Crooked Timber

What causes schizophrenia? The short answer may be "nothing" or more precisely "no one thing." In most cases, schizophrenia is an end result of a complex interaction between thousands of genes and multiple environmental risk factors--none of which on their own causes schizophrenia. Daniel Weinberger, in his classic paper on brain development and schizophrenia, entertained the "unlikely" possibility that schizophrenia is "not the result of a discrete event or illness process at all, but rather one end of the developmental spectrum that for genetic and/or other reasons 0.5% of the population will fall into." Over 20 years later, this unlikely scenario is looking more realistic. Schizophrenia is increasingly considered a subtle neurodevelopmental disorder of brain connectivity, of how the functional circuits in our brains are wired. Schizophrenia may in fact be the tail end of a distribution of how the estimated 20 billion neurons and their trillions of synaptic connections in our brains are generated, eleminated, and maintained. Schizophrenia may be the uniquely human price we pay as a species for the complexity of our brain; in the end, more or less by genetic and environmental chance, some of us get wired for psychosis.

This eloquent passage by John H. Gilmore, M.D., from a recent editorial in the American Journal of Psychiatry, struck me as emblematic of the field now. In one sense, his statement seems obvious--we nod knowingly, muttering the mantra that the mind is complicated, etc. But in another sense, it seems to dash our hopes. For what if not only schizophrenia, but most or all mental disorders, are no more easily accounted for than are other complex psychological features, such as intelligence, personality, or the nature of consciousness itself?

Even if we never expected to find THE CAUSE of most mental disorders, the smoking guns, nonetheless we have nourished hopes that one or two of the myriad causes might be found to predominate and to offer chances to nip in the bud "the thousand natural shocks that flesh is heir to." This lust for explanation certainly isn't unique to psychiatrists--patients themselves continually cast about for a simple and compelling narrative, whether it be the abusive parent, the head injury at age 12, or whatever.

Potentially the most embarrassing question psychiatrists are asked is "What caused this?" We still cannot legitimately answer beyond vague references to genes, synapes, and life experience, all of which offers little more clarity than the notorious "chemical imbalance." It may be that we are not only in practice (that is, currently with all our technical limitations), but crucially in theory (that is, forever and by nature of the inquiry) no better able to explain why Johnny is depressed than we can explain why his IQ is 112, or why he prefers baseball to football, or why he likes going to church. The contingency goes all the way down.

Gilmore's editorial also implies that mental disorders may not be contingent afflictions, but may be closely bound up with the very nature of the human animal. It is easy to imagine a world without AIDS (oh right, most of history), and even cancer seems no more integral to human identity than smallpox long must have seemed. But a world in which suicide, madness, and addiction don't happen, period, seems no easier to envision than a world wholly without war or poverty. That isn't to say that it can't or won't happen, but it would involve a radical alteration in human experience.

The murkiness of etiology continues to frustrate the project of neatly carving out mental disorders from the (hopefully) broader region known as normality. All we see wherever we look are continua and shades of gray, and the distinction between treatment and enhancement grows fuzzier. If we had a pill that would increase IQ by ten points, then why would an increase from 50 to 60 be "treatment" (of mental retardation) and an increase from 100 to 110 would be "enhancement" if mental retardation is merely part of the natural (normal?) distribution of intelligence? These distinctions threaten to be made primarily based on pragmatic and political bases (e.g. how many IQ-raising pills can we afford to make, how will be distribute them, etc.).

I've always been struck by the example of Alzheimer's disease, the prevalence of which climbs above 50% in individuals over 85. In this case dementia becomes normative, and statistically an example of "normal" aging. Arguably it is no more a "disorder" than death itself is a disorder. So if we had effective treatments for Alzheimer's "disease," then they could be viewed as an example of "enhancement," as an alleviation of potentially normal aging. What we label "disease" is merely what we would choose not to live with.

