RIP Chemical Imbalance in the Brain

As to what causes depression, the short answer is we don't know. It is convenient to say that it is a result of a chemical imbalance in the brain, but this is not entirely accurate ...
- Living Well with Depression and Bipolar Disorder, 2006

Let me rephrase that. "Chemical imbalance in the brain" is wholly inaccurate and misleading. My book goes to great lengths to point out that our brains are not chemical soup, but I was willing to concede it was okay to use the term in a pinch. No more.

Last night, I began reading Robert Whitaker's "Anatomy of an Epidemic," published earlier this year. Robert Whitaker (pictured here) is a journalist who got into reporting on mental health quite by accident. His meticulously researched "Madness in America" (2002) challenged the narrative that the introduction of psychiatric meds changed the treatment of mental illness for the better. His current book continues this line of reasoning.

What jumped out and hit me in the face in reading the first 100 pages is that the "chemical imbalance" myth continues to flourish despite overwhelming evidence to the contrary. Here's how it breaks down:

Psychiatric meds were developed serendipitously, with no knowledge of the underlying brain function. This is old news. The first antidepressants, for instance, were originally developed to treat TB. Some of the patients, it was discovered, became lively. In 1958, inproniazid (an MAO-I) hit the market as a psychic "energizer." A year later, imipramine (a tricyclic) came on the scene.

As Whitaker reports: "The New York Times called them antidepressants for the first time."

The first antipsychotics, in the meantime, came out of research for safe anesthetic agents (and before that for malaria). As part of a cocktail, one experimental med induced "artificial hibernation." In France, in 1952, two doctors used a variation of this med to quiet down psychotic patients. Very soon after, Thorazine (chlorpromazine), came on the market as a major tranquilizer or "neuroleptic" (meaning it took hold of the nervous system).

Whitaker notes: "Physicians in the US similarly understood this drug was not fixing any known pathology." Only in 1963, after an NIMH study, did Thorazine and similar compounds become acknowledged as "antipsychotics". Thus the new psychiatric meds were viewed as antidotes for specific disorders, comparable to antibiotics. But to make their case, scientists needed to backfill their claims with a credible theory.

Employing the equivalent of reverse engineering, researchers figured out that antidepressants worked by enhancing serotonin communication between the neurons. Likewise, antipsychotics took effect by blocking dopamine transmission. So far so good. But, could depression be seen as an undersupply of one neurotransmitter and psychosis an oversupply of another? A "chemical imbalance," in other words?

The obvious way to prove that was to analyze the cerebrospinal fluid (CSF) of unmedicated patients. Serotonin that is not recycled in the brain is metabolized as 5-HIAA. Likewise, dopamine is broken down to HVA. The levels of these metabolites in the CSF are acknowledged to relate to the levels of their corresponding neurotransmitters in the brain. Over the course of fifteen years to the mid-seventies, researchers found that the various metabolite levels in patients were no different than those in the general population.

In other words, no chemical imbalance. This is science at its best, disproving its own claims through its own methods, though the theory kept getting revived from time to time, especially with the commercial success of Prozac.

In the meantime, however, researchers began to paint a far more accurate and nuanced picture. With the administration of an SSRI antidepressant, we have learned, the brain attempts to compensate by turning down serotonin release in presynaptic neurons and reducing the density of serotonin receptors in postsynaptic neurons. This is the brain's attempt to maintain homeostatsis (equilibrium), to keep serotonin at levels as they were prior to the introduction of the drug.

Only after two weeks or more does the antidepressant begin to assert itself. The brain's compensating mechanisms break down. Serotonin now floods the synapse and latches onto postsynaptic receptors. Something similar happens with the introduction of an antipsychotic. Presynaptic neurons react by pumping out more dopamine and postsynaptic neurons increase their density. Only later does the blockade begin.

According to Whitaker, "the medicine clearly doesn't fix a chemical imbalance in the brain." Quite the contrary, these meds are causing chemical imbalances, and science is quite okay with that. Exhibit A cited by Whitaker is a 1996 article by former NIMH director Steve Hyman, which notes that the brain on meds is functioning in a manner that is "qualitatively as well as quantitatively different from the normal state."

