The links between mental disorders
nature.com
nature.com
- This article reveals the folly of viewing a complex system (the mind) through a mechanistic lens. We want to be able to look at the mind the way we look at a malfunctioning car ("ah, the timing belt's out") or computer ("one of the memory sticks died"), repair/replace that component and expect it to carry on as "normal". This can never work. The mind is an organic, emergent phenomenon, not something that has been "designed" to work in any "normal" way; it has evolved to adapt to circumstances that can change and differ dramatically for all kinds of reasons. So, trying to categorise "disorders" into discrete definitions with distinct "causes" in order to restore the mind to some "normal" state cannot possibly work.
- I realised after a few years of researching this stuff that the notion that psychiatric "disorders" manifest due to "bad genes" doesn't make sense. The whole point of evolution is that only genes that promote survival and replication can make it through. Sure, you can get random mutations, but that doesn't explain why so many people have the same kinds of "disorders". So whatever are the genes that "cause psychiatric disorders" in big enough clusters that they can even be attempted to be named and described in the DSM, those genes must be there for a reason that has aided our survival - even if they have some negative aspects too (nature is all about tradeoffs after all). Realising this changed the way I view mental "illness". I realised that my depression was my mind's way of telling me that something was wrong in my life (relationships, career, physiological health) and I needed time out to examine it, understand it and correct it. Schizophrenia can be seen as an alteration of your perceptions to numb you from a stressful/traumatic situation, a trigger of extreme creative thinking to help solve serious life problems, or a display of aberrant behaviour to signal to outsiders that you are in need of help (see studies of how often schizophrenia manifests after a period of severe stress or trauma). Bipolar can be seen as a pattern of swinging between a high energy/creativity state in order to get important things achieved quickly, and a low-energy state for recovery.
- The discussion in this article seems astonishingly simplistic and naïve to anyone who has read/heard any of the many researchers who have spent years examining mental "illness" from the perspective of trauma, and who have found success treating all kinds of conditions through trauma healing techniques. Such figures include Stan Grof, Ram Dass, Iain McGilchrist, Peter Levine and Gabor Maté.
- My own experience: I'm one of those who has fit the diagnosis for several conditions at times in my life; depression and anxiety most clearly, but also (at least mildly) bipolar, borderline PD, ADHD, some addiction. I tried all the conventional things (pharmaceuticals, mainstream psychiatric talk therapy) and didn't get much relief. About 8 years ago I discovered unconventional approaches to subconscious trauma healing, and have undertaken these consistently ever since, and my "disorders" have steadily resolved. All that's left is some latent anxiety, but that continues to improve too.
This paragraph in the article says it all:
As a result, the world’s largest funder of mental-health science, the US National Institute of Mental Health, changed the way it funded research.
Like so much in medical research, efforts are governed by what research will be funded, and ideally what will lead to the discovery of a drug or intervention that can generate billions of dollars of revenues. Those researchers who figured this stuff out decades ago don't need to be considered.
Beginning in 2011, it began demanding more studies of the biological basis of disorders, instead of their symptoms, under a programme called the Research Domain Criteria. There has since been an explosion of research into the biological basis of psychopathology, with studies focusing on genetics and neuroanatomy, among other fields.
"Focusing on genetics and neuroanatomy" is the perfect way to miss the forest for the trees.
But if researchers hoped to demystify psychopathology, they still have a long way to go: the key finding has been just how complex psychopathology really is.
Complexity doesn't have be difficult to understand.
Sigh.
There are plenty of inheritable genetic physical diseases. The evolution is not machine to make us perfect not God. You can't treat it this way.
So I can respond to something solid, can you name some?
It's very rare.
What is known about mental "illnesses" are that they sometimes manifest when certain combinations of genes are present, but not always, and when you look at the details of cases you can pretty much always find an outer-world factor that triggers the state (e..g, abuse, trauma, neglect etc).
So we're talking about very different things.
If you want a few well-known examples: Cystic fibrosis, Muscular Dystrophy, Canavan Disease, and Hemophilia.
There's lots of obvious bad stuff floating around in our genomes. It's not surprising that the roots of mental illness, heart disease, diabetes, and others are hereditary too.
There's a huge difference between conditions that are caused by a single-gene defect vs conditions that sometimes arise when a combination of genes are present/expressed in combination with other (e.g. environmental) factors.
> There's lots of obvious bad stuff floating around in our genomes
Too handwavy. Please be specific :)
“In the genes ------------
One pillar of this future approach is a better understanding of the genetics of mental illness. In the past decade, studies of psychopathological genetics have become large enough to draw robust conclusions.
The studies reveal that no individual gene contributes much to the risk of a psychopathology; instead, hundreds of genes each have a small effect. A 2009 study found that thousands of gene variants were risk factors for schizophrenia. Many were also associated with bipolar disorder, suggesting that some genes contribute to both disorders.
