialist concepts that form the basis of general medicine. Central to these is the idea of reductionism, the belief that higher or more complex functions or entities can be reduced to or explained away as the outcome of activity or processes at less complex levels. This notion is certainly not new, and underlies all of the more orthodox sciences such as physics, chemistry and biology. Thus, we say that a towel dries in the sun, not because the sun spirit sucks the water out of it, but because water molecules trapped in its fibers acquire energy from the sun and, as explained by the kinetic theory of heat, break free of their mutual attraction and drift off. Cars move because of chemical energy in petrol, antibiotics safely destroy bacteria in the body, "sunrise" is the impression given by the earth's rotation, and so on. What we see is the outcome of unseen processes among invisible particles. Reductionism "explains away" the appearances.

So too with the mind: biological reductionism argues that all thoughts, all mental activity or events of all kinds, result directly from certain neurophysiological events, and that a perfect understanding of all human affairs will automatically follow from a perfect understanding of the brain. Over the past hundred or more years, people have increasingly tended to accept that reductionism will explain human affairs just as it explains, say, ape affairs or cabbage affairs. I believe that this confidence has been misplaced (even in apes), but the set of beliefs and attitudes known as biological psychiatry depend very closely on reductionist concepts.

1-2. Biological Psychiatry in Practice

So what is biological psychiatry? Moving from the restricted to the general, three themes are seen in the literature:

1. "Biological psychiatry investigates possible pathophysiological bases to mental disorder" [1].

2. "Mental disorder is brain disorder" [2].

3. "All mental events are brain events" [3].

Since each of these themes defines a field of study and limits the means of investigation, they constitute research programs. In each case, the field of study is mental disorder, which is to be viewed and investigated from the standpoint of the established biological sciences. Unfortunately, the field of mental disorder is rather difficult to define, especially at its edges (e.g. separating normality from personality disorder), but mainstream mental illness is sufficiently well-defined to leave no doubt. Similarly, there is general agreement as to the nature of questions that can be asked in biological research, the form in which they must be cast, and the methods of investigation.

With few exceptions, research in all areas of biological psychiatry adheres closely to accepted methodologies. Techniques are borrowed from other, successful disciplines, adapted as necessary to human research, and then applied in a standard form. Necessarily, psychiatry lags a little behind the latest research in biology, as it takes time to understand the significance of recent developments and somewhat longer to apply these to questions in psychiatry (as well as the inevitable delays in funding). But while these aspects of research in the biology of psychiatry may be unexceptionable, there is another, more problematic, element, namely the nature and form of the questions being asked. Unlike a field with an agreed scientific methodology, there is no formal means of deciding whether questions in psychiatry are of a form suitable for this type of research. They derive informally from the researcher's overall view of the subject matter, meaning his apprehension or ontology of the nature of mental disorder. Unfortunately, my apprehension may well seem a misapprehension to you.

1-2(A). Restricted Biological Psychiatry

The references quoted above represent three quite divergent views on the nature of mental disorder. The first reference, by Berger and Brodie, is taken from a large, respected textbook of psychiatry. It is based on the empirical evidence that some sorts of brain disease can result in recognized syndromes of mental illness. The different contributors to that section of the handbook carefully avoided any particular theoretical commitments, as the conclusion to the section on schizophrenia shows: "... studies of the biology of schizophrenia have produced many findings of CNS dysfunction, none specific for this disease and none shared by everyone with the diagnosis ... Direct evidence for a specific neurotransmitter or receptor abnormality is not yet available. One hopes that as knowledge of normal CNS anatomy and physiology expands and new methods for exploring aberrations from normal become available, new insights into the cause or causes of this very devastating illness will be possible" [1, p 449].

This is a commendably cautious stance in an area fraught with conceptual and methodological difficulties. Only a person who denies that disturbances of brain function can affect mental function (hardly a tenable position) could take exception to this attempt to map out an area of research. As they noted, the results of this research program have been remarkably slow coming.