In his article, Dr Hyman concludes:

Psychiatric research must now extend its efforts beyond the synapse, to an understanding of cellular and molecular neurobiology (in particular, postreceptor signal transduction) as well as to a better understanding of the architecture and function of neural systems.

It's a new world out there. Forget "chemical imbalance."

For an alternative metaphor, check out The Brain is an Ecosystem.

***

This is the first in a series that intends to use Whitaker's book as a talking point on a vast range of topics. We are not out to prove Whitaker right or wrong. Rather, the purpose is to start a conversation on issues that cry out for our attention. Your comments welcome ...

The Chilean Miners: Resilence vs Vulnerability

As I write this, the seventeenth Chilean miner, Omar Reygadas (pictured here), has been delivered from the pits of hell. For a number of miners, hell will continue to pursue them - into their homes, their daily lives, their dreams. Others will leave hell below the surface. We have already witnessed a lot of commentary on this. The issue focuses on resilience vs vulnerability, which inspired me to dig this out of a much longer piece I'd written a number of years back:

According to an article on Harvard’s Intelihealth: "There is some evidence that people who receive counseling and supportive therapy immediately after a trauma have a lower risk of developing PTSD than those who don't."

A feature article in the New York Times Magazine by Lauren Slater, author of Prozac Diary, challenges that assumption, making a strong case for keeping trauma repressed, contrary to an industry of therapy built on prizing loose bad experiences from survivors. As early as 1952, a study found that psychotherapy in general healed no more than the passage of time, and observations coming out of 9/11 indicate that many survivors actually got worse in the hands of their therapists. The article cites an Israeli study of 116 heart attack victims, which found those who repressed the occurrence "fared better in the long run." After seven months, the "repressors" experienced only seven percent PTSD compared to 19 percent among those who sought to "lift the lid."

Researchers hypothesize that repressors may perceive the magnitude of events differently, say "where you see a downpour, they see a drizzle." Another theory is that repressors are good at turning attention away from the disaster, or else believing - rightly or wrongly - that they can cope. According to Kansas City psychologist Richard Gist, who has assisted survivors of disasters but is questioning the worth of his efforts: "For all we know, the repressors are actually the normal ones who effectively cope with the many tragedies life presents. Why are we not more fascinated with these displays of resilience and grace? Why are we only fascinated with frailty?"

In this blog and other outlets, I frequently refer to two studies that shed light on how our brain interacts with our environment and vice-versa. The bottom line is that those of us born with certain gene variations (say the short allele to the serotonin transporter gene) appear to be predisposed to over-react to stressful situations, which opens the floodgates to depression, anxiety, PTSD, and no end of maladaptive behaviors.

A lot more research needs to be done, but it appears that resilience and vulnerability are genetic traits rather than moral virtues or defects. Technically, one may ascribe the traits to character, keeping in mind that character is heritable. No doubt, miners possess "the right stuff" to spend a good deal of their waking lives deep inside the earth. What we have yet to learn is how much horror the resilient can be exposed to before they, in turn, become vulnerable.

Two studies conducted on populations involved in the Serbian-Albanian conflict - people who reported being deprived of food and water, being in a combat situation, fleeing their homes, and being close to death - found a high rate of psychiatric disorder amongst the survivors. What surprised the researchers was how high this figure was - 43 percent, twice their expectations. Adopting less conservative criteria raised the incidence to 83.5 percent.

Obviously, "get over it" and "stiff upper lip" are misguided attempts by the resilient in forcing their agendas on the vulnerable. Equally, we the vulnerable need to be mindful of ramming our therapies down the unwilling throats of the resilient. We have so much to learn. In the meantime, we have a lot to celebrate.

Where Is God?

I just finished reading Karen Armstrong's "The Case for God," which does not actually make a case for God. Ms Armstrong (pictured here) is way too smart for that. The idea of some kind of infinite absolute outside our comprehension hardly lends itself to argument, much less proof, either theological or scientific. Believe it or not, until the nineteenth century, science and religion were pretty cool with that.

