June 2013 Psychiatry & Philosophy Newsletter

What’s New

jock_suitA series of questions from newsletter reader, Jack Fenwick, has focused on some critical issues facing this model of mind, and also some very important social issues facing humanity. I’ll quote his email (with one or two minor changes):

“”Whilst you’ve now convinced me that mental disorder can be generated in the psychological realm and it is basically distorted personality rules that are driving disordered thought and behavior, does it not raise the question of how those rules came to be codified in the first place? What is the developmental process that creates them, is this not where biology (in terms of epigenetic effects), might come into play?

Children can potentially be exposed to the full spectrum of psycho-social environmental possibilities – from the nightmarish to the pristine – during their development. How is some can have a horrible experience during their development years (arguably where most of the personality rules are coded) but turn out balanced and functioning in the end?; likewise, why do some come from stable backgrounds, both at home and in their wider social settings, but go on to become mentally disordered? Is this where biology might have a causative role in the development of a disordered mind?”I’ve only done a cursory bit of reading into the genetics of personality development (says Jack). Though I suppose that’s a solecism, because from what I did read, it seems genetics doesn’t have much to say at all about personality. They certainly couldn’t find any genes to correlate for certain personality traits. Still, I think we are left with the question, what mechanism causes some to become disordered despite being exposed to the same or similar psycho-social milieu in developmental years?”

I’ll start with the points as he lists them: “… mental disorder can be generated in the psychological realm…”

If, by virtue of its very high-powered, multi-modal, multi-channel switching capacity, the brain functions as an information processor (which it certainly does), then there is no reason to believe that primary errors cannot arise in its information processing without any prior errors in its physical structure as a switching machine. Anybody who says that primary psychological disorders cannot arise due to errors in the brain’s algorithms or in its data set clearly doesn’t know the first thing about information processors.

I am not saying that, as a matter of necessity, all or most mental disorder is a primary psychological disturbance, even though it certainly seems to be true as a matter of daily experience. All I have to do here is show that the claim by biological psychiatrists, that all mental disorder is necessarily due to a “chemical imbalance of the brain” is utter hogwash, and that has been done. So when the director of the US NIMH, Dr Thomas Insel, says that their new research “…framework conceptualizes mental illnesses as brain disorders…” he is talking rubbish. There is absolutely no proof in the scientific or philosophical literature that there is any basis to this belief. Anyway, it flies in the face of common sense to say that information can’t be corrupted for some reason or another. Just crazy.

“…basically distorted personality rules that are driving disordered thought and behavior…” A large part of the work on the biocognitive model is directed at the notion of normal thought and behavior, because this is logically prior to abnormal or disturbed thoughts, experiences and behaviors. I think the concept of personality is pretty straightforward, it is the set of unique rules each of us has that guide our daily activities in such a way as to distinguish us from our neighbors. This draws a line between personality and culture, which is the set of rules that we have in common with our neighbors. A lot of mental disorder does arise from “distorted personality rules” but a lot also arises from people being submitted to massive or prolonged psychological distress. A woman trapped in an unhappy marriage may have a perfectly normal personality but can still develop a severe depressive state. A normal soldier can develop a disabling state of agitation as a result of overwhelming experiences in the field. A couple I saw this week are very distressed to the point of struggling to manage just because their son is in a mental hospital and seems to be getting worse, not better.

Of course, abnormal personality factors can make it more difficult for a person to cope with routine psychological pressures (“Ohmigod, hurry, we’re going to miss the train!” “Calm down, there’s another one due in five minutes.”) At the same time, some people with even moderate personality disturbance can’t cope with normal life but thrive in adversity: there are some people who actually like drama! A lot of the people who built the British Empire had quite gross personality disorders but nobody minded as long as they stayed overseas. The real job is to sort the personality factors from the reactive. That’s when the work gets interesting.

“…raise the question of how those rules came to be codified in the first place?

