Applying reason to mental illness.

[Floppit]

We've touched on this topic from various angles but I would be interested in a positive thread on the subject. By positive I mean what to do rather than what not to do.

One of the difficulties that mental health research has to overcome eventually is that it will always be a soft target for pointing fingers and laughing at it's previous mistakes. It has faced incalculable obstacles, a lack of tools for seeing the brain in action (until very recently a total lack), a lack of funding, a confused distinction between science and philosophy, a lack of funding and stigma to name but a few.

I'm arguing from the premise that mental illness does exist, I can no more believe that the brain above all other body organs is not vulnerable to malfunction than I can believe fairies!

The systems of diagnosis and treatment are far from perfect but that's our current reality. Within such realities how do we go about developing a reasoned approach?

In particular I'm interested in how to get past some of the very black versus white thinking regrading mental health, an example would be culpability in regard to mental illness.

[Harryprice]

I'm arguing from the premise that mental illness does exist, I can no more believe that the brain above all other body organs is not vulnerable to malfunction than I can believe fairies!

There are certainly illnesses that cause psychological symptoms, like Porphyria or lead poisoning, whose affect on the brain is understood. However, what I suspect you are talking about is 'disorders' which are a collection of symptoms defined by a committee. This distinction is central to the problem that psychiatry faces. How do we know that these disorders are not simply the extremes of genetic variability and not diseases at all?

If that were true, perhaps we should be looking at how best to help such people integrate into society rather that doping them with drugs to keep them 'under control'.

[Floppit]

If that were true, perhaps we should be looking at how best to help such people integrate into society rather that doping them with drugs to keep them 'under control'.

How would that be achieved without labelling? How would issues be described and knowledge shared? Whoever forms those labels how do they rise above being just a committee enough to be heard by every day people who's opinions will ultimately decide the level of funding, without which it's hard to see how it can be looked at rationally.

In addition I doubt all can be explained in terms of genetic extremes, most other organs of the body suffer both long and short term illness and I've yet to hear any sound reason why the brain should be any different.

[Harryprice]

How would that be achieved without labelling? How would issues be described and knowledge shared? Whoever forms those labels how do they rise above being just a committee enough to be heard by every day people who's opinions will ultimately decide the level of funding, without which it's hard to see how it can be looked at rationally.

It would require radical new thinking of a type unlikely to be seen in an unfashionable end of medicine. For instance, you could drop the whole 'disorder' model and move to one based on purely addressing the particular symptoms presented by any one individual (since we don't know that defined disorders equate to any particular disease). There are ways other than drugs to alleviate some symptoms. like providing distractions such as producing artworks. In some cases, like depression, there may be external reasons for the symptoms, like the subject is living a truly horrible life and/or taking drugs that could be looked at. There are all sorts of things that could be tried, if there was a will to get away from the 'diagnose them from a book and chuck drugs at them' approach.

In addition I doubt all can be explained in terms of genetic extremes, most other organs of the body suffer both long and short term illness and I've yet to hear any sound reason why the brain should be any different.

As I said before, the brain is subject to diseases, like any other organ, but I suspect most organic disease that cause psychological symptoms have probably already been identified.

As far as the 'disorders' are concerned the only consistent evidence for their causes so far is genetic. So based on that, a model of extremes of genetic variability looks worth exploring, except hardly no one is bothering as far as I know.

It is possible to identify consistent 'operational' differences between 'normal' and 'disordered' brains in scans and that is where most effort is going. Whether one represents 'correct' and the other 'incorrect' operation is open to debate.

If a genetic variation model was explored, why wouldn't disabling disorders simply die out? Well, there may be genetic trade-offs. Just as sickle cell anemia confers resistance to malaria, some disorders may boost creativity (see here, for instance). Anecdotally, it is often said that many creative people have some kind of mild (or even severe) disorder - this is why I suggested involving art creation as a distraction.