1-2(B). Unrestricted Biological Psychiatry

The second reference, from a textbook by the British psychiatrist Michael Trimble, represents a very much harder line on the nature of mental disorder, as his opening quote shows: "Mental disorders are neither more nor less than nervous diseases in which mental symptoms predominate, and their entire separation from other nervous diseases has been a sad hindrance to progress" (attributed to Henry Maudsley, 1870). Later, he quoted the German psychiatrist Griesinger as "... reflecting the essential nature of biological psychiatry ... 'Insanity being a disease, and that disease being an affection of the brain ...'" (p11).

Trimble quickly dismissed the possibility that psychological factors can cause mental illness. He approvingly quoted Maudsley's acerbic dismissal of metaphysics (p21-3), immediately labeling psychoanalysis (and all psychodynamic theories) as metaphysics. He continued: "The distractions of psychoanalysis for present-day psychiatry cannot be overemphasized. To base theories of etiology, pathogenesis and treatment on ideas that were dominant nearly a hundred years ago makes little sense ... Psychiatry ... tenaciously accepts so much of the old dogma, and so reluctantly embraces the new." Psychiatry, he insisted, is "... concerned with behavior in its widest sense, and has continually searched for knowledge of brain-behavior relationships and somatic underpinnings of psychopathology."

We can conclude from this that Trimble's position is as follows:

1. All mental disorder is brain disorder;

2. Psychiatry is essentially a biological discipline;

3. Psychodynamics is outmoded and empty metaphysics.

These are fairly blunt statements of intent, but they are certainly not unusual. These ideas dominate psychiatry in the late twentieth century, especially in Britain, Scandinavia and, more recently, the United States. In fact, one of the doyens of American psychiatry, Samuel Guze, recently asked whether there is any other kind ofpsychiatry besides the biological, adding: "... there is no such thing as a psychiatry which is too biological" [4, p315]. Stated as baldly as this, we can see why some people have started to worry about "hegemonistic biologism" in psychiatry [5].

The greater part of Trimble's text consists of detailed accounts of biological research in a wide variety of mental disorders. Oddly enough, and in clear contrast with the moderate stance seen in Berger and Brodie, neither the book itself nor any of its chapters contains a summary, almost as though the author believed that the research material spoke for itself. To my mind, this is a serious omission, one which makes sense only if its readers accept the basic premises of his case as outlined above. In Trimble's schema, all pathological mind-body interaction goes but one way, from the body to the mind, a view most psychiatrists would reject. The concept of psychosomatics rests on the notion that the mind can influence the body.

The unanswered question in Trimble's approach to psychiatry is clear: Is it a fact that all mental disorder is brain disease? This is certainly not trivial as the whole objective of clinical and theoretical psychiatry is to understand the nature of the phenomena of mental disorder. However, regardless of how many professors line up behind the biological banners, the matter cannot be resolved by fiat. In this type of question, mere weight of opinion counts for nothing. Unfortunately, Trimble shows no awareness that there may be an issue at stake here. Mental disorder is brain disorder; therefore, as hollow metaphysics, all other considerations lie outside the purview of psychiatry and, by intimation, of rational thought. But Maudsley's nineteenth century dictum is the critical issue here, and the following argument will show some of its weaknesses.

Consider Maudsley's proposition:

Proposition P1: All mental disorder is (just a special form of) brain disorder.

In the first place, there is no logical way of proving this assertion true as it is not a necessary truth. At best, it could be an empirical truth, inductively true but thereby open to refutation by finding a single case of psychologically-determined mental disorder. This point is important. If Trimble asserts that it is impossible for mental disorder to be caused by anything other than brain disease, then he is making the same type of wild and unsupported statement of which he finds psychoanalysts guilty. But if he allows that there may be cases of mental disorder that do not result from brain disease, then he had no grounds for making his assertion in the first place.

Nonetheless, we can disprove P1 by considering the truth value of its negation, as follows:

P2: No cases of mental disorder are not also cases of brain disease.

This sounds a little clumsy, so it can be rephrased as follows:

P2a: There are no cases of psychologically-determined mental disorder.