According to Ms Armstrong, religious fundamentalism - whether Christian or Muslim or other variety - is a relatively new phenomenon, as is most mainstream belief. A God beyond imagination does not submit to pat answers. Pat answers, in fact, are highly suspect. Define the infinite? Think about it. To define is to limit. To reduce God to our level of understanding is to lose touch with God.

Scripture, which raises more questions than answers, is always open to reinterpretation. Liturgy and observances are living meditations on eternal mysteries, not empty ritual. Through immersion in a practice, through rigorous inquiry, through opening oneself to new possibilities, new realizations emerge. One becomes a better person, in closer touch with God, whatever God is.

Throughout the ages, says Armstrong, religion was the means, not the end, and this applied to all faiths, irrespective of their surface differences. Even terms such as "dogma" and "belief" had different meanings and usages, more in the sense of entering into an ongoing and typically unpredictable dialogue rather than mindlessly yielding to foreordained assertions.

Ironically, the liberating spread of ancient Greek philosophy in the Middle Ages also gave rise to the type of stultifying over-intellectualism that would later set the scene for a hardening of attitudes. With the mass printing of Bibles, selected scriptural passages were deployed by competing faiths and sects to separate themselves out from one another.

Nevertheless, maintains Armstrong, faith and science maintained a sort of working mutual accord. Neither was trying to dictate to the other. Even the Galileo controversy, Armstrong argues, was overstated. (Galileo, it seems, was spoiling for a fight.) In any event, when the dust settled, religious and scientific authority appeared to be in harmony. Newtonian physics, in fact, seemed to prove the existence of God. Some higher power had to have set the mechanics of the universe in motion. This was as self-evident to Newton as it was to the rationalist philosophers his discoveries inspired.

Yes, Europe erupted into senseless religious warfare - change always exceeds society's capacity to peacefully absorb it - but with the emergence of a modern Europe came the belief that the solution to any problem (no matter how intractable) and the explanation to any phenomenon (no matter how mysterious) would yield to the power of reason.

God could be explained scientifically. Organized religion was comfortable with that. The Christianity of America's Founding Fathers was very different than the Christianity we practice today, irrespective of denomination. The catch is that reason has its limits. Alas, scientific enquiry breaks down in the pursuit of that which is beyond imagination.

On top of that, arid intellectualism failed to satisfy essential human needs, which set in motion a revivalist reaction. Still, no one seriously argued that Scripture trumped science. That would soon change. First, Charles Lyell showed that the earth was shaped - and still being shaped - by slow-moving forces spanning eons. Then Darwin came on the scene. Nevertheless, Armstrong is quick to point out, Darwin's ideas were readily accepted by the scientific community and not seriously challenged at first by religion.

That didn't last long. Scientism extremists became anti-religious. Religious extremists became anti-science. Even in mainstream religions, new emphasis was given to the literal interpretation of Scripture, with those presumed closer to God claiming an authority they never dared lay claim to before. Thus, in 1870 the doctrine of papal infallibility was adopted by the Catholic Church.

Nevertheless, by the 1960s, people were seriously asking, "Is God dead?" Mainstream church attendance was in sharp decline and religious fundamentalism was a fringe movement. A new secular culture was dawning.

Well, you know the rest of the story. In the US, today, religious fundamentalism is driving much of the political and social agenda. The history lesson, Armstrong tells us, is that every threat to the old order spawns an irrational reaction, with each new religious outbreak more bizarre than the one that proceeded it. A lot of what passes for both mainstream and fundamentalist religion today, if I am reading Armstrong correctly, bears very little semblance to the religion of the past.

The extremists in our midst - the likes of Dawkins and Sullivan - argue that our world would be a lot happier if we could somehow stamp out all religion and disabuse ourselves of the notion of God. But that, Armstrong argues, misses the point. Just because religion has no pat answers for God (even if they profess to offer them) does not preclude the existence of God. And religion at its best - even the ones we may find abhorrent to us - offers the prospect of bringing us closer to that which is beyond imagination.

Truth will always elude us, as does reality. But in our quest, we can arrive at reasonable approximations, which serve to launch us to our next round of approximations, then the next. Let the journey begin ...

iPhone Photo of the Day: Pacific Sunset

Torrey Pines, La Jolla, CA.

