Category Archives: Biological Model

Stigma, The Brain And Brain Illnesses

By Dr David Laing Dawson

Every day the news contains at least one item describing our struggle to understand a difficult or troublesome or tragic human behaviour. As I write this there is an ongoing trial of a man accused of killing, dismembering, and then burning a Calgary man and woman and their grandson who happened to be on a sleep over with his grandparents. It is reported that the accused held a grudge against this grandfather because of a failed business arrangement years ago. The grudge “grew in his mind” until….

Then I read of a woman who committed suicide two months after the birth of a child. The grieving husband wants to shed light on post-partum depression but the emphasis in the article was about trying to alleviate the shame some women feel because they cannot breast feed.

This is the article that stuck in my mind because it emphasized the problem of stigma, the need for awareness, and the “let’s talk about it” approach to “mental health”. All well and good. But it continued the trend of trying to understand these tragic behaviours as the consequence of some kind of rational, all-be-it extreme, thought processes.

I understand this. When confronted by any odd human behaviour we try to “understand” it by applying two mechanisms: a logical sequence of cause and effect and empathy (how would I behave in similar circumstances?).

We live our lives believing in the supremacy of mind; we organize socially and act independently within an assumption of “mind”, of “free will”, of “choice” and consequences and personal responsibility. We are very reluctant to accept the fact that the brain can hijack this process, that the brain is the primary organ dictating human behaviour, that the brain, this biological computer system of cells and neurohomones and fragile connections, can go wrong. This reluctance has extreme advocates such as Bonnie Burstow who thinks…. or who’s brain leads her to think…

Actually I have no idea what she really thinks and why she thinks  it.

But phrases like “mental health issues”, euphemisms for mental illness, and much anti-stigma publicity continue to support the primacy of mind and downplay the role of brain. They continue to support the notion that all troubles, with a little support, acceptance and understanding, can get better, be overcome.

This does a tremendous disservice to those who suffer from true, serious mental illness.

From her culture, her family, and perhaps from all the current pop cultural emphasis on breast feeding, the new mother in question probably felt some degree of disappointment that she could not breast feed. But this was not an experience that propelled her, through a logical sequence of thought processes, to suicide.

No. Serious postpartum depression, and postpartum psychosis is as clearly as any serious mental illness, a brain problem. The brain has hijacked the thinking process. It is no longer rational. This is a brain illness.

Prevention of the tragic consequences of this illness requires knowing which women who have given birth are at risk, screening for and identifying this illness, recognizing it as a brain illness, and treating it vigorously as one would treat any serious and life-threatening illness.

Sure, let’s talk about it and de-stigmatize it, but we also need to recognize that it is an illness, a brain illness, and offer, make available, medical/psychiatric treatment, and occasionally protect by holding the sufferer in a safe environment while waiting for treatment to take effect.

And, contrary to what Bonnie Burstow and the anti-psychiatry people say, we now have effective treatment for depression and psychosis.

Understanding the Disease Model

By Dr David Laing Dawson

I had a friendly argument with a colleague the other day. He reminded me that we had been arguing about this topic for 40 years. I think our arguments are mostly ways of clarifying our own thoughts about a very complicated question involving concepts of mind, of cognition, and of the brain, that organ who’s function makes us human.

Mental illness, disease, disorder, serious mental illness, continuum, spectrum, problem, affliction – when is it both valid and useful to consider aberrations (or non-typical) variations in behaviour and thought, illnesses? In some ways these words are just words, and few would care if we referred to arthritis in any of these terms. But when it comes to behavior, thought, and communication (rather than joint flexibility and joint pain) our dearly held beliefs about self, autonomy, will, power, consciousness, and mortality come into play. The discussion becomes political.

Before the medical disease concept evolved in the 18th and 19th century most afflictions were considered very personal and specific, and the causes very personal and specific. An obvious grouping of afflictions might mean God was particularly disappointed in a whole family or tribe. The Miasmists thought that perhaps God did not have that much control over everything and proposed that the causes might be found in the atmosphere, the miasma, physical, spiritual, emotional. An excess or a deficit. The Naturopaths liked this idea but knowing nothing of physiology, metabolism, or nutrition, concocted potions and powders with dozens of ingredients positing that the body might choose from the lot that which it needed. Each of these ideas continues to echo in the pursuit of health today. Especially in the commercial exploitation of our pursuit of health.