In philosophy of mind the "hard problem of consciousness" is the vexed question of how a physical brain produces the experience of subjectivity. As a bad pun I can think of a second "hard" problem of consciousness, that is, the existential reality that consciousness is hard to tolerate at times--it can be raw nerve held up to the universe. But there could be a third kind, a sense in which the brain is evolutionarily hard to produce, the most complex object in the universe that we know of. Mistakes were made. To paraphrase Samuel Johnson's infamously misogynistic (and anti-clerical) comparison of women preachers to dogs walking on their hind legs, one marvels not that it isn't always done well, but that it is done at all.

The Impossible Profession

In a nice segue to the last post, and with a thanks to Retriever (since the current New Yorker hasn't quite arrived at the house yet), it was a pleasure to read Louis Menand's take on psychiatry's discontents. It is probably the best single overview of the profession's vexing ambiguities that I have seen; it's all there--the diagnostic quibbles, the ideological clashes, the greedy pharmaceutical companies.

Talk about fact and metaphor...on the way in this morning, I was thinking about how wisdom in psychiatry is a microcosm of wisdom in life, that is, learning to distinguish facts from metaphors, or things we can't change from things we can. Medicine is metaphorical to begin with, but psychiatry is meta-metaphorical; it engages metaphors to understand how our minds make metaphors.

It's good every now and then to revisit the obvious: nothing in medicine or psychiatry comes pre-stamped with a "DISEASE" label. The marvelously complex human body (including the brain), developed through natural selection, behaves in mulitfariously patterned ways with variable implications for life-span and subjective distress. All that science can do is to identify and trace these patterns in all their hideousness or glory; everything else--how to describe these patterns and what if anything to do about them--is the stuff of politics in the broadest sense of social wrangling and consensus (or the lack thereof).

Doctors are trained and appointed to diagnose and treat, most literally, but more widely, they act as society's representatives and arbiters when it comes to managing (juggling?) facts and metaphors as they pertain to the body (again, including the mind) and its existential frailty. Whether or not to compel treatment, or whether or not to recommend disability, or even to grant the "sick role" are not fundamentally scientific, but rather bespeak the negotiated attitudes of the culture at large. As Menand suggests, perhaps our error is to expect medicine and psychiatry to be primarily scientific in the first place. What happens in the lab or the clinical trial is (one hopes) science; what happens in the consulting room is quite different. The mistake is to assume a congruence between science and moral authority. In either direction, it is quite possible to have one without the other.

There is much more to be said, but this is a lunch hour post.

Complementary Cultures

"One could divide humanity into two classes: 1) those who master a metaphor, and 2) those who hold by a formula. Those with a bent for both are far too few, they do not comprise a class."

Heinrich von Kleist

I was struck by a passage from Rebecca Newberger Goldstein's 36 Arguments for the Existence of God in which Jonas Elijah Klapper, the breathtakingly bombastic caricature-of-a-humanist, offers the following riff:

"But, no, I'm not impressed by the slide-rule mentality. I remain unimpressed with the mathematical arts in general. What are the so-called exact sciences but the failure of metaphor and metonymy? I've always experienced mathematics as a personal affront. It is a form of torture for the imaginatively gifted, the very totalitarianism of thought, one line being made to march strictly in step behind the other, all leading inexorably to a single undeviating conclusion. A proof out of Euclid recalls to my mind nothing so much as the troops goose-stepping before the Supreme Dictator. I have always delighted in my mind's refusal to follow a single line of any mathematical explanation offered to me. Why should these exact sciences exact anything from me? Or, as Dostoevsky's Underground Man shrewdly argues, 'Good God, what do I care about the laws of nature and arithmetic if, for one reason or another, I don't like these laws, including the "two times two is four?"' Dostoevsky spurned the hegemaniacal logic, and I can do no less."

It is ludicrous, and it bespeaks a pride bordering on the Satanic ("Better to reign in Hell than to serve in Heaven"), but it does contain the kernel of a point. It brings to mind William Blake's objections to Newton and certain excesses of the Enlightenment: "I must create my own system or be enslaved by another man's." Also Dickinson's "Tell the Truth but tell it slant." Is meaning ultimately a matter of temperament?