Dinner for 200

Usually, when I sit down and have dinner all I have to worry about is where I will spill my food. But that changed about 18 months ago, when I took my seat as the new guy on the NAMI San Diego board. I made the rookie mistake of breathing too loud, and next thing I was drafted into service on the committee that plans our annual Inspiration Awards Dinner. Last year’s dinner was such a great success that I found myself, through no fault of my own, reassigned to this year’s committee.

There are 800 million things that can go wrong in putting on a dinner and dinner program for 200. As you can see from the photo, none of them happened. Here I am, just after the Dinner, with John Bell, who received our Young Advocate of the Year Award. John is very recently back from Iraq, where he has served as a medic in the Army. In April, John organized a 5K run concurrent with our local NAMI walk to bring awareness to mental health issues for those who serve our country.

John was a surprise guest at the Dinner, having had his leave request approved only two days before. He is currently stationed at Fort Benning, GA. It was my honor to sit at the table with John and his fiancee, Melissa.

Many thanks to Annie Dunlop, NAMI SD’s development and events manager, who took the lead in organizing the dinner, our board president Lisa Ponfick and Executive Director Shannon Jaccard, Councilman Todd Gloria who MC’d the affair, our awardees, sponsors, and all our volunteers and staff who made Friday evening an occasion to remember.

Sylvia Plath: In Her Own Words

This is a lightly edited version of a piece I wrote 11 years ago ...

It was a bitter cold winter in 1963, and an American mother of two was doing her best to cope on her own in London, not long after being jilted by her husband for another woman. Poet Sylvia Plath, 30, left out bread and milk for her two toddlers sleeping in an upstairs bedroom.

Then she turned on the gas.

Following the posthumous publication of her Ariel poems, Sylvia Plath became a feminist cause celebre, with ex-husband poet Ted Hughes vilified as an accomplice to her death. Completely overlooked by these critics, however, was Exhibit A, the writer's very own words, her semi-autobiographical novel, The Bell Jar.

Check out this description of her shock treatment:

" ... with each flash a great jolt drubbed me till I thought my bones would break and the sap fly out of me like a split plant."

The book also recounted her attempted suicide at age 20, not to mention her morbid preoccupation with death. The Bell Jar was a metaphor for the feelings of hopelessness and despair and self-contempt she carried with her everywhere:

How did I know that someday - at college, in Europe, somewhere, anywhere - the bell jar, with it's stifling distortions, wouldn't descend again?

Make no mistake, this book is THE depression memoir, published out of time in an age of neurosis. Her Journals, published in full for the first time a number of years ago, shed far more light. According to an article in the Guardian:

"It is here in her diaries that Plath reveals what she really thinks - about her depression, about her sexuality and about Hughes."

In an early entry, she reveals her manic as well as depressive side: "God, is this all it is, the ricocheting down the corridor of laughter and tears? Of self-worship and self-loathing? Of glory and disgust?"

And again: "It is as if my life were magically run by two electric currents: joyous and positive and despairing negative; whichever is running at the moment dominates my life, floods it. I am now flooded with despair, almost hysteria, as if I were smothering."

On the day after she met Ted Hughes, she wrote a poem "about the dark forces of lust." Entitled "Pursuit," it begins: "There is a panther stalks me down:/One day I'll have my death of him."

But first came the grim foretelling of her suicide attempt at age 20. In November 1952, she wrote:

God, if ever I have come close to wanting to commit suicide, it is now, with the groggy sleepless blood dragging through my veins, and the air thick and gray with rain and the damn little men across the street pounding on the roof with picks and axes and chisels, and the acrid hellish stench of tar ... My world falls apart, crumbles, 'The centre does not hold.' There is no integrating force, only the naked fear, the urge of self-preservation.

With a wisdom way beyond her years, she notes:

I am afraid, I am not solid, but hollow. I feel behind my eyes a numb, paralysed cavern, a pit of hell, a mimicking nothingness, I never thought, I never wrote, I never suffered. I want to kill myself, to escape from responsibility, to crawl back abjectly into the womb. I do not know who I am, where I am going - and I am the one who has to decide the answers to these hideous questions. I long for a noble escape from freedom - I am weak, tired, in revolt from the strong constructive humanitarian faith which presupposes a healthy, active intellect and will. There is nowhere to go - not home, where I would blubber and cry, a grotesque fool, into my mother's skirts - not to men where I want more than the stern, final, paternal directive - not to church which is liberal, free - no, I turn wearily to the totalitarian dictatorship where I am absolved of all personal responsibility and can sacrifice myself in a "splurge of altruism" on the altar of the Cause with a capital "C".