The disease model is founded on the idea that if a number of people suffer the same symptoms and signs, and if their affliction follows the same course with the same outcome then perhaps these people suffer from the same “thing”. This in turn raises the possibility that the cause is the same in all cases and that a treatment that works for one will work for the others. To study this we need to name (diagnose) the thing and describe it’s symptoms, signs, and natural course. Given that we are biological beings it is reasonable to think that some of the signs of these diseases will be biological, and that the causes might be as well. But first the chore is to observe, study, collate, find groupings and test this hypothesis.

In a sense the disease model has picked off all the low hanging fruit, those illnesses with very specific causes and courses and, of course, those for which we have found specific treatments, cures and prevention.

The disease model, and some rudimentary epidemiology, led Dr. John Snow to the source of an outbreak of cholera and then to speculate that the cause, residing in the water supply, “behaved as if it were a living organism”. This before we knew about bacteria, let alone viruses, prions, DNA, and neurohomones.

The same disease model has led to the near eradication of Polio. Drs. Alzheimer and Kraeplin applied the disease model to older people with failing cognitive processes and singled out an illness we now call Alzheimers. Dr. Alzheimer had the advantage of being able to examine the brains of his patients soon after diagnosis. Dr. Kraeplin went on to apply the disease model to a younger group of patients with peculiar cognitive difficulties, some similar to dementia, some not, and singled out a group he called dementia praecox, and another group he called manic depressive. Similarly and more recently the disease model singled out autism from the broader group of mentally handicapped children.

The disease model also allows us to study afflictions and find remedies before, sometimes long before we establish with certainty the causes of the affliction. Who on earth but a cruel idealogue would want us to stop treating and reducing suffering until we find an exact and specific cause of the affliction in question, be it cancer, arthritis, or schizophrenia. Yet that is the cant of the anti-psychiatry folks.

Yet the disease model allows us, sometimes by accident, to find remedies that work, can be proven to work, before we nail down etiology. Now, as mentioned earlier, the disease model has picked off the low hanging fruit, those afflictions caused by single alien organisms, and very specific genetic aberrations. We are left with those that are undoubtedly the product of complex combinations of genetic vulnerability, epigenetic influences in the womb, environmental influences, developmental timing, excesses, and deficits.

But we should no more give up on the disease model for schizophrenia and depression than for heart disease, cancer, arthritis, ALS, and dementia.

Our argument was actually about OCD. Having some Obsessive and Compulsive traits can be an asset of course, and of great help in medical school, while extreme OC traits can be debilitating. The “D” of OCD is the initial for “disorder” of course, but is OCD, in annoying to debilitating form, a disease?

Unfortunately the word “disease” has become freighted with negative association, and for my friend, too much associated with “biological cause”.

Ultimately he may think of OCD as a mind problem, while I may think of it as a mind/brain problem, but it is the discipline of the medical disease concept that allows us to study it and find remedies we can test.

Psychiatry, Eugenics and Mad In America Scare Tactics – Part I

By Marvin Ross

Much of what I read on the Robert Whitaker website, Mad in America, stretches logic but this newest blog has to be one of the biggest stretches I’ve seen. Dr Robert Berezin, a US psychiatrist, warns that psychiatry is moving closer and closer to eugenics.

As defined by dictionary.com “eugenics is a word that made everyone at the event uncomfortable. … The very subject evokes dark visions of forced sterilization and the eugenics horrors of the early 20th century. … The study of hereditary improvement of the human race by controlled selective breeding.”

The most famous proponent of eugenics was Adolph Hitler who wanted a pure Aryan race but the subject has been advocated by many in recent history in an attempt to eradicate debilitating diseases. In fact, one could say that the reason for amniocentesis is to do just that. Sampling of the amniotic fluid of pregnant women can predict such things as Down’s Syndrome. And some parents will opt for abortion if Down’s is found but many do not.

Amniocentesis can also predict such genetic conditions as Tay Sachs Disease where the infant usually only lasts to about age 4. But, nowhere in the article by Dr Berezin does he actually show that modern psychiatry is planning to eliminate anyone who suffers from schizophrenia or any other psychiatric disorder.