I thought also of Consilience, in which Edward O. Wilson argues that there is no aspect of experience, including the supposed mysteries of morality, art, and religion, that, in theory at least (whether we as a species can or will ever know and understand enough to grasp it all is a different matter), cannot be accounted for by objective (i.e. scientific, broadly considered) understanding. Subjectivity may, like ultraviolet light or atoms themselves, be a phenomenon we can never perceive directly, but one that will eventually be found to follow certain laws.

Wilson's book was published in 1998, when postmodernism more of a force to be reckoned with, but I was struck by his approach to the postmodernists' insistence upon decentered, contextual meaning (Nietzsche's notion of truth as a "mobile army of metaphors"). He quotes a passage by George Scialabba:

Foucault was grappling with the deepest, most intractable dilemmas of modern identity....For those who believe that neither God nor natural law nor transcendent Reason exists, and who recognize the varied and subtle ways in which material interest--power--has corrupted, even constituted, every previous morality, how is one to live, to what values can one hold fast?

To this Wilson answers:

"How and what indeed? To solve these disturbing problems, let us begin by simply walking away from Foucault and existentialist despair...To Foucault I would say, if I could (and without meaning to sound patronizing), it's not so bad...The true will be sorted from the false, and we will understand one another very well, the more quickly because we are all of the same species and possess biologically similar brains."

This is a mind-bogglingly optimistic sort of monism, in which the ancient histories of individual and cultural difference melt away in the radiance of the one objective eye of the "view from nowhere," in contrast to the sheltered, shadowed, and limited perspective of the "view from somewhere," that is, from where (and what) individuals find themselves to be.

However, as a psychiatrist I am intrigued by an element of diagnosis in Wilson's view, his suggestion that beyond a certain point, the hand-wringing of threatened nihilism cannot be logically answered (any more than the specters of suicide or unequivocal delusion can be logically answered). It can only be denied and rejected as moral pathology, as toxic to the range of human potential that has been the consensus of human beings across cultures and ages. Has anyone considered "nihilism" for DSM-V?

Yet Wilson throws a bone to those grappling with nihilism:

"Nevertheless, here is a salute to the postmodernists. As today's celebrants of corybantic Romanticism, they enrich culture. They say to the rest of us: Maybe, just maybe, you are wrong. Their ideas are like sparks from firework explosions that travel away in all directions, devoid of following energy, soon to wink out in the dimensionless dark. Yet a few will endure long enough to cast light on unexpected subjects."

But getting away from pathology per se and focusing on psychological understanding, it is important to see Romantics as one end of the continuum of epistemology, the other end being the Classicists I suppose. Epistemology can't be understood apart from human needs. The fictional Klapper, no less than Blake, Kierkegaard, or Dickinson, is saying, "I need something that your Enlightenment, your 'consilience,' can't provide." It is only when this need--for ambiguity that is--becomes so overwhelming that it cannot be reasonably satisfied that it becomes nihilistic psychopathology. For it must exist in tension with the complementary human need for order, which has its own well-known pathologies.

Wallace Stevens nails the ambivalences of the Romantic mindset in "The Motive from Metaphor:"

You like it under the trees in autumn,

Because everything is half dead,

The wind moves like a cripple among the leaves

And repeats words without meaning.

In the same way, you were happy in spring,

With the half colors of quarter-things,

The slightly brighter sky, the melting clouds,

The single bird, the obscure moon--

The obscure moon lighting an obscure world

Of things that would never be quite expressed,

Where you yourself were never quite yourself

And did not want nor have to be,

Desiring the exhilarations of changes:

The motive for metaphor, shrinking from

The weight of primary noon,

The A B C of being,

The ruddy temper, the hammer

Of red and blue, the hard sound--

Steel against intimation--the sharp flash,

The vital, arrogant, fatal, dominant X.

