Jan 11, 2023·edited Jan 11, 2023

Psychiatry must be a big mess if we ask if mental disorders are true "brain disorders". Do gastroenterologist question whether hepatitis is a disorder of the liver or do urologists challenge the concept of an enlarged prostate? They don’t. Yet, psychiatrists keep wondering if there is something ethereal hiding behind amygdalae and basal ganglia. No wonder other physicians roll their collective eyes listening to us.

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Of course, mental disorders are disorders of the brain. What else could they be?

But I understand how someone might get confused into thinking that these are societal, not biological. Take voyeurism, for instance. It’s not pathological to achieve sexual arousal by looking at naked or undressing people. It turns into a disease when one can’t stop spying on non-consenting people and is arrested and prosecuted for it. ‘The confused’ fails to recognize that voyeurism is not the disease of sexual arousal (the drive) but a mismatch with weak biological inhibition (the brakes) in the face of obvious negative consequences. By analogy, if someone crushes a car with a Corvette engine and Fiat 500 brakes, it would be a car and the driver problem (one or both must be fixed) and not the freeway with rules and speed signs.

Even though society labeled voyeurs mentally ill, voyeurism is not a social disease. Instead, it’s the inability to control the drive. Voyeurism is the disease of brain neurocircuits, not society. The emergence of novel diseases with social and economic advances is not new. For example, there was no common issue with presbyopia during the Stone Age; no learning disabilities and ADHD before universal education; pedophilia was not a problem before it became illegal; and fewer were labeled as exhibitionists after the opening of nudist beaches.

Most of the confusion in psychiatric taxonomy and diagnosis comes from the DSM, which avoids talking about the nature of mental diseases, leaving it to the readers to define. Psychiatric diagnosis would look less mysterious and confusing if one applies a sensible medical model. For that, we must accept the brain as a collection of separate, closely related units, a.k.a. neurocircuits. Ultimately, their dysfunction (it can be deficit, excess, instability, or mismatch) determines thoughts, emotions, and behaviors that we identify as pathological, leading to mental disorders.

In medicine, the evaluation starts with a “review of systems” (cardiovascular, GI, endocrine, nervous, etc.) Grouping symptoms and linking them back to the “units” that generate them is the standard medical practice. In psychiatry, we should start an evaluation with a review of functional neurocircuits. The brain has myriads of them, each serving specific functions, but not all are relevant to psychiatric diagnosis. Mostly, these are the circuits for arousal, mood, automaticity, executive control, reality testing, social relatedness, and information processing. In medicine, the treatments target the organs. In psychiatry, the target is neurocircuits, not descriptive diagnoses, despite the “indications.”

American psychiatrists have been taught to gather bits and pieces from patients’ narratives and turn them into a descriptive label (e.g., major depression, post-traumatic stress disorder, autistic disorder, schizophrenia, etc.). Then, treat the label as a whole. That’s how DSM avoids mentioning the brain and neurocircuits. In contrast to medical classifications, the Manual cuts off the link between symptoms and the organs that generate them. That is its major failure. However, it will be impractical to “repeal and replace” DSM. Instead, we should begin with deconstructing DSM diagnoses. First, separate and then group the jumbled and sometimes contradictory criteria according to contributing neurocircuit.

There is more; unfortunately, blogs' format has limitations. Another time, perhaps.

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Dr Misha, thank you for the comment. The sense in which psychiatric disorders are "obviously" brain disorders is one distinct sense of the term "brain disorder." There is a physicalist sense in which all psychological phenomena can be understood as complex biological interactions, but that is as true of normal psychology as it is of psychopathology. Anneli Jefferson outlines the various coherent ways in which we can understand the concept of brain disorder. This requires thinking of the level of explanation/organization at which a condition is best characterized and also about the level of explanation/organization at which the norms/judgments of abnormality operate. The norms of abnormality are very different at the neurological and the psychological levels. This is the context in which this discussion is taking place.

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Mar 4, 2023·edited Mar 4, 2023

Awais, thanks for your comments and apologies for the delayed afterthoughts. And separate thanks for opening the forum to share ideas.

I see problems with Anneli Jefferson’s attempt at all-encompassing classification and also with HiTop and DSM. In all cases, there is a failed effort to stretch the taxonomy over the biological and also analytical models of psychopathology. Unfortunately, they can’t merge and are too far apart in their vision of etiology, pathology, and treatments.

Therapists--using an umbrella term for non-prescribing mental health providers--have no need for the brain complexity and individual neurocircuits. For them, the brain is a superfluous luxury that doesn't alter the course of either dynamic or, for that matter, cognitive-behavioral therapy. Furthermore, the ambivalence and confusion about societal, mental, and biological roles in mental illness led to an ill-conceived biopsychosocial (plus spiritual) model, giving an impression that all parts play an equal role in diagnosis and are universally applied in treatment, as demonstrated by the ubiquitous 3 overlapping circles. But alas, these are neither equal nor overlapping.

To wit, a female Pakistani schoolteacher and a male Norwegian chef look and sound quite different when describing their experience with depression, families, marriage, and work. The patients’ gender and ethnicity shape the narratives. A psychiatrist must tease out relevant symptoms to uncover the specific disease symptoms underneath the personal stories. Because of the absence of objective, standardized diagnostic tools, psychiatrists must rely on numerous peripheral factors when searching for the best-fitting diagnoses.

In psychodynamic psychotherapy, the disease biology and precise diagnosis are immaterial if a therapist focuses on marriage, self-esteem, and communication issues. However, the ethnicity, culture, SE factors, and religion play only a minor role in medical treatment. The individual biological characteristics and clinical symptoms, not the narrative, lead to the treatment choices. Our Pakistani teacher would get the same prescription as the Norwegian chef. Meanwhile, her ethnically and culturally identical twin sister, diagnosed with anorexia and panic disorder, will be treated pharmacologically differently.

In sum, psychiatric treatment–-and I mean pharmacological (including invasive and semi-invasive interventions, like TcMS)–-is biological. If we employ brain-based interventions, our classification and terminology must be also brain-based. So far, they weren’t. The new DSM-5-TR (essentially, a money-making gimmick) doesn’t have it. And the HiTop, on the surface, appears to possess an internal (biological) organization and a scientific foundation, but, in reality, it hasn’t. But, again, this forum is not the place for detailed criticism of the scheme.

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P.S. Awais, you mention, in passing, that "The norms of abnormality are very different at the neurological and the psychological levels."

I am curious, in which way? Are they also different from psychiatric? TIA.

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