A humanistic paradigm for mental illness

Mental illnesses are much more than biological, physiological phenomena. Any attempt to reduce them down to the same features as other illnesses such as fever or cancer is inherently flawed. Genome-wide association studies (GWAS, pronounced “gee wahs”), attempts to scan individuals for thousands of genes to determine which variations lead to traits we can observe, have shown little substance for the past few decades. GWAS supporters argue that, if we find these genetic variations (single nucleotide polymorphisms (SNPs, pronounced “snips”) more frequently among those with a certain genetic trait (or a phenotype, an observable characteristic), the SNPs must be related to them somehow. GWAS studies themselves have already shown little correlation and similarity between one another, and, instead, many GWAS studies under the same conditions have returned significantly different results. Contemporary scholars such as Robert Plomin, in his book Blueprint: How DNA Makes Us Who We Are, have argued GWAS is a form of a “polygenic score” which can predict disorders. But these methods of de-humanizing mental illness and psychiatry into strict, science-exclusive disciplines have not shown the results they have claimed they will produce. Psychiatry as a field needs to return to its roots through philosophy and humanized notions of disease. Through thought-provoking questions and discussions on the nature of mental illness as it relates to the unconscious, debates between Freudians and Jungians on how to understand experience, and the resistance to pharmaceutical-lead pressures from industry to turn mental health into a for-profit system, we need a new humanized paradigm for psychiatry.

Psychiatry has dealt severe blows to Aristotle’s notion of man as inherently rational and, instead, embraced the idea that much of who we are is determined by genetics and other biological factors. The simplistic, reductionist view of mental illness as purely a genetic disorder has left psychiatry in the doldrums of intellectual activity and only furthered the stigma of mental illness itself. Regardless of these negative consequences, however, the differences between the science of the mind and that of the body are enough to present issues with this view in principle. The mind and body have different languages, different concepts (with differing levels of abstraction and complexity), and different sets of tools and techniques we use to study them. Psychological and physiological study of a patient in a state of anxiety might result in two separate and distinct sets of descriptive data, measurements, and formulations. There is no way to unify the two by translation into a common language or conceptual framework. We rely on analogy and comparison using abstract concepts of “disease,” instead. From a computational perspective, our psychophysiological and psychosomatic data consist in essence of covariance data, demonstrating coincidence of events occurring in the two realms within specified time intervals at a frequency beyond chance.

Arguing mental illnesses are just like body illnesses causes us to view those suffering from mental health issues as fundamentally flawed or different from other people. It leaves those suffering in fatalistic, defeatist views and, in many cases, even a cynical, disillusioned state of mind. In the most extreme case, they may even lead to eugenics-based arguments that throw ethics under the bus for the pursuit of scientific perfection. The body-based view of mental illness has let psychiatrists, researchers, and other industry professionals ignore much of what makes mental illnesses what they are. Depression becomes simply a lack of serotonin that Prozac will alleviate, and other illnesses only need patients to take medicine without much else. It’s easy to see how these disease models can be abused for industry-related motives to maximize profit under the veil of minimizing human suffering.

Instead, we need to view mental illness through dynamic, human-based issues everyone faces about who we are as human beings. We can, then, treat individuals from existential points of view in their methods of valuing life and finding a purpose in the world. Those entering psychiatry with backgrounds in mathematics, economics, and biology need to understand the etiology of disease, metaphysics of psychology, logic of diagnosis, and causal assumptions underlying epidemiology. They need the patience and reflective abilities to discover what the human mind undergoes when suffering from mental health issues far beyond what sort of gene may be responsible for depression or schizophrenia. Even the causal models GWAS purportedly infers need to be scrutinized for their epistemic limits before being put into practice. Since their inception, GWAS studies have put forward hundreds of genes responsible for different phenotypes, and, despite the wide availability of data and the large of amount of data to begin with, these GWAS studies haven’t had much more success than the genetics studies before them. Instead, scientists argue that, because they haven’t found correlations, the causes must be more complicated and composed of more and more genetic phenomena. They’ve yet to uncover specific mechanisms or causal relationships for disease, and rely on reductionist approaches that genes that are significantly expressed must cause the phenotypes themselves. Neuroscientist Kevin Mitchell summed it up: “Simply put, nothing really definitive comes out. In fact, the strongest result from these studies is a general one, and it is ‘negative’: there are no convergent patterns of gene expression in adult brain that characterise these various psychiatric conditions.” in his blog post “If genomics is the answer, what’s the question? A commentary on PsychENCODE.”