But the Journals also reveal a very much alive side to the poet, whose run-on writing shimmers with a bebop sense of fifties hip we normally associate with the likes of Kerouac and company:

Falcons Yard, and the syncopated strut of a piano upstairs, and oh it was very Bohemian, with boys in turtle-neck sweaters and girls being blue-eye-lidded or elegant in black. Derrek was there, with guitar, and Bert was looking shining and proud as if he had just delivered five babies, said something obvious about having drunk a lot ... By this time I had spilled one drink, partly into my mouth, partly over my hands and the floor, and the jazz was beginning to get under my skin, and I started dancing with Luke and knew I was very bad, having crossed the river and banged into the trees, yelling about the poems, and he only smiling with the far-off look of a cretin satan. He wrote those things, and he was slobbing around. Well, I was slobbing around, blub, maundering and I didn't even have the excuse of having written those things; I suppose if you can write sestinas which bam crash through lines and rules after having raped them to the purpose, then you can be satanic and smile like a cretin beelzebub.

Hours later, she wrote her "Pursuit" poem, dedicated to Ted, and later "Lady Lazarus," where she boasted:

I rise with my red hair

And I eat men like air

In a sense, Sylvia Plath has been restored to life, by the power of her own pen, by the power of her own words. That such a vital force was struck down by depression makes her short life all the more tragic. But her own words also portray triumph, of a woman who overcame tremendous odds just to find some joy in her life, a joy she was able to manifest in full measure.

Exegesis

"Thrice was I beaten with rods, once was I stoned, thrice I suffered shipwreck, a night and a day I have been in the deep."

Paul was on a mission, literally a mission from God. His first two Letters - Romans and First Corinthians - reflect the optimism of one with God on his side: confident, bossy, out to change the world.

Second Corinthians, written many years later, reflects a different Paul: weary and disenchanted, struggling to keep his faith. What happened? We pick up the story in Acts of the Apostles, when a mob from Antioch and Iconium stoned Paul and dragged him out of the city, leaving him for dead. Acts also reports that Paul and his companions were at the mercy of a mob in Ephesus, city of the Temple of Diana.

Even when Paul succeeded in setting up Christian communities throughout Asia Minor and Greece, his Letters reveal his frustration with the inadequacies of his followers. Indeed, it is clear that some of these communities were in open rebellion against their founder.

And so we come to his extraordinary admission in Second Corinthians. He holds nothing back: the public floggings, the stoning, the shipwrecks, the rigors of travel, the exhaustion and privations, the personal betrayals, of being set upon by bandits. But all that pales in comparison to what is really on his mind. "I fear," he writes to his Corinthian community, "that when I come I may find you different from what I wish you to be."

All that suffering - for nothing? Is that what life is all about? God, what happened? I thought Paul was Your anointed servant. I thought he had Your blessing.

Either God isn't talking or no one is listening. Perhaps His half of the conversation went something like this:

You presume to act in My name? Well, let's see how sincere you are after a mob has tried to crack open your skull. You think you are committed? Then let's see how committed you are holding on for dear life to a piece of boat in the open sea. You want it real bad? Let's see how bad you want it when your friends turn on you, your followers abandon you, and your love is returned in endless measure with hate. You want to spread light? Well let's see how it feels when the darkness closes in.

And there you are, all alone, your life up in smoke.

It's not in God's nature to make things easy. You want an easy life, then do something easy. You want to accomplish something, well don't expect any breaks. The nature of things is you will be tested. The last we hear from Paul in the New Testament is in Rome, under house arrest. "I considered all toil and all achievement," says Ecclesiastes, "and it all comes from rivalry between man and man. This too is emptiness and chasing the wind."