“Ah, now you’re talking. I have always believed we are Homo nomotheticus, the rule-abider, even before we can be Homo sapiens, the knower. A rule is simply a regularity. We have untold rules in our systems, our entire biology is based on regularities, but the rules of our informational states are different. In short, if we don’t have rules, we’re nothing. We can’t even speak without rules to say what each sound signifies. Thus, Chomsky’s concept of a rule-based generative grammar is a subset of the larger biocognitive model of mind, which says that rules are the basis of everything we do. So how do we acquire rules? I think it is true to say that we are rule-gatherers extraordinaire, from the moment we can lift our heads, we are constantly scanning the environment to extract generalisations that we use to survive. We mine our surroundings for rules that allow us to predict the next few minutes, and we never stop. We need to know what is safe to eat and drink, where we can safely walk, what we can touch and what has to be avoided, who is likely to be dangerous and so on. If we can’t find generalisations that allow us to make sense of the world, we die.

So now we start to see how the rules cluster. There are the normal rules that a reasonably sensible chimp could work out, like what is safe to swing from, what is safe to eat and which animals not to annoy. These are so basic to human life that we hardly give them the title of “rules,” we just call them common sense. Next, there are the rules of language which, as Chomsky likes to point out, we extract from the social environment very early in life, based on very limited experience of language. I’ve talked about this in Chap. 8 of my second book,Humanizing Psychiatry: the biocognitive model. Third, we have the rules of culture, including subcultures, and last the rules of personality. They form a sort of hierarchy but this is not fixed in concrete (or in biochemistry). What is the nature of a rule? It is an instruction of what to do in certain circumstances, essentially information coded in memory, but it doesn’t have to be explicit memory. It’s highly likely that, of all the tens of thousands of rules we have, a large part of them are learned implicitly. Indeed, the rules of language are being learned before we can form a sentence.

One topic that I find very interesting is the question of innate behavioral dispositions or, in social terms, human nature. That is, what are the inherent dispositions to act in certain ways that are part of our biological heritage? There are dispositions, that much cannot be denied: we are social animals; we are highly competitive and quickly form dominance hierarchies; we are territorial and xenophobic; we have a strong sense of curiosity or exploration drive; we are both selfish and altruistic, and we don’t tolerate uncertainty. We need to know what lies over the next hill so we will go and have a look (males will, females are usually content with this valley) but if we can’t find out, we will invent a convincing story to fill the gap. I think a lot of these are hormonally driven, just as they are in the other higher apes, so we are probably better talking about a “higher primate nature” rather than human nature, because it’s practically the same thing. More on these questions next month.

Here is a great link to the Nine Circles of Scientific Hell. I’d say they would be pretty crowded……and here’s a good example of people who should populate the lowest level of Scientific Hell forever, with no remissions:


Not (Anything Goes).

Here in Brisbane, we have a small group of psychiatrists called the Philosophy Interest Group (PIG for short) which meets to try to foster some sense of awareness of the broader issues in psychiatry. At a recent meeting, conversation turned to Heidegger and various other luminaries of the continental school of philosophy. I said they could not be used in psychiatry because their concepts are so poorly defined that anybody can read whatever they like into them, that phenomenological philosophy cannot form the basis of a single model of mind and thence a model of mental disorder or of treatment. In particular, they do not define limits to psychiatry and they thus licence “anything goes,” which opens the door to all sorts of fringe, loopy and/or dangerous (but often highly profitable) “therapies.”

Well, did that bring the demons of hell down on my neck! “Psychiatry doesn’t need a single model of mental disorder, we can use what we like for different cases. We can use a bit of this model and a bit of that to build a treatment program that is tailored for the individual rather than the ‘one size fits all’ approach of orthodox psychiatry.” Very clearly, the other members were highly satisfied with their (unanimous) rejection of my pedantic view of theories in psychiatry. One of them suggested we need to be creative in our concept of mental disorder, as there are multiple universes we can access to understand the patient, including the ordinary physical universe, the emotional universe and the spiritual. These coincide in the individual person but also different people’s emotional universes intersect so it is possible to have direct access to another person’s emotional state (or something like that, the bit about intersecting universes was a little garbled).

