A mini-rebellion broke out last summer in psychiatry, perhaps the most disputatious of all medical disciplines. The current rebels are demanding changes in the official handbook -- the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, known as DSM-IV, which lists the conditions that the association designates as disorders (and that health-insurance companies will pay psychiatrists for treating). The rebels want to add to that list a category called relational disorders, which would encompass the emotional and behavioral distress that can emerge through misunderstanding between such partners as husband and wife, or parent and child.
The psychiatric association rejects the rebels’ proposal, arguing that contemporary psychiatry views mental illnesses as linked to brain disorders in the same way that other medical specialties, like cardiology, link the conditions they study to disorders in bodily organs. Relational disorders defy that medical model, because only an individual, not a relationship, can have a sick brain.
But the idea that the only real psychiatric disorders are those tied to brain defects -- an idea sometimes expressed by the slogan “for every twisted thought, its twisted neuron” -- is incoherent in both philosophy and application.
First, the philosophy: Of course, nothing happens in mental life without brains. The brain is the source of our thinking, including our hopes, our fears, our ups, our downs. Everything that could be considered psychological -- both normal and abnormal -- is produced by the neurobiological capacities of the brain. But the conclusion that every mental disorder derives from brain disorder oversimplifies a profound matter.
All consciousness comes from the brain, but consciousness interacts with the brain that generates it in a special, as yet inexplicable, way. The conscious mind gives a personal, privately sensed direction to the brain’s activity. Although how subjective thought can direct the objective activity of the brain puzzles scientists, the implication is that some mental disorders derive from brain deficits and others from personal thoughts and decisions.
More specifically, the conscious mind is not a product of the brain in the same way that urine is a product of the kidney, or bile a product of the liver. Those bodily products offer no mysteries to science today. Their sources are clear, and their utility obvious. But the conscious mind, although just as surely a biological product, causes subsequent activity in the bodily organ -- the brain -- from which it emerges.
A mindless world would work automatically. The mind-full world, as we know from direct experience, works with choices, reasons, plans, hopes -- all perceived as “mine.” With the freedom produced by consciousness, we have the makings of happiness and sadness -- and, of course, of good and ill.
Consciousness is an interactive property of brain life, with both bottom-up and top-down aspects. Brains bring about consciousness (bottom up), but consciousness leads brain activity to follow its designs (top down).
We know that interaction as plainly as we know ourselves. But neuroscientists have no conception of how the brain operates to produce or relate to consciousness as we experience it. The mind-brain problem remains a fundamental enigma to science.
Psychiatrists cannot and should not wait for the solution to that problem -- nor should they prejudge its character, as the medical model of psychiatry does. They must identify and treat mental problems that come from the bottom up, the top down, or both together. One group is no more real than another.
Bottom-up problems are easier to understand because they derive from physical ailments like infectious diseases or vascular strokes, which break down the brain just as similar afflictions damage or destroy other organs. The indication in consciousness of a disruption of the underlying brain will be the appearance of symptoms like dementia or hallucinations. Broken brain parts bring about broken mental faculties. Psychiatrists, along with neurologists and other brain scientists, can link the brain damage to the character and extent of those deformations of mind -- from the bottom up -- and then work to cure them.
Top-down mental disorders do not emerge as deformations of mental faculties but as emotional and behavioral responses -- quite normal in their character but causing distress in their quality and degree -- to unexpected or unwelcome results of the conscious mind’s assumptions, plans, and choices. With our freedom to choose, we can get into serious trouble even when our brain machinery works properly. Our conscious mind determines whether we behave in a way that disappoints our friends and leads to painful feelings of embarrassment and shame, or behave in a way that makes others admire us.
Top-down disorders are dysfunctional rather than deformational. They bring demoralization, anger, and resentment from frustrated intentions and desires. The brain supports the intentions and registers the distress, but conscious thought is responsible for choosing the intentions. Only better thought and planning will lead to recovery.
With top-down disorders, psychiatrists work as teachers or coaches to conscious agents, not as apothecaries or nerve mechanics. The object of that psychiatric effort is to illuminate a patient’s situation, mature or enrich his or her goals in life, and help him or her see how to achieve them.
Bottom-up and top-down aspects of consciousness can interact in some clinical situations. Specifically, a bottom-up affliction like Alzheimer’s disease or bipolar disorder will also -- by its consciously appreciated implications for the future -- provoke top-down fears, worries, and concerns. That explains why such conditions call for both medications and psychotherapy: medications for the bottom-up symptoms, and therapy for top-down anxieties.
So much for the philosophy behind psychiatry’s medical model; how about its application? Patients with either deformational (bottom-up) or dysfunctional (top-down) disorders go to a psychiatrist because they want an expert to identify their trouble and prescribe a treatment. To say that only the deformational disorders are really psychiatric -- and thus to presume that the dysfunctional disorders are either not disorders at all or are deformational disorders in disguise -- is folly. Any distressing mental state or behavior that causes a patient to seek help from a psychiatrist is a real disorder.
Relational disorders are real in just that sense, and a manual of psychiatric diagnoses should include them. They are common complaints of people who come to psychiatrists for treatment. They rest on misapprehensions and misunderstandings between partners in a relationship and generate much mental distress. But they respond well to treatment when a therapist guides both parties to reframe their habits and adapt more accommodating demeanors. With such top-down treatment, the brains of both individuals distressed by the relational problem will change -- but through conscious reflection and redirection, not through manipulations of brain tissue. Contemporary claims that psychotherapy works directly on the brain ignore the intervening role of consciousness and its top-down power.
The mini-rebellion of the summer of 2002 may encourage the American Psychiatric Association to abandon its stubborn commitment to an untenably rigid medical model. That welcome change would underline what psychiatrists agree about: The mind is a phenomenon of life, actively involved in health and affliction, derived from and yet guiding neurobiological activity. It would also help bring about a classification of psychiatric disorders that reflects the clinical implications of the interaction between the mind and the brain.
Paul R. McHugh is a professor of psychiatry at the Johns Hopkins University School of Medicine.
http://chronicle.com Section: The Chronicle Review Volume 49, Issue 13, Page B14