Wednesday, June 9, 2010

Is the Psychiatry of 1952 More Relevant to Our Recovery Than the Psychiatry of 2010?

From my keynote I gave to the DBSA Kansas State conference in Kansas in late April ...

Let’s turn to another researcher I heard speak in San Francisco.

This is a guy called Robert Sapolsky of Stanford. And he has dedicated his life to studying stress. So, Dr Sapolsky asks us to imagine a rat who has been trained to press a lever to avoid a mild shock.

Now, as he describes it:

The anticipation of mastery might induce a flood of dopamine to the frontal cortex and trigger pleasure. If the lever is disconnected, however, so that pressing it no longer prevents shocks, the rat will frantically press the lever repeatedly, attempting to gain control.

This, says Dr Sapolsky, is the essence of anxiety.

In human terms, I would describe it this way. Imagine waiting for a hot date to show up. The anticipation of a great night ahead triggers pleasure. But then the date doesn’t turn up on time. Pleasure changes to anxiety. And then it looks like the date will not turn up at all. So, to return to the rat, the real rat, not the no good bastard:

The shocks continue. The rat finds its attempts at coping useless. The rat basically gives up. Key neurotransmitters are depleted while stress hormones increase. In the words of Dr Sapolsky: The rat “has learned to be helpless, passive and involuted. If anxiety is a crackling, menacing brushfire, depression is a suffocating heavy blanket thrown on top of it."

That's a pretty good description, right? Says quite a lot about what we go through.

So, here you are. You’re all dressed up with nowhere to go. In the space of an hour or two, you have gone from pleasure to anxiety to depression.

Is this normal? Yeh, of course it is. The front end and the back end of the brain are working exactly as they should be. Yes, the result sucks, but if we have any kind of feelings at all, depressed is the state we’re supposed to be in.

Now, in a resilient brain, we will bounce back. Life may suck, but we cope, life goes on.

But suppose our brains are vulnerable. Say we don’t bounce back. Say we start thinking we’re worthless. Say we start over-ruminating. We lie in bed all day. And say this goes on for four months.

I’m going to finish up in a bit, but I want to throw another one at you here. I’m sure you’re aware that earlier this year the DSM-5 Task Force came out with a draft. Are people aware of that? Okay, good.

To keep it short: The DSM is due for an update in 2003. And this is the diagnostic Bible - okay? - put out by the American Psychiatric Association. No - 2013. Is that the same as two thousand - I don't know. I'm one of these guys who doesn't know if three-fifths is more than half or less than half.

Anyway, the DSM-IV is the current edition, which came out in 1994, and that's based on the DSM-III Revised which came out in 1987, which in turn is based on the DSM-III which came out in 1980, with hardly any changes all the way along. And guess what? The DSM-5 of 2013 is going to continue that tradition of making sweet F-all changes. So, basically, we're going to come out with a document that's going to set the tone for psychiatry for the next 20 years based on the DSM-III of 1980 and its ridiculously - stupid - criteria for depression.

Anyway, while I was doing my research, I dug out the old DSM-I from 1952 and the DSM-II from 1968. Basically, these are much the same and they're supposed to represent ancient history, you know, before psychiatry got modern, stuck in 1980 Ground Hog Day forever. Much of the DSM I and II had to do with this Freudian artifact called “neurosis.”

Well, guess what? According to these ancient DSMs, depression was a form of neurosis. Okay, fine. And guess what drove neurosis? Anxiety!

That’s not all. These ancient DSMs tried to break down mental illness two ways: That which they saw as biology-based - which they didn't have a clue about -  and that which was the result of a maladaptive response to stress.

So. Freeze-frame. Stress-anxiety-depression. Does that sound very close to the language Dr Sapolsky was using? Is the psychiatry of 1952 more relevant to our recovery than the psychiatry of 2010?

Well, in one sense, yes. The psychiatry back then was interested in looking under the hood, but they lacked the means. No brain scans. No gene tests. The best they could do was speculate about neurosis.

The old psychiatry also had no idea that stress was related to biology. They thought that just about all mental illness was a product of the mind as distinct from the brain. Nevertheless they knew that true recovery involved digging below the surface, deep into the mind. The catch was the only tool at their disposal - psychoanalysis - really didn’t work for most people. And it really didn't get patients all that much better.

Well these days, we know a lot more about recovery. There are a lot of tools available to us. We know a lot of them have very good success rates, and we heard a lot about that this morning.

After lunch, I will be giving another talk. I’m looking forward to concentrating more on recovery tools. And you will also hear more speakers talk about recovery. But what I want to emphasize here is:

Recovery starts with knowledge. It helps knowing that we have vulnerable brains. That the back and front ends of our brains don’t always act the way they should. That they don’t always talk to each other the way they should. That we have a tendency to over-react. That we also have a tendency to both over-think and under-think.

Not only that, our brains are slow in resetting to normal.

What this means is - instead of coping with life, life becomes a struggle.

Do we have some kind of consensus on this? We're on the same page with this? Because - you know - you really get this wisdom going to DBSA support groups and also NAMI groups. And other groups. There's a lot of patient and family wisdom there.

Mental illness is simple, really. We get overwhelmed, overloaded. Too much of one thing, too much of everything. Too much thought, too much emotion, too much sensory input. Too much of nothing, even. Think of a fire in your brain or of being trapped deep underground, unable to breathe. There is no way the brain can respond rationally.

The brain copes, instead, by flipping out or shutting down.

But this doesn’t mean we have to give up. It only means we have to work harder and smarter.

So - know thyself. Look under the hood. Check out what’s really happening inside. Take nothing for granted. Question everything.

So here we are, on our journey, somewhere in the Land of Oz, looking to return home, to Kansas ...


Anonymous said...

Do you know anything about Recovery, Inc. started by Abraham Lowe?

John McManamy said...

Hey, Donna. Yes I do, and I strongly endorse it. Dr Lowe was way ahead of his time.