Just as human cultures over the millenia may have gained from the tension between piety and apostasy, they have likely been enriched by complementary needs for fact and metaphor, reality and fantasy. Yes, there is literally nothing outside of reality, and metaphor is "merely" a subcategory of fact, but Homo sapiens is so constituted as to need its Romantic consolations. Eliot ("Humankind cannot bear very much reality") and Nietzsche ("It is only as an aesthetic phenomenon that existence and the world are justified") had it right. Good riddance to metaphysical dualism, but as for psychological and cultural dualism(s), not so fast.

Poetic Diagnosis

I wasn't familiar with this poem, which I happened upon this morning:

Neurotics

No one gives you a thought, as day by day
You drag your feet, clay-thick with misery.
None think how stalemate in you grinds away,
Holding your spinning wheels an inch too high
To bite on earth. The mind, it's said, is free:
But not your minds. They, rusted stiff, admit
Only what will accuse or horrify,
Like slot-machines only bent pennies fit.

So year by year your tense unfinished faces
Sink further from the light. No one pretends
To want to help you now. For interest passes
Always towards the young and more insistent,
And skirts locked rooms where a hired darkness ends
Your long defence against the non-existent.

Philip Larkin

In some ways this seems a harsh, unlovely, and ungenerous piece, but on the other hand it has its accuracies. When it was written, in 1949 according to my volume, "neurosis" of course was a commonplace term owing to the cultural prominence of psychoanalysis. Neurosis remains a widely recognizable term, of course, but one no longer finds it in mainstream psychiatric diagnosis, as it has been split into myriad anxiety, mood, and perhaps personality disorders.

However, the construct of "neuroticism," which is a general tendency to emotional negativity and instability and susceptibility to stress, still exists as one of five major components of personality as identified in psychological testing (the other four are openness vs. conventionality, conscientiousness vs. expediency, extroversion vs. introversion, and agreeability vs. its lack). Neuroticism is correlated with increased risk for depression, anxiety, and eating disorders among other things. To my mind, describing someone as broadly neurotic can be more helpful and convenient than listing the five DSM-IV diagnoses they may happen to meet criteria for.

As for Larkin's poem, it painfully depicts the disfiguring and ostracizing effects that neuroticism can have; no, it is not (quite) leprosy, but it can alienate almost as much. It conveys the sense of stasis and sluggishness ("clay-thick"), of emotional torpor that results not from repose, but from wasteful psychological exertion (the metaphor of wheels spinning but gaining no traction on earth is just right).

Larkin puts his finger on the core problem of neurosis, which is the lack of internal freedom; while philosophers forever debate freedom vs. determinism in the abstract, the neurotic battles fatalism on a daily basis. Cheer up; don't be afraid; eat less; exercise. How can these things seem so impossible? For one thing, the neurotic lives in a different perceptual world from the rest of us, with a mind that will "admit only what will accuse or horrify."

"Tense unfinished faces" is perfect, suggesting the way in which anxiety inhibits and blurs individuation. There is a sense in which neurosis is a disabled identity. I'm not sure that "hired darkness" works as well, but I assume Larkin means here the classic avoidance by which the neurotic seeks to fend off "non-existent" threats, although ironically the threats in question are in reality all-too-existent, merely within the neurotic's "locked rooms," and not without as he imagines.

The Concept of Anxiety

There is no Hope without Fear, and no Fear without Hope.

Spinoza


Today's Times, drawing on now famous research by Jerome Kagan, features a long review article on anxiety and it's relation to temperament. This is a great example of science confirming ancient intuition, in this case the fact that persons really are wired differently from conception. As the article states, any emotion has three components: physiology, subjectivity, and behavior--the question for life is how far the latter two can be unyoked from the first.

I don't have a great deal to say about anxiety except that as compared to the other major mental disorders--mood, psychosis, and substance abuse--it may be the one most likely to hide in plain sight. Anxiety can generate profound misery and grave impairment but does not, in itself, advertise by means of catatonia, craziness, or intoxication. And while all psychological symptoms exist on gray continua, the point at which anxiety becomes pathological may be the hardest of all to pinpoint. Anxiety, after all, is adaptive.