What he talks about is the fact that genetics is being employed to try to understand these conditions better. He states that:

The accepted (and dangerous) belief is that psychiatry deals with brain diseases – inherited brain diseases. We are back to absolute genetic determinism. Today’s extremely bad science is employed to validate not only the idea that schizophrenia and manic-depression are genetic brain diseases, but that depression, anxiety, phobias, psychopathy, and alcoholism are caused by bad genes

I have no idea why he considers the genetic research to be bad science other than he does not agree with it. So what if he doesn’t. He does state that “The temperamental digestion of trauma into our personalities is the source of psychiatric conditions.” But, as Dr David Laing Dawson has written on this blog:

Childhood deprivation and childhood trauma, severe and real trauma, can lead to a lifetime of struggle, failure, depression, dysthymia, emotional pain, addictions, alcoholism, fear, emotional dysregulation, failed relationships, an increase in suicide risk, and sometimes a purpose, a mission in life to help others. But not a persistent psychotic illness. On the other hand teenagers developing schizophrenia apart from a protective family are vulnerable, vulnerable to predators and bullies. So we often find a small association between schizophrenia and trauma, but not a causative relationship.

Dr Berezin’s concern does not come from anything that anyone has said about aborting fetuses that genetic testing proves will be born with schizophrenia or bipolar disorder or any serious psychiatric condition. And the reason for that is that genetics and the understanding of the causes of these diseases is nowhere near a point that this can be demonstrated with 100% accuracy. Science is a long way from getting to that point if it ever is able to.

Suggesting that these research avenues will lead to abortion, eugenics or something similar is absurd and nothing but scare tactics perpetrated by someone who does not agree with the causation theories being investigated. If these avenues lead nowhere and it is discovered that science has been on the wrong path, then science will self correct. Attempting to generate unfounded fear is counterproductive.

Next Part II by Dr David Laing Dawson

On Models, Concepts, Power, and Politics – Part II

By Dr David Laing Dawson

We are all guilty of using language badly, without clarity of definition. We talk of concepts as if they are physical entities. Words that denote complex relationships, even systems of abstract thought, can become epithets, mindless accusations. Over time some words we use take on meaning quite opposite to their original meaning. Usually, behind every shift in meaning lies the politics of power and ingrained attitudes.

What are we talking about when we use terms like medical model, disease model, biological model, bio-psycho-social model, holistic model?

Maybe that is not the real question. Because often when people use those terms they are really expressing attitudes and power positions, or railing against someone else’s attitude and power position.

So instead I will ask the question, what do these terms in their original form and intent mean?

Let’s take the “medical model”. This really speaks of the relationship between doctor/healer and patient/sufferer. It has been pointed out that this particular social contract predates the disease model by many centuries, and that in most or all cultures someone is assigned, earns and accepts the role of “doctor/healer/shaman”. It speaks of a set of guidelines, expectations regarding this relationship, a set of responsibilities and privileges assigned to each (doctor and patient) within the unspoken but generally well known and accepted contract. It is the contract you want your doctor to fulfill when you go to her as a patient with chest pain or a psychotic family member. The doctor’s side of the contract is succinctly explained in the Hippocratic oath, though all the nuances of this contract could fill a large book.

We know that for chronic illness the medical model requires adjustment: the doctor takes a little less responsibility, the patient more, and allied health professionals, and family members share the burden and some of the responsibility.

We also know that for some situations the same medical model that works so well for acute illness can be dangerous when applied to something like addictions. For when the doctor reaches for her prescription pad, she is fulfilling her social contract with this patient to do her “utmost to relieve suffering” – but simple relief of suffering may not bode well for an addict, no matter how much he or she is demanding it.

Physicians in this part of the world have adopted the “disease model”, a scientific and systematic approach to their patient’s illnesses. It is a model, as described before, that implies cause and effect, determined by evidence and science, and an attempt to alter or correct the primary or necessary cause of the distress (e.g. bacteria) and to alleviate symptoms and suffering by understanding their pathogenesis, their mechanisms. This is not all biological in nature: the prescription of antibiotics to kill the germs (biology, reductionistic), the prescription of aspirin to quell the fever (symptom relief from evidence and understanding the mechanism of fever), the advice of bed rest and fluids (holistic health) and the letter excusing someone from work for a few days (definitely a social intervention), to say nothing of reassurance and explanation (cognitive/psychological intervention).