Psychiatry needs a deeper understanding of the etiology of disease. As Freud wrote in Mourning and Melancholia, psychopathology has two etiological components: constitutional (including genetic) predispositions and early experiential factors. He used this multifaceted dynamic view of psychiatric illness to demonstrate the role environmental factors and traumatic events play in the causation of posttraumatic stress disorder (PTSD), especially ones early on in life. Much the same way Johann Sebastian Bach was Bach not because he simply had the appropriate genes, but through his study of music at such a young age, the brain forms through these combinations of genetics and experience. Studies such as those by psychiatrists Charles Nemeroff and Paul Plotsky have verified depressed patients release more corticotropin-releasing factors (CRFs) in their central nervous system in mammals. Memories themselves form and evolve through the prefrontal cortex as it integrates sensory information and links this information to planned movement. Research in neuroscience has revealed the prefrontal cortex is part of a short-term holding function for information, including information stored in declarative memory. Neuroscientists Joaquin Fuster and Patricia Goldman suggested the prefrontal cortex represents some aspects of working memory in recalling from preconscious to conscious. It plays essential roles in speaking, driving, weighing ethical decisions, or performing mathematical calculations. This suggests it may be involved in coordinating functions that psychoanalysis experts claim function between ego and superego. This holds promising results for the benefits of psychoanalytic therapy. The extent to which psychoanalysis may bring about changes in habits, attitudes, and conscious and unconscious behavior through differences in gene expression that produce neurophysiological changes relies on this connection between biology and psychoanalysis. Brain imaging techniques may, then, improve these techniques for neurotic illnesses through psychotherapy. Neuroscientist Eric Kandel has further argued the need for a dialogue between biology and psychoanalysis towards these goals.

Such a dialogue should address how biology and psychoanalysis have drifted apart from one another over the 20th century. Both fields have faced a mix of strides and setbacks over this time period. Advances in bacteriology would lead biologists to believe toxins in the intestine, mouth, and sinuses harm brain functions. While it may have seemed controversial at the time, recent microbial work has suggested possible that bacterial imbalance alters the body’s metabolism of dopamine and other molecules that may contribute to depression. Similarly, the theory bacteria causes peptic ulcers proposed in 1983 was met with widespread contempt, but, as experimental evidence has since shown it true, antibiotics are now regularly used to ulcers. Meanwhile, the twisted practice of the transorbital lobotomy spread across the United States in the 1940s. It was only until the 1970s it was banned in most countries, after psychiatrists raised concerns of its safety, ethics, and effectiveness. Psychiatry itself faced challenges to its legitimacy given its stance of homosexuality as a mental illness until the 1970s as well as the reformation of mental hospitals from what scientists compared to concentration camps. Psychiatrist Aaron Beck proposed the effectiveness of cognitive behavioral techniques in treating psychiatric disorders with a 1977 study showing cognitive-behavioral therapy (CBT) outperforming one of the leading antidepressants of the time. Researchers would further show the neurophysiological basis for CBT, suggesting the more we discover about the brain the easier it will be to disregard the apparent divide between mind and body. CBT has faced criticism, though, with its supposed effectiveness and its own theory that don’t appropriately account for agency, free will, and rationality. These chaotic, turbulent histories of both fields make a dialogue between them difficult, but possible and necessary to address the issues they face.

Psychoanalysts themselves have raised arguments for and against a reductionist biology of mind. Psychiatrist and author Marshall Edelson wrote in Hypothesis and Evidence in Psychoanalysis, “Efforts to tie psychoanalytic theory to a neurobiological foundation, or to mix hypotheses about mind and hypotheses about brain in one theory, should be resisted as expressions of logical confusion. Efforts to tie psychoanalytic theory to a neurobiological foundation, or to mix hypotheses about mind and hypotheses about brain in one theory, should be resisted as expressions of logical confusion.” Others believe there’s fertile room for cultivating psychoanalysis in the context of the science of the mind. French biologist François Jacob wrote in 1998, “The century that is ending has been preoccupied with nucleic acids and proteins. The next one will concentrate on memory and desire. Will it be able to answer the questions they pose?” in Of Flies, Mice, and Men. Kandel also believes future research on the mind will focus on memory and desire through a combination of biology and psychoanalysis with greater scientific understandings of the unconscious. Kandel has argued that research in biology will make strides in the genetic basis for the unconscious mental processes and their roles in psychopathology in solidarity with psychoanalysis.

Psychiatry needs philosophy. Researchers in the field need to draw from Plato, Freud, Jung, Adler, and many other thinkers who have put forward ideas on what it means to be human given the constrains of the human mind. When Freud laid the foundations of psychoanalysis, one may have argued that his ideas paralleled Plato’s. He adopted Plato’s theory of dreams and similar ideas of the tripartite human soul. Freud’s idea of unconscious also bears similarity to Aquinas’ who believed human acts come through reason, yet still have unconscious desires and habits. Freud contrasted Jung on the meaning of sex as the former believed it was the cause of all human desire and the latter had his doubts about that idea. Freud contested Adler’s ideas of the social realm of equal importance to the individual and that role of sole interest individuals have in advancing social welfare. Though these theories have met a combination of arguments for and against them in many different contexts over the past century, their relevance remains. Kandel has argued that we should not get stuck on Freud to idolize or denigrate him. While many of Freud’s ideas have been rejected as pseudoscientific or sexist, many elements of psychoanalysis remain in psychiatry and psychology. Psychiatric literature and psychoanalysis themselves need Nietzsche, Proust, Schopenhauer, Kant, and Descartes to put them in an appropriate context.

These issues of psychiatry have formed the foundation for many of society’s issues. We’ve created an individualistic view that our psychological shortcomings are solely due to biological deficiencies as though we were computers that simply haven’t been programmed the right way. The same way culture fashions us to understand aesthetics, value, ethics, and other humanistic qualities, our struggles with mental illness are better explained in the way our bodies understand the world. In this sense, our mental health is the way we search for meaning and satisfaction in the world. As such we need a humanized notion of mental illness.

Originally published at https://hussainather.com on May 24, 2019.