But, as the diagnostic category of Post-Traumatic Stress Disorder explicitly recognizes, Proposition P2a is empirically false so Trimble's basic proposition, P1, is false. Despite his assertion, not all mental disorder is due to brain disease. A complete list of all brain diseases (known and unknown: we're talking hypothetically here) would not account for all mental disorders. There will always be some left over as examples of pure psychological disorder. He is therefore unwarranted in his remaining assertions, that psychodynamics is outmoded and empty metaphysics, and that psychiatry is essentially a biological discipline.

Returning to P1, there is another way of tackling Trimble's metaphysical stance on mental disorder, which is to look at the nature of the "human machine." In any complex machine (i.e. one that controls its own output by means of its information-processing capabilities), the disordered output resulting from an unseen physical disturbance of one sort or another can always be mimicked by a programming error. For people, what this means is that any and all disturbed behavior can in principle have either physical or psychological causes. Every psychiatrist keeps this critical point in mind all day: "Is what I am seeing a genuine psychological disorder, or is it really a physical illness such as a tumor, or is it just clever acting?" For anybody who takes the job seriously, this question is a ceaseless worry because there is no reliable rule of thumb.

For these two reasons, I assert that Trimble's case for biological psychiatry must fail. It seems to me that Trimble could only have overlooked these quite elementary considerations if he had assumed a more general position with respect to the mind. His basic proposition, P1, would become valid under the following, specific condition. Assume that:

P3: All mental events are brain events.

Given this very broad assumption, it would then follow that, as a subset of the universal set of mental events, all abnormal mental events (the stuff of mental disorder) will necessarily be brain events. Assuming that one is justified in judging brain events normal or abnormal according to whether their associated mental events are normal or not (and I don't believe this assumption is justified), it would therefore follow that:

P1: All mental disorder is brain disorder.

Accepting this argument would validate Trimble's thesis, but P3 is part of a much larger question, namely, metaphysics. At its most basic level, a successful account of mental disorder depends on a successful account of mind. Were Maudsley, or Trimble, or Guze, or any other biological psychiatrist ever aware of that? It seems to me that psychiatrists simply assumed that whatever worked in biology would automatically work in human psychology.

This principle was never questioned. It was accepted as part of the world-view, the ontology, on which reductionist biology depends, as Guze noted: "Most of us who adhere to the medical model believe that the fullest understanding of human health and illness, including psychiatric conditions, will depend increasingly on growing knowledge in biology ... this explains the redefinition of many personal and social problems into concerns of medicine" [6, p7]. This implies that a complete understanding of human biology will give a complete understanding of personal and social problems. I see no evidence to support this extreme position.

I asked whether we are justified in judging brain events normal or abnormal according to whether their associated mental events are normal or not. If, for the purposes of the argument, we accept that mental events just are brain events, how then should we judge the brain events if we decide that the mental event is abnormal? The question is simple: can a normal brain event still constitute an abnormal mental event. I would say yes, it can. Consider the example of grief. When we experience a massive loss of one sort or other, we typically go through a particular response known as the grief reaction. This is sufficiently common in its incidence and form to be regarded as a normal event. But grief, as we all know, is horrible; life would be far easier if we didn't have to feel it. So is grief normal or abnormal, and how should we classify the brain events underlying it? It depends on how you look at it, which is, of course, no basis for determining brain events abnormal.

It is perfectly legitimate to allow that abnormal mental events could be the outcome of normal mental events, because nobody has ever proven a strict one-to-one relationship between mental events and their (assumed) underlying brain events. People tend to use the analogy of computers to explain the difference between normal and abnormal mental and brain events. The machinery of a computer (its hardware) may be perfectly normal yet it persists in producing an abnormal output. We explain this by saying that its programs (software) are defective. By analogy, people argue that while the brain's physical machinery (its "wetware") may be perfectly normal, its programs (belief systems and information) may be disorganized, thereby producing an incoherent output (weird behavior). This is an interesting analogy, but there is nothing to say that brains and computers run by the same principles.

(Continues…)

---

Excerpted from "Humanizing Madness"
by .
Copyright © 2007 Niall McLaren.
Excerpted by permission of Loving Healing Press, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.

---