Those who rail against the “medical model” are almost always railing against not the concepts or methodologies of modern medicine but about the status and power of the doctor.

A biological model is reductionistic. It is a focus on biological impairments, mechanisms and pathways that lead to symptoms and distress.

The bio-psycho-social model (which has been called the three legged stool) attempts to add and understand the influences of cognition/emotion and social environment to the problem at hand.

Fair enough, but in practice we want to find, if it exists, the necessary cause of the distress, the illness, the disease. This could be biological. It could be a bad marriage. The bio-psycho-social model reminds us of this, and that all spheres may be playing a role.

Though in truth I would like it to be renamed the bio-socio-psychological model, because it seems clear to me, in my amateur studies of ethnology, evolution, societies, social groups, and human behaviour, that we are primarily biological beings, driven by instinct and biological mechanisms, that secondarily we are social beings, our behaviours and thoughts modified by the social imperatives of our cultures, societies, families, and only lastly are we psychological beings, with our behaviour, to some small extent, driven by thought, reasoning, logic, compassion, understanding. Usually our thoughts are used to simply rationalize or justify those behaviours driven by biology and social imperatives.

A Comment on “Me, My Mind and Baked Beans” & “The Holocaust Intrudes…”

stone of madness     By Dr David Laing Dawson

There is no doubt we need to be careful and cautious with labels. And comparing The Holocaust (as Peter Kinderman did) to anything other than another systematic and extensive act of genocide trivializes the former and reduces whatever criticism was intended of the target to a nasty school yard epithet. It is just plain thoughtless, stupid, and insensitive – as James Coyne pointed out.

But the concept of disease is just that, a concept. The word itself is a conjunction of “dis” and “ease”. The modern concept of disease has a two or three hundred-year history. And it is, after all, the very concept that allowed us to eradicate – well, almost eradicate – measles, mumps, polio, diphtheria, cholera, to treat some cancers, heart disease, pneumonia, and to improve the lives of those suffering from the conditions of bipolar disorder, depression, and schizophrenia.

We have philosophical and scientific approaches to the concept of disease, and folk definitions. These may invoke evolution, constructivism, objectivism, adaptation, and concepts of “abnormal” and “normal”. And “normal” itself, can entail ideas of function, value, ideals, averages, and adaptation, as well as bell curves, actuarial tables, standard deviations.

The concept of disease does also imply a biological insult, difference, or malfunction of some sort, from its history of scientifically seeking cause and effect and the linkages between them, of leaving older explanatory concepts of magic, karma, miasma, destiny, god, evil, the devil and possession behind, to say nothing of the wholly unfounded notion that a “refrigerator mother” can cause autism or psychosis in her child.

We do have a recent history of overusing the disease concept in our modern world, of allowing flawed ideals and values (and commerce) to inform some of our definitions. But, in truth, it was not the overreaching concept of disease that caused damage, but the laws of the time that allowed abuse to follow. And the abuse, as is usually the case, was of power, not of semantics.

Today, on one side of the coin, we have the advocates for addictions and alcoholism petitioning for those afflictions to be called diseases, and on the other side, certain U.K. psychologists  asking that all mental disorders be removed from under the rubric of disease. The former, I’m sure, because the concept of disease does absolve one of some moral responsibility for his or her behaviour, and the latter, I’m sure, because the concept of disease requires a physician to head the team of professional helpers.

But let us bring this down to basics:

We perceive someone to be “badly off.” He may or may not perceive himself to be badly off. We then ask ourselves if the disease concept will be of benefit in this situation. Does the idea of “illness” fit? Is he suffering? Is he causing others to suffer? Folk definitions may be applied at this point: “Call the cops.” “He needs a doctor.” “He seems to be okay, he’s not bothering anybody.” “He needs his medications adjusted.” “He’s just a little eccentric.” “That’s just Joe being Joe.” Or even that contradictory but common conclusion, “What a sick bastard.”