OK, saith I, but tell me how you would set limits to this. I knew a psychiatrist once who said that all mental disorder is due to lack of self-esteem caused by lack of love in infancy and the way to treat it was to give the patients some love now to make up for it. Trouble is, his idea of love was carnal and he eventually went to prison for a long time, but not before he had damaged a lot of people. Given that we can essentially make up a model to suit anybody, and no two psychiatrists are required to agree on what is wrong with the patient or how to treat him/her, why should anybody take psychiatry seriously, certainly to the point of paying them to do something that nobody else can do? Didn’t get an answer to this, meeting broke up soon after, leaving me hugely pissed off. In 1996, I wrote a short paper called The Myth of Eclecticism in Psychiatrywhich should have finished this sort of stuff off. Seems that if you chop one head off the beast, another pops up.

What, it seems, are the choices in psychiatry? A dehumanizing, reductionist approach that sees humans as nothing more than collections of brain enzymes to be drugged, cut or electrified, versus some weirdo, fun-filled, touchy-feely, new age fantasy? We don’t need to go into the risks of treating people as pithed toads, you can see that every day at work. On the other side of the fence, if we let unprovable notions in, then there is no limit, in no time, people are going to be invoking gods to justify what they do to patients, or importing morality into mental disorder and so on. Or is there a third path, a formal, articulated theory of human mental life and what can go wrong with it? I believe there is a formal theory of mind and its discontents and it is our job to find it, not to use our prejudices to do horrible things to people who can’t protect themselves.

So over the next few editions of this newsletter, I want to explore the formal ideas behind the work that has led to the biocognitive model of mind. The basic principles are as follow:

First principle: The human mind is a real thing, able to act in the real, tangible universe, which we can understand.

Two: There is a rational, natural account of human mind. This means that we don’t have to invoke the supernatural to explain the mind.

Three: There is only one correct theory of mind, and…

Four: It follows, then, that there are only certain ways that minds can malfunction, so there is only one correct theory of mental disorder. Biological psychiatry is not it.

We will talk more of these limits over the next few weeks. Any contributions or ideas, objections etc. are welcome.

A fascinating look at recent history (if fifty years is still recent), of how one determined woman blocked drug companies releasing thalidomide in the US in the early 60s, thereby preventing an epidemic of phocomelia. What a pity that lesson isn’t more widely taught.

Psychologists love to name things, and here’s one I hadn’t come across: The Coolidge Effect.

In experiments with rats it has been observed that after vigorous copulation with a new partner, male rats soon completely ignore this partner, but when a new female is introduced, they immediately are revitalized – at least sufficiently to become sexually active once more. This can be repeated again and again until the male rat is completely exhausted. This unexpected finding has been observed in all tested male animals, but also in females. Female rodents for instance flirt more and present themselves more attractively when observed by new males than in the presence of males with whom they had already had sex.

This phenomenon has been called the “Coolidge Effect” after the American president. On a visit to a farm, Mrs Coolidge had been shown a rooster who could copulate with his hens all day long, day after day. She was quite taken with the idea and asked the farmer to let the president know about this. After hearing it, the famously reticent Pres. Coolidge thought for a moment and asked: “Does he do that with the same hen?”

“No, sir” replied the farmer.

“Please tell that to Mrs. Coolidge,” said the president as he strolled away.

I see a media flurry over the recent announcement that the US National Institute of Mental Health (NIMH) has decided it’s not going along with DSM-5 but will focus its efforts on its own program, the Research Domain Criteria (RDoC). Dr Thomas Insel, Director of NIMH, has finally agreed that what the DSM project lacks is not reliability, but validity. That is, if we have a hundred psychiatrists and show them a patient and they all agree, Yes, he’s schizophrenic for sure, then we have 100% reliability (every similar case will reliably be placed in the same category) but are they right? That is, should he actually be placed in that category in the first place. “Patients deserve better,” he said, and pointed to the RDoC as an example of what he thought was better, i.e. a system of diagnosis based on biomarkers. But don’t be in a hurry, he warned, it will be at least a decade before they see any results (and $15bln at current spend rates).