Anxiety and depression often travel together, but arguably they present differing core experiences. If the sine qua non of depression is loss (of a good, of an attachment), that of anxiety is dissatisfaction, the feeling that something is wrong that cannot be set right. In obsessive-compulsive disorder it is the immediate environment that is defective, while post-traumatic stress disorder entails a deep flaw in (social) reality itself--the world itself becomes antagonistic. For the socially anxious, it is the self that is unacceptable. And perhaps generalized and panic anxiety are the most closely aligned to fear, such that the future itself cannot be trusted.

If psychosis is metaphysical, and if the phenomenology of depression is somehow religious--the suspicion that there is not, in the end, enough good in the universe to make up for the bad--then the experience of anxiety is fundamentally moral and/or aesthetic--it is desperately important that something be made right. The other day D. G. Myers at A Commonplace Blog proposed a list of the "most depressing novels of all time" (I agreed with the choices with the notable exception of Miss Lonelyhearts, which is darkly hilarious, and not at all depressing). What are some of the most anxiogenic writings of all time? Hamlet, surely, inasuch as his uncle's perfidy and his mother's frailty constitute the rotten taint at the root of the prince's world. "Notes from the Underground." "The Waste Land." The Trial. Others?

Who Are You Calling Fat?

"I have a certain alacrity in sinking."

Falstaff


A survey suggests that the majority of Americans are not convinced that they are as fat as health experts say they are, or at least, they don't seem very alarmed about it. 82 percent said that obesity is either no problem or only a mild problem for themselves or their families. I don't know if they were asked whether obesity is a problem for other people and their families; my guess is that the numbers in that case would come out differently. But clearly this is out of step with the near-panic of many health experts over the epidemic of obesity.

This is the perennially interesting question of who gets to define what an illness is. Obviously opinion polls don't settle purely scientific questions. I believe I've seen multiple polls suggesting that the majority of Americans do not give full credence to the theory of evolution. While this fact is fascinating on cultural and sociological grounds, it detracts nothing from the validity of evolution itself.

The question with obesity is whether the poll in question reflects mere denial of the prevailing metabolic state, disbelief in the alleged health effects of obesity, or a declaration that whatever those effects might be, most folks don't care enough to tackle the problem. It hasn't helped, of course, that there has been significant ambiguity about health effects; while morbid obesity clearly hastens mortality, it is far from completely settled, so far as I know, that obesity in the moderate range shortens life span.

Obviously there are other ways obesity may be detrimental, primarily through increased morbidity, that is, suffering related to arthritis, diabetes, or other secondary conditions. These complications arguably increase health care costs. Obesity is problematic in other miscellaneous and logistical ways, for instance, even by increasing consumption of jet fuel for higher passenger payloads. None of this is to comment in any way on the causes of obesity, or the locus of responsibility, merely the consequences.

So the poll results may just reflect ignorance--people just don't understand, or don't want to understand, the social impact of obesity. But what if, at some level, they do, but they don't deeply care enough to label it a problem? Certainly in psychiatry, lack of insight is a common predicament--individuals with alcoholism or schizophrenia often enough can't or won't grant that they have a problem. But in those cases we stipulate that if they were placed before a jury of their peers, so to speak, or before a hypothetically rational person, they would be found to have a problem.

Alcoholism and schizophrenia do not reach epidemic status; it is easier to see the outlier as "disordered." But what happens when the outliers become the majority--can they define their putative disorder out of existence, or at least redefine it so that it again becomes a minority state? For instance, one could imagine a redefinition of morbid obesity as obesity, period, and what we now call moderate obesity, within a new and broader normal range. Even if such a change reduced average life span, the majority consensus would be a repudiation of the designation "illness" or "problem." There are, after all, values other than health-related values.

Yes, maybe technically the doctor makes the diagnosis, but if the "patient" doesn't consult the doctor, or even if he ignores the doctor's advice, is there still an "illness" or a "problem?" If the majority of patients were to do this, maybe not. In the country of the blind, the seeing man is king. But in the country of the overweight, the lean man is...malnourished. In a patient population of the contentedly curvaceous, the alarmed doctor is...alarmist.