This person is brought to or finds his way to a medical professional. The medical professional asks herself similar questions: “Is he badly off?” “Does he perceive himself to be badly off?” “Is he suffering?” “Is he causing others to suffer?” And, then, “Does the concept of disease offer any help in this situation?”

And there is absolutely no doubt (how could there be any doubt today?), that for those behaviours and experiences, those symptoms and signs and suffering that constitute severe mental and emotional disorders, that fulfill the definitions of schizophrenia, bipolar disorder, severe anxiety disorder, severe depression, the answer is YES, ABSOLUTELY.

And that ‘yes’ encompasses treatment today, and research tomorrow.

 

The Psychiatric Interview and the Biology of Mental Illness

By David Laing Dawson MD

I am tired of the mind/body argument, the dichotomy. I am tired of hearing about “new” models, theories, and psychotherapy processes, new gimmicks. I am as tired of the overreaching DSM IV and V as I am of  mental illness denial.

Here is what a psychiatrist actually does, or at least what I do:

I read whatever information is given to me about the patient I am about to see. From this I am already formulating some lines of inquiry, some hypotheses to be considered. The one certainty at this moment is that I am seeing these people because they have a problem and they want help.

As my patient or family enters I am watching them, how they interact, how they sit, walk, speak, what their eyes are telling me. I say or do something to break the ice, from the weather to the news to the book the eleven year-old is clutching or the new Blackberry his mother is putting back in her purse, or the pink Samsung the teenager is holding as if it were a lifeline to planet Earth.

And then I ask questions and listen and watch. The questions are not random but neither are they detached from the reality in the room. Some are derived from science and experience, some from high and low culture; some are designed to ease my patient’s or family’s journey to full disclosure of the whole story. And right from the beginning and throughout this process I am asking myself if I should be thinking of this, this problem unfolding, as an illness, an illness derived from its biological origins, or as a psychological reaction to something, as a parenting or family problem, even sometimes as a broader social problem, a misfit of school and child, as a serious harbinger of a life long deficit, or merely a developmental stage, a passing thing, and even if it might really be no problem at all, just a bump in the messiness of life. And always, how much is this present realty, this “talking to a psychiatrist”, impacting the story I am hearing?

Sometimes I know the answer to these questions by the end of the appointment. Sometimes I know that I will not know the full answer for a month or a year or two. Sometimes I fear I will never know.

But, far more importantly, I am also asking myself these questions: Is someone suffering? How badly is he or she suffering? Do I (we) have the means to alleviate this suffering? And my choice of the means to alleviate this suffering will depend on the patient and her family’s feelings, thoughts, convictions as much as my own interpretations and conclusions. And of course, that prime directive, “Do no harm.”

But, if you have sat on a mattress beside a young man in a full-blown schizophrenic psychosis, or paced the corridors with a manic librarian, or sat for any length of time with a woman in a state of agitated depression, or debilitating obsessions, you will know that a.) There is a lot of suffering here, and b.) These are brain things, biological illnesses.

It is not an uncomplicated matter. The  modern concept of disease has only been with us a hundred and fifty years or so. And this very concept, this idea of disease, could well be the reason you are alive reading this now, and did not die from diphtheria, pertussis, polio, perhaps cancer – or be more crippled than you are with arthritis. It is also the concept that has allowed us to successfully treat severe depression, mania, psychosis.

I am sure some of my colleagues over-use the illness/disease concept when trying to understand a perplexing behaviour. And some I know under-utilize it.  I’m sure I get it wrong sometimes. And many non-physician mental health workers simply apply the feel-good concept of the month, or bypass any attempt to understand the problem, it’s roots and pathways, and focus instead on strengths and goals and those things that we all know contribute to a healthier life.

Fair enough. But instead of arguing about concepts of illness/disease/mind/brain/body, we should focus on relief of suffering, and helping someone return to a level of functioning he or she desires, and we should use all the tools in our tool box to accomplish this, providing we have evidence they actually work.

 

 

Mental Illness Literacy

By Marvin Ross

In a recent Huffington Post blog, Susan Inman (After Her Brain Broke: Helping My Daughter Recover Her Sanity), wrote about the need for greater literacy about mental illness. And, like me, Susan often gets inundated with comments from opponents. One was from John Read, a psychologist at the University of Melbourne.