[Floppit]

It would require radical new thinking of a type unlikely to be seen in an unfashionable end of medicine. For instance, you could drop the whole 'disorder' model and move to one based on purely addressing the particular symptoms presented by any one individual (since we don't know that defined disorders equate to any particular disease). There are ways other than drugs to alleviate some symptoms. like providing distractions such as producing artworks. In some cases, like depression, there may be external reasons for the symptoms, like the subject is living a truly horrible life and/or taking drugs that could be looked at. There are all sorts of things that could be tried, if there was a will to get away from the 'diagnose them from a book and chuck drugs at them' approach.

I'm not sure that it would be so much 'unfashionable' as impossible. To take each symptom rather than look at patterns of symptoms would create a scattergun pattern, moreover one would spend as much time assessing the validity of distinction between symptoms, is hearing voices distinct from seeing things not there? I totally agree that drugs seem overused as the first line of attack, as is (I believe) counselling, we have tools to assess for what has been learned, perhaps they are crude but they could be refined. Where a problem is causing a fundamental disabling effect to a person's life, preventing them from work, destroying their relationships, stopping them from leaving the house or catching them in a loop of handwashing to the point their skin is being eroded - then there is a real need for careful assessment. For example I was listening to a radio discussion on adult autism diagnosis and they discussed being 'treated' with anti psychotics as a result of misdiagnosis, no cognitive tests before presumption of psychosis. Some symptoms between these two things (autism and psychosis) may be shared but that doesn't mean they should be lumped together.

As I said before, the brain is subject to diseases, like any other organ, but I suspect most organic disease that cause psychological symptoms have probably already been identified.

I doubt this, I'm not sure that I can adequately show it is not the case, with a good chunk of time I may well try. I remember a lecturer many moons ago talking about schizophrenia and the issue of denial it exists - while I forgotten much of what he went on to say I remember his opening statement almost word for word:
"When faced with a guy with his finger stuffed up his arse to stop his brains falling out while he pulls the hair from his head because it belongs to his father, you don't doubt something is wrong!"
I've spent time with people at the hard end of mental disarray. I remember one gentleman (very descriptive word, he was gentle!) who talked to someone not there, like it was a conversation, not always talking but pausing and responding. Initially I filled the pauses trying to check what he said, I thought I had misheard, I thought he was talking to me, my responses were met with confusion and then his escaping! Eventually I learned not to respond and he relaxed - I was pregnant at that time, heavily so. I went back to work at the same place after the baby had been born and for the first time he spoke to me (as me), it took two attempts because I hadn't been listening, with the second attempt he patted his belly which matched with his words was unmistakably a question to me. The interaction lasted seconds before he continued his endless argument with the other person not there but I doubt I will ever forget a tiny little window which he was looking out of and so bloody briefly I got to look in. As far as I know we don't have the tools to physically diagnose what was happening to that guy, I think there is evidence of organic changes but whether they are cause or effect is questionable. Like the old lecturer, if I'm honest, despite the lack of physical proof I find the experience compelling enough to be personally sure that something is very wrong.

It is possible to identify consistent 'operational' differences between 'normal' and 'disordered' brains in scans and that is where most effort is going. Whether one represents 'correct' and the other 'incorrect' operation is open to debate.

I think the problem with this kind of study is it sheds little light on what is cause versus effect because of the brain's plasticity.

If a genetic variation model was explored, why wouldn't disabling disorders simply die out? Well, there may be genetic trade-offs. Just as sickle cell anemia confers resistance to malaria, some disorders may boost creativity (see here, for instance). Anecdotally, it is often said that many creative people have some kind of mild (or even severe) disorder - this is why I suggested involving art creation as a distraction.

I think there are trade offs but that doesn't mean the issues that people bring to their GP can be ignored or in any way sidelined. No-one would accept leaving Sickle Cell to run it's course just because it has an upside, similarly if someone presents as being severely challenged in terms of autonomy and also very distressed, whether the root cause has an upside is somewhat academic. Where people are happy how they are perhaps as society we should trust them not to be begging for help in the first place.