He’s right, patients certainly do deserve better. Oddly enough, quite a few people have been saying just that for quite a few years but it’s nice to know the NIMH is finally starting to catch up. The question of validity is critical. Consider another example, educating Aboriginal children in the north of Western Australia many years ago. I remember a teacher telling me they were hopeless, it was a waste of time talking to them as they didn’t have the intellectual firepower to do anything more than sit in the dirt scratching their scabies. Another teacher agreed firmly with him, so here we have a case of 100% reliability. They looked at the same cases and came to the same conclusion. All very good, but was their diagnosis valid? In fact, it wasn’t. All the children had chronic otitis media, so they weren’t stupid, not stupid, just struggling along with about 10% hearing. Same goes for psychiatry. We may be able to train psychiatrists to be pretty reliable on matters such as ADHD but does that prove anything? No, nothing at all, it only shows that people can be trained to agree, just as once they were trained to agree that this sign or that meant witchcraft. So validity is the sticking point but, with my usual tastelessness, I pointed out some years ago that RDoC can’t provide validity (Cells, circuits and syndromes. A critique of the NIMH RDoC project. Ethical Human Psychology and Psychiatry 2011, 13: 229-236; an expanded and less polite version is Chap. 9 in Mind-Body Problem Explained, published 2012).

The American Psychiatric Association isn’t taking this barrage from NIMH lying down. Dr David Kupfer, Chairman of the DSM-5 committee, retorted that his DSM-5 “represents the strongest system currently available” for classifying psychiatric disorders. “We’ve been telling patients for several decades that we are waiting for biomarkers (i.e. from bioresearchers). We’re still waiting,” he said tartly. Oh dear, there’s dissension in the camp. Interesting, because for decades, psychiatrists have been eating out on the promise of biomarkers and cures for their putative “chemical imbalances.” Now it looks as though we may have a few more decades to wait. One wonders how long it will be before it dawns on somebody in NIMH or any of the other agencies that perhaps there aren’t any? That, by definition, psychological matters don’t have biomarkers?

To set the record straight, a rather panicky press release by Dr Jeffrey Lieberman, dated May 18th 2013, pointedly not sanctioned by the APA, said both he and his good friend, Tom Insel, didn’t mean anything like that and it was all a silly misunderstanding. It ended with the comment: “Psychiatrists would like nothing more than to see laboratory tests and imaging — routine in diagnosing other diseases — incorporated into the DSM and clinical practice.” Well, that depends on which psychiatrists you’ve been talking to. Those with shares in drug companies and tech firms might but those of us who have a formal model of mental disorder don’t need it.

Enough talk. This month, I’ve been too busy revising basic cell biology and neuroscience to read anything else. If anybody has read an interesting book, feel free to send in a review. Also, my little handbook on philosophy for medical students is available on Amazon’s Kindle for the princely sum of $4.95, that works out at about 2c per definition. Cheap!

This month I’d like to highlight Dr Richard Smith, a man who worked at BMJ for 25 years, the last 13 of which he was the editor. He has written a scathing critique of the publishing industry titled “Medical Journal are an Extension of the Marketing Arm of Pharmaceutical Companies” (FULL TEXT LINK) which was published in PLOS back in 2005. At barely over two pages it is stunningly succinct and comes highly recommended. He has also published a groundbreaking book, The Trouble with Medical Journals. His unique experience in the field including many personal anecdotes makes his message particularly compelling.