Susan was arguing that we need greater understanding of the biological causes of serious mental illness and I agree. Read, however, commented that:

“The evidence is over 50 studies all showing that biological beliefs increase fear and stigma. I’m afraid you are swallowing drug company propaganda, there is no evidence that these drugs prevent violence.”

When challenged to provide sources, he countered with:

“If anyone is interested in what the reserch (sic) says on this issue……

READ, J. (2007). Why promulgating biological ideology increases prejudice against people labeled ‘schizophrenic’. Australian Psychologist, 42, 118-128.

READ, J., HASLAM, N., SAYCE, L., DAVIES, E. (2006).Prejudice and schizophrenia: A review of the ‘Mental illness is an Illness like any other’ approach. Acta Psychiatrica Scandinavica,114, 303-318.”

In an article  that I wrote for the World Fellowship for Schizophrenia and Allied Disorders in 2010, I mentioned the Read approach. Basically that approach states that we should ignore the illness in favour of viewing mental health problems as part of our shared humanity. One of the research papers by Read that I commented on was a 2002 paper which compared the biological explanation of mental illness to a psychosocial explanation. And while Read points out that the psychosocial explanation helped reduce stigma more that the biological, he admits there was no statistical difference between the two.

This is the link to his first article that he cited in his comments to Ms Inman. You can decide but note the lack of objectivity in his title. Biological explanations are cited as ideology that are promulgated and schizophrenia is in quotes. The second paper he cited deals mostly with surveys  asking people what they considered to be the causes of mental illness. Many of them believed that the causes were psychosocial which just proves that Susan Inman is correct in wanting to see greater literacy.

But again, to prove his point, he says that a study that showed a video of a person describing their psychotic experiences increased perceptions of dangerousness and unpredictability in viewers. However, a video explaining the same experiences in terms of adverse life events, led to a slight but non significant improvement in attitudes by those who viewed it.

Again with the non significance. It means there was no difference between the two. The responses were the exact same! Someone who acts scary and displays very abnormal and aberrant behaviour is going to be shunned regardless of the explanation for that behaviour. He does cite a number of papers but they date from 1955 to the latest in 2005.

In my 2010 article, I quoted Dr Heather Stuart, an expert in stigma at Queens University in Kingston, Ontario who said that there have only been six controlled studies of stigma. One of them by Patrick Corrigan found that education did lead to improved attitudes. I could not find a reference to that paper in the one by Read.

As an example, those with advanced symptoms of Hansen’s Disease looked very frightening and were isolated from society. The Leper Colonies existed because no one understood the disease and were afraid they might get it too. But then, modern medicine came along, discovered Leprosy was caused by a bacteria, learned to treat it early and we no longer have people disfigured when treated early. We might still cringe at the thought of leprosy but likely no one has ever seen an advanced case.

In a similar vein, the solution for schizophrenia stigma is not to pretend it isn’t what it is but to provide treatment. As Queen’s University psychiatrist Julio Arboleda-Flores said in his 2003 editorial in the Canadian Journal of Psychiatry, “the best approach is to limit the possibilities for people to become violent via proper and timely treatment and management of their symptoms and preventing social situations that might lead to contextual violence;” he writes that “this could be the single most important way to combat stigma.”

And one way to ensure that is to have greater mental illness literacy as Susan suggested.

Now I also have to comment on a post to Susan’s blog by someone who is continually criticizing both Susan and I for our writing on the medical model for schizophrenia. Suzanne Beachy did post a number of comments which you can see for yourself but my favourite is her announcement that another critic of the medical model, Rossa Forbes, has just announced that her son is cured of his schizophrenia.

It seems that his cure was delayed by their being “sidetracked by institutional psychiatry perpetrating the false belief that there was something gone horribly wrong with his brain and only they knew the magic formula to set things right again.” If you go to Ms Forbes blog, you will see her extolling how well her son now is which is wonderful. In fact, she says, he is so well that he has reduced his Abilify to half its dose and is planning to go completely off slowly over time. Abilify, of course, is an anti-psychotic used to treat schizophrenia and is prescribed by psychiatrists.

I am dumbstruck as I am with all the critics of modern science.