[Harryprice]

To take each symptom rather than look at patterns of symptoms would create a scattergun pattern, moreover one would spend as much time assessing the validity of distinction between symptoms, is hearing voices distinct from seeing things not there?

I would count both symptoms as hallucination but since little, if any, work has been done on this approach it's difficult to say definitively.

I doubt this, I'm not sure that I can adequately show it is not the case, with a good chunk of time I may well try. I remember a lecturer many moons ago talking about schizophrenia and the issue of denial it exists - while I forgotten much of what he went on to say I remember his opening statement almost word for word:
"When faced with a guy with his finger stuffed up his arse to stop his brains falling out while he pulls the hair from his head because it belongs to his father, you don't doubt something is wrong!"

And there is revealed the attitude that causes the current approach. Someone behaves in a strange way and the first thing we do is categorise the individual as 'schizophrenic' (or whatever else in the 'book of symptom spotting'), as though it were an organic disease, and start feeding the drugs. There is no attempt to analyse the symptoms themselves (no I don't mean psychoanalysis which is even worse).

I've spent time with people at the hard end of mental disarray...

As have many of us. But have you ever taken the time to examine the symptoms? What people with disorders do and say usually makes logical sense once you understand their assumptions which are radically different to most people's. Such people are actually quite predictable if you take the time to analyse what they are saying. This offers a possible new way forward. The way that someone with dementia, for instance, confabulates makes perfect sense when you see the world from their tiny time window.

I think the problem with this kind of study is it sheds little light on what is cause versus effect because of the brain's plasticity.

Yes.

I think there are trade offs but that doesn't mean the issues that people bring to their GP can be ignored or in any way sidelined. No-one would accept leaving Sickle Cell to run it's course just because it has an upside, similarly if someone presents as being severely challenged in terms of autonomy and also very distressed, whether the root cause has an upside is somewhat academic. Where people are happy how they are perhaps as society we should trust them not to be begging for help in the first place.

I only mentioned sickle cell and malaria to illustrate why some serious disease might be conserved by evolution. Sometimes evolution conserves a nasty disease because there is a useful upside. It doesn't mean it shouldn't be treated.

Regarding creativity and mental disorders, I read somewhere though I don't have the reference to hand, that intelligent people with disorders can be highly creative. This is because they can harness the symptoms, of unusual spontaneous thoughts and connections, to positive effect. However, less intelligent sufferers of disorders may simply get the downside without the creativity. It sounds harsh but that's life.

[Floppit]

I would count both symptoms as hallucination but since little, if any, work has been done on this approach it's difficult to say definitively.

I think you missed my point somewhat, the above distinction between auditory and visual hallucination was just an example. My point was that by changing the focus of study from disorder to symptoms you still retain the problem of valid classification, ie what gets lumped together and what gets separated and how those labels/boundaries are shown to be accurate descriptors. When discussing behaviour and subjective experience it becomes almost impossible to extinguish blurring around the edges and therefore an enormous amount of work can take place and still leave a product as imperfect as what we have now. It still leaves the question of who, if not committees, decides what is what.

I doubt this, I'm not sure that I can adequately show it is not the case, with a good chunk of time I may well try. I remember a lecturer many moons ago talking about schizophrenia and the issue of denial it exists - while I forgotten much of what he went on to say I remember his opening statement almost word for word:
"When faced with a guy with his finger stuffed up his arse to stop his brains falling out while he pulls the hair from his head because it belongs to his father, you don't doubt something is wrong!"

And there is revealed the attitude that causes the current approach. Someone behaves in a strange way and the first thing we do is categorise the individual as 'schizophrenic' (or whatever else in the 'book of symptom spotting'), as though it were an organic disease, and start feeding the drugs. There is no attempt to analyse the symptoms themselves (no I don't mean psychoanalysis which is even worse).