Clement of Rome reports that for all his hardships, Paul "won the noble renown." There is no surviving account of whether or not he died a martyr. Let's trust he died a man at peace.

Rerun- Is Mental Illness an American Disease?

This from late January ...

An article by author Ethan Watters in the Jan 8 NY Times Magazine throws down the gauntlet:

For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world. We have done this in the name of science, believing that our approaches reveal the biological basis of psychic suffering and dispel prescientific myths and harmful stigma. There is now good evidence to suggest that in the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. ...

The article, "The Americanization of Mental Illness," is an adaptation from the just-released book, ‘‘Crazy Like Us: The Globalization of the American Psyche.” In the article, Mr Watters uses the example of a “culturally specific” form of anorexia documented by one researcher in Hong Kong during the 80s and 90s. Unlike Americans with anorexia, those in Hong Kong simply complained of bloated stomachs without dieting or expressing fear of becoming fat. The illness was rare.

Then, in 1994, in the wake of the death of a school girl, the local press attempted to explain the phenomenon using American diagnostic language. According to Watters, “the transfer of knowledge about the nature of anorexia (including how and why it was manifested and who was at risk) went only one way: from West to East.” Not surprisingly, there was an outbreak of “fat phobia.”

Says Watters:

In the end, what cross-cultural psychiatrists and anthropologists have to tell us is that all mental illnesses, including depression, P.T.S.D. and even schizophrenia, can be every bit as influenced by cultural beliefs and expectations today as hysterical-leg paralysis or the vapors or zar or any other mental illness ever experienced in the history of human madness.

This does not mean the illness or the pain is not real, Watters is quick to add. But an illness of the mind needs to be understood in its cultural context. Ironically, says Watters, the western notion (promoted by advocacy groups such as NAMI) that mental illness is a no-fault “brain disease” may have the opposite effect of increasing rather than reducing stigma. According to Watters, citing the research of Sheila Mehta of Auburn University:

The problem, it appears, is that the biomedical narrative about an illness like schizophrenia carries with it the subtle assumption that a brain made ill through biomedical or genetic abnormalities is more thoroughly broken and permanently abnormal than one made ill though life events.

The author cites a four-decades study that found a steady rise in the American public in their perceptions of schizophrenia as dangerous. Meanwhile, in Turkey, according to a study, “those who labeled schizophrenic behavior as akil hastaligi (illness of the brain or reasoning abilities) were more inclined to assert that schizophrenics were aggressive and should not live freely in the community than those who saw the disorder as ruhsal hastagi (a disorder of the spiritual or inner self).”

Most of us are aware of three WHO studies over the course of 30 years (starting in the 70s) that found that patients outside the US and Europe had significantly lower relapse rates (as much as two-thirds lower in one follow-up). Watters reports on anthropologist Juli McGruder from the University of Puget Sound who spent years in Zanzibar studying families of those with schizophrenia. There Muslim and spirit possession beliefs are incorporated into healing practices. Rather than spirits being “cast out,” they are “coaxed out” with acts of kindness.

Says Watters: “Since the illness was seen as the work of outside forces, it was understood as an affliction for the sufferer but not as an identity.”

The author adds:

The course of a metastasizing cancer is unlikely to be changed by how we talk about it. With schizophrenia, however, symptoms are inevitably entangled in a person’s complex interactions with those around him or her. In fact, researchers have long documented how certain emotional reactions from family members correlate with higher relapse rates for people who have a diagnosis of schizophrenia.

This negativity is referred to by experts as “high expressed emotion (high EE),” which include criticism, hostility and emotional overinvolvement (such as overprotectiveness). White American families caring for a family member with schizophrenia have notoriously high EE rates, with much lower EE rates among Mexican and other families.

It’s not that American families are unenlightened, says Watters. Rather, they “were simply expressing a particularly American view of the self,” and “applying the same assumptions about human nature that they applied to themselves.”

No one is seriously talking about withholding meds and other western treatments and therapies from individuals in need. But we do need to be mindful, says Watters, that even our best science is far from culturally neutral. Thus:

Offering the latest Western mental-health theories, treatments and categories in an attempt to ameliorate the psychological stress sparked by modernization and globalization is not a solution; it may be part of the problem.