Dr Smith’s paper above is excellent paired with Kalman Applbaum’s  “Is Marketing the Enemy of Pharmaceutical Innovation? (FULL TEXT LINK)” We generally think that R&D goes in the order of; Research—–>Development—–>Marketing
But in reality it goes
Market Research—->Research—->Development—->Marketing
He also points out that direct to consumer advertising accounts for 14% of marketing costs but “thought leader development” was estimated to be 20% and rising!
Some other papers from Applbaum- Both Full Text
Getting to Yes: Corporate Power & the Creation of a Psychopharmaceutical Blockbuster.
Pharmaceutical Marketing and the Invention of the Medical Consumer

Send your questions to jockmclaren2@gmail.com with the word ‘question’ in the title. Start submitting now for next month.

Thanks again to Jack Fenwick who provided the question for this month’s newsletter.
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  1. Dr Andrew Kinsella

    You know I think the whole debate has become too polarised.

    DSM was always meant to be only a way of classifying human mental distress according to symptoms– more as a research tool and a heuristic than as a means of reifying the biological model of psychiatry. Equally the initial proponents of the strictly biological psychiatry models often operated from the excellent motive of relieving the mental distress of parents who felt they had been responsible for the way their children were struggling.

    Take ADHD for example- (you can have mine– it is a damn nuisance:).
    The idea that a problem with attention regulation might be a primary cause of mental distress is a perfectly valid one- and was first formally posited by The Buddha.
    However, the idea of a unified, genetic disorder that is related to dopamine production and has no positive features is more than a little crazy. It does not fit into any reasonable view of human evolution.

    However- when I was diagnosed at 46 (and I was having horrible working memory issues and problems with losing track in conversations etc)- what I took from the diagnosis was that the primary issue causing chaos and distress in my life, and the primary reason my behaviour was causing chaos and distress in the lives of others was poor ATTention, not a negative INTention.

    I certainly found, and still do find, stimulants remarkably useful at times- but by no means the be all and end all of the solution. In fact I used the stability and focus given me by dexamphetamine to learn mindfulness meditation. At this point I am recognised as a Buddhist meditation teacher within a Tibetan lineage, and have remarkably good attention- though still imperfect.

    While the idea of all psychiatric problems as a “brain disease” is a fatuous oversimplification, and one that can be profitably exploited by Big Pharma, the point is that all behaviour is manifested through the body- which, in turn is operated by the brain.

    Personally I am certain that Mind is an entity which is not an emergent phenomenon of the physical structure of the brain, but this still does not rule out the relevance of the brain-body interaction.

    One can, and should choose multiple points of intervention in any case of psychological suffering.
    This goes right down from spiritual approaches, helping a person to resolve long term patterns of aversive behaviour associated with prior trauma, to interventions designed to optimise brain function.

    Meditation, relaxation exercises, and training in biofeedback to achieve better autonomic balance, exercise,positive social interaction, and parental effectiveness training –are all great non drug intervention. However- in the case of ADHD many patients will not have enough stability to get started on these approaches. In these cases, medication can be enormously beneficial.

    It troubles me to see so much of the debate around psychiatry dumbed down to either- or approaches. Yes medications are over used (especially antidepressants- which are minimally more effective than placebo), and antipsychotics, whose side effect profile is severe, and radically over-stated.

    However, there is a role for intelligent use of medications in psychiatric conditions.

    My final comment would be- that I now see many adult ADHD patients, and am continually impressed with their enormous ability to “self stabilise” when some basic steps are taken to allow their brains to function better. Some need specific psychotherapy- but not all that many.

  2. I am fascinated by your books and articles.
    But I am disappointed that you do not discuss how you employ the biocognitive model in real life situations. Is the model discussed with the client?
    In your book ‘Humanizing psychiatry’, while discussing case 10-1, you write “…takes account of his early longitudinal personal development and also offers a point of intervention: treat the anxiety. This was done and, in two outpatient appointment spread over a week, the quality of his life was dramatically improved”, but do not describe the interventions employed. I hope you write more about ‘re-construction’ than ‘deconstruction’
    Personally I find Acceptance and commitment therapy and Narrative psychiatry interesting.

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