I think this is entirely wrong. We all behave in strange ways at some time in our lives yet we do not all get diagnosed as mentally ill. I also disagree that mental illness as serious as schizophrenia are diagnosed as a first resort even when there are a level of problems that bring a person to the healthcare system. Personally if mental health treatment began with diagnosis and then moved to treatment I think it would be a step forward - but what more often happens is treatment (AD's, counselling) prior to careful diagnosis. If a GP is concerned a case is beyond their means to diagnose they are often forced to attempt to plug the gap while referrals may be refused and waiting lists waited on. In turn this surely impacts on figures for effectiveness of treatments? At least I would imagine so if the practitioner isn't sure they've given the right script in the first place and is unable to gain the patient access to further examination. Just to be clear though - I don't see any of that as entirely to blame for the shortcomings of MH treatments, just something that muddies the waters and is creating stumbling blocks to improving the knowledge we have.

As have many of us. But have you ever taken the time to examine the symptoms? What people with disorders do and say usually makes logical sense once you understand their assumptions which are radically different to most people's. Such people are actually quite predictable if you take the time to analyse what they are saying. This offers a possible new way forward. The way that someone with dementia, for instance, confabulates makes perfect sense when you see the world from their tiny time window.

Of course it's understandable for a person to confabulate events if they have dementia - but that in no way suggests dementia is somehow less clinical or less problematic to the person presenting with a symptom - confabulation.

Regarding creativity and mental disorders, I read somewhere though I don't have the reference to hand, that intelligent people with disorders can be highly creative. This is because they can harness the symptoms, of unusual spontaneous thoughts and connections, to positive effect. However, less intelligent sufferers of disorders may simply get the downside without the creativity. It sounds harsh but that's life.

If someone is sleeping on the streets, gets urinated on at night by piss heads and has no relationship left with the family they once had, if they ask for help then sod the upsides! I figure we as society just have to suck it up and accept the loss of a few Van Goughs! But, actually, I don't think the line is anyway as clear as that - there are intelligent people making a fortune from selling skills others perceive them to have and yet are still topping themselves - ok, for some I don't think that in itself means they are mentally ill but I would suggest that where a person asks (and in the UK MH system pretty much has to beg) for help it's neither here nor there whether they 'should' accept the hand that's dealt - any more than it would be if someone was suffering from Sickle Cell.

Where help is forced on a person it's a different issue altogether, but for that the MCA thread is probably a better place as I think the act comes closer than I could get to stating what should be deciding factors when considering whether a person has capacity.

Like I said earlier I think mental illnesses are real, but at the same time doubt we have our classification system spruced up for sunday lunch. As for how to scrub the whole thing up, I think my answer would be laboriously, checking reality against the ideas, accurate diagnosis within the current system so that we can more reliably see what data supports as valid versus pants! In terms of treatment, without improved care over diagnosis it's difficult to see how reliability can be effectively measured.

I think we should take what we have (maybe with some careful pruning) not chuck it all out - if for no other reason than we have bog all to replace it with as yet and people still show up at their wits end - could we really just say 'have you thought of painting'? I think GPs need to have better access to refer when they know they need to and take basic common sense steps like checking cognition prior to psychology - to avoid classic stuff ups like autism being 'treated' with anti psychotics!

[Harryprice]

Fine - you fix the system ... good luck ...

[Floppit]

Damn!! I was actually looking forward to your response - did you feel I was out of order?

[Harryprice]

You asked for ideas, I gave you some, you didn't like them, I got bored! Simples! I have 'when people don't like my ideas I get bored' disorder. It's quite rare.

[dalriada]

You asked for ideas, I gave you some, you didn't like them, I got bored! Simples! I have 'when people don't like my ideas I get bored' disorder. It's quite rare.

Not rare enough....

[Floppit]

I have 'when people don't like my ideas I get bored' disorder.

I thought that was a childhood disorder?