Something to think about ...

The Hypomania Dilemma

I love reading Willa Goodfellow's blog, Prozac Monologues. Willa (pictured here) is smart, insightful, and like all good writers she poses questions rather than serving up easy answers. Case in point:

Willa's wife Helen was invited to a function at the home of Sally Mason, president of the University of Iowa. Willa got to tag along. As she explains it:

Helen likes to show me off, because I am good at parties, can talk with anybody, good social skills. And I am cute.

So far, so good.

Anticipating wine at the function, she decided to skip her afternoon Valium. Besides, she wanted to be mentally sharp. Later into the function, the host engaged Helen and Willa in a conversation. They were standing in front of a bookcase populated with books by Iowa Writers Workshop authors. The workshop is the pride and joy of the university.

In Willa's words, "That is when the evil twin appeared." Pointing to a Pulitzer book, "Gilead" by Marilynne Robinson, the evil twin let loose: "Boring. Boring, boring, boring."

Gracious host that she was, Dr Mason acknowledged it was a difficult book to read. Willa says she could have redeemed herself by offering that it was difficult for her, as well. After all, the book was about depressed small town Iowa clergy, and - guess what? - Willa had been one herself. All manner of fascinating conversation could have flowed.

But, no. Willa pointed to another book. As she reports: "This time I said, 'I hate this book ...'" Dr Mason moved on to other guests.

Willa observes that her psychiatrist would have a ready solution to her unwanted hypomania, namely to go on the meds she had been refusing. But there is a catch, as Willa relates:

Those meds would give me a flat affect, facial tics and forty pounds. Helen would have no reason to let me out of the house at all. I would no longer even be cute.

Willa cites a 2003 study by Pope and Scott that pointed to a clear discordance between psychiatrists and patients. The psychiatrists in the study thought that bipolars went off their meds because we "miss our highs." The patients who quit cited other reasons. In 2006, I heard Dr Scott talk about her study at the International Society of Bipolar Disorder conference in Edinburgh. When I included it as a PowerPoint slide in a grand rounds I gave two years later to clinicians at a hospital in Princeton, NJ I was greeted with stony cold frozen Kelvin grade silence.

It didn't help when the next thing out of my mouth was: "Get over it. When your patients complain to you about feeling like fat stupid zombie eunuchs on the meds you prescribe - and on the meds you overprescribe - they are not doing this to ruin your day."

In an ideal world, we could all be our smart, funny, insightful, and engaging selves without having to worry about causing a social embarrassment. Operating with a clear head is our most valuable asset, but there are risks, illness or no illness. I could opt for faux pas-free life, but at what cost? An existence devoid of laughter?

Psychiatrists tell us we need to stay on our meds, and for many of us that is very good advice. But that is the easy answer. Willa poses questions ...

Rethinking Psychiatry - Another Look at Paradigms

Yesterday, I re-ran an earlier blog post that talked about paradigms and how psychiatry is ripe for a new one. Thomas Kuhn (pictured here) literally owns the word paradigm. In his seminal 1962 book, The Structure of Scientific Revolutions, Kuhn points out that far from being an objective and dispassionate exercise, scientific research operates from existing conceptual frameworks until they are no longer sustainable.

Thus Ptolemy to Copernicus, Newton to Einstein, and so on. Almost inevitably, the old order is toppled by those outside the field or those just entering the field, who have little or no stake in the status quo.

In psychiatry, we have seen a similar transition from Freud to biological psychiatry. But that paradigm is being challenged by breakthrough discoveries in brain science and what could become "the new science of the mind," as put forward by 2000 Nobel Laureate Eric Kandel, who stated at a conference I attended:

A major need of psychiatry in the future is to put the psychotherapeutic arm of psychiatry on the same solid biological footing as the pharmacological aspect of psychiatry.

In January, after I posted my piece for the first time, Willa challenged the notion of psychopharmacology on a solid biological footing, noting that in medicine "the paradigms dictate the treatments." Unsuccessful treatments, she said, do not challenge the paradigm. "They simply are problems to be solved within the existing paradigm." Thus unacceptable side effects induce researchers to find new meds rather than lessening the reliance on meds.

Yesterday, in response to my second posting, Tony added that every FDA medication in essence carries the warning that says: "We have no idea how this stuff works, but it does... kinda, sorta a little better than a placebo..."

Obviously, we have a lot of frustrated and very well-informed patients challenging the biological psychiatry mindset in the form of the recovery movement. Had psychiatry come up with new meds that worked a lot better than the old ones, with practitioners smart enough to work with us, the current paradigm might be more secure right now.

Mark added another twist to this, of transpersonal psychiatry (that expands on Freud and Grof and others) vying for attention with the new brain science. In Mark's words:

My personal view is that the biological researchers are trapped by their paradigm to look only at the brain. They cannot conceive the possibility of mental disease having any other source than the physical matter of the brain itself. By their paradigm, they not only believe that but refuse to look at any other evidence which would point to the contrary.

He concludes: "The race is on. Let the best emerging paradigm win."

Mark's post really got me thinking. Are the various paradigms-in-waiting mutually exclusive? Or do we see a grand unified theory on the horizon? My bets are on the latter. Here's how I see it:

To my knowledge, every brain scientist is operating off a genes-environment paradigm, which takes into account both biology and how we respond to the world around us. In the old days, psychiatry distinguished between biological causes to mental illness (such as neurosyphilis) and what they saw maladaptive reactions to stress and interpersonal relations.

This harkens back to the old mind-brain distinction. Since we lacked the tools to see into the brain, the first DSM of 1952 classified depression and schizophrenia and bipolar and the like as "reactions" rooted in neurosis or psychosis or personality rather than biology.

Biological psychiatry tipped over that Freudian paradigm, but in the process lost track of the fact that there was a lot of validity to Freud and his followers. Our behaviors are indeed shaped by our environment and buried traumas. The catch was that the only known therapy of the day - psychoanalysis - did not work for serious mental illness. Thus a paradigm ripe for tipping.

The biological psychiatry paradigm naively assumed we could simply find something wrong in the brain and fix it, with no regard to environment, without being able to pinpoint cause and effect. Thus an antidepressant for depression, a mood stabilizer for bipolar, and so on. The catch was that even magic bullets are problematic if someone has to contend with an abusive relationship or a toxic work situation.

The new brain science has broken down the mind-brain distinction. We now know that some of us inherit vulnerable brains that are prone to breaking down under stress, which in turn manifests as various forms of illness episodes and maladaptive behaviors. Those with more resilient genes are far more likely to take stress in stride. This new brain science validates the "diathesis-stress" hypothesis advanced during the seventies.

These discoveries cut across all psychiatric diagnoses and blur the categorical distinctions, spurring researchers to dig deeper into underlying causes (endophenotype) rather than the outer symptoms of phenotype. This demands a new approach to diagnostic psychiatry, which is more likely to come from outside the field rather than from within.

The new brain science has also revealed that the brain is plastic, capable of reshaping itself. In essence, the brain is software rather than hardware, and we can change the software to make us more resilient and better able to adapt to whatever life may throw our way. It also works the other way - that sustained stress and trauma can change our software for the worse.

Likewise, we can change our environment. If we know, for instance, that we have a genetic predisposition to alcoholism, we learn to avoid situations that put us at risk.

We now have a new model of the brain interacting with the environment and vice-versa, each capable of change, each capable of changing the other. Thus we see the beginnings of a grand unified theory waiting for the next Einstein, where Freud and biological psychiatry are reconciled, along with ancient precepts. Mind and brain are one, leading to new insights into behavioral causes and effects and possible treatments and therapies and self-help tools. This is already well underway.

Those operating within the current paradigm, who simply expect brain science to validate biological psychiatry can be regarded as intellectual dinosaurs. Their days are numbered, but they won't go down without a fight. Some form of Kandel's new science of the mind will emerge and maybe it will no longer be called psychiatry.

But this new paradigm, like all paradigms, will only be a temporary placeholder, awaiting a newer paradigm to unseat it, such is the nature of scientific discovery. Absolute truth will always elude us. The best we can do is proceed on the facts as we know them, with an assist from inspired speculation. This will yield us the best approximation of reality. That is, until a better one comes along.