This is not to say that the same genes are involved in all brain disorders: far from it. A team led by geneticist Benjamin Neale at Massachusetts General Hospital in Boston and psychiatrist Aiden Corvin at Trinity College Dublin found in 2018 that neurological disorders such as epilepsy and multiple sclerosis are genetically distinct from psychiatric disorders such as schizophrenia and depression (see ‘Mental map’).”
Even that passage of the article you quote doesn't characterise the genes as "bad stuff"; just known genes that seem to correlate with the (contextually undesirable) conditions manifesting.
Your reply to me misses the point that I was making and argues against a point I wasn't making – which strikingly is the very thing that prompted me to counter your top-level post.
In response to your comment:
> You decried those examples as handwavy
To clarify, I didn't say the examples were handwavy; I pointed out the crucial distinction between disorders specifically attributable to specific gene defects (like Huntington's and cystic fibrosis), vs. conditions that arise through the interaction between positively-selected genes and environmental triggers. It's a category error.
What I referred to as "handwavy" was the sentence "There's lots of obvious bad stuff floating around in our genomes" - specifically the phrase "lots of obvious bad stuff".
I was calling this out as an unexamined assumption, rather than a the simple incontrovertible fact that it was presented as.
> and pointed out that moreover this ground had already been covered in the article and that the article concurred with those examples
But the article doesn't concur with those examples.
The commenter listed illnesses caused by specific-gene defects, and the passage you quoted names several psychiatric conditions that are known to not be caused directly by specific-gene defects. Again, a category error.
> Your reply to me misses the point that I was making and argues against a point I wasn't making – which strikingly is the very thing that prompted me to counter your top-level post.
You seem to have read my top comment as directly critiquing the article itself, rather than the approach that has dominated the field (along with the rest of medicine) for decades. (Fair enough that you read it that way.)
I acknowledged to you that the article conveys that some researchers are rethinking the approach, but I don't see evidence of enough of a rethink.
Most importantly, they're still looking at things mechanistically; studying brain structure, going deeper trying to find particular genetic "causes" (after the many years of looking at genes have yielded little useful insight), and proposing some mysterious "p factor" and asserting: "if it is real, it has a startling implication: there could be a single therapeutic target for psychiatric disorders". That's what I mean by the "mechanistic lens".
The core position I'm arguing against, which is presented in the article and by several commenters, is that mental "illness" is likely caused by "bad" genes or biological processes "going wrong". My position is that we should generally assume that the genes are meant to be there, and focus on what in the person's life is causing the genes or biological systems to express in an undesirable way (which is what the practitioners I've named have been doing for years/decades with great success).
I've expressed my position at length in other comments. At the time of writing, the position I've articulated in detail hasn't been refuted. I'd welcome anyone to do so, so I can learn more about the topic.
For almost all of them (possibly all of them in some cases), there is evidence of links with auto-immunity and the presence of active pathogens (including viruses, bacteria, funguses, etc), suggesting that the illness is related to the body's efforts to fight off or cope with pathogens, or to some effect of the pathogen's activity.
Those who invoke conditions like Huntington's Disease and haemophilia are on more solid ground, as these are directly attributable to single-gene mutations. But these conditions are also very very rare, unlike mental "disorders".
Mendelian diseases are not the only sort of genetic disorder. This is a misunderstanding of genetics.
Source: I was a university researcher in psychiatric genetics
As a professional in the field you'll know the terminology better than me and that's great, but you must understand the distinction I'm trying to make.
In the former case, we can clearly see a 1:1 causal link from genetic defect to the manifestation of the disease (whether it's a single gene or more is not central to the point).
In the latter case, the genetic predisposition is there, but there must also be some other form of conditional trigger.
One of your examples with which I'm quite familiar is asthma, which I've experienced at times in my life (though neither of my parents did).
I started experiencing it at about age 9 (as an allergic reaction to dust, dust mite and possibly other chronic infections I had at that age). Then it stopped in my mid teens. Then it started again when I smoked tobacco in my 20s, then stopped as soon as I stopped smoking. Then it started again in my mid 30s when I was experiencing severe stress and anxiety, then it stopped when I undertook a combination of approaches to reduce the stress/anxiety in my life, and a dietary program and other remedies to reduce chronic infections. That was 6 years ago and I've not needed asthma medication ever since.
The point is, there's nothing genetically deterministic about my asthma, given that it's come and gone through out my life and has been clearly influenced by environmental factors.
Further, it's plausible that the asthma has been a beneficial symptom, to protect my body from allergens and pathogens, and signal that I needed to change my lifestyle. Certainly, it was a big part of what signalled to me that I need to stop smoking, and later to clean up my diet and make other improvements to my emotional and physical health.
As I've proposed in several other comments, it's just as plausible that the conditions we regard as mental "illnesses" are likely not genetic flaws or other malfunctions at all, but rather beneficial adaptations that have been selected for by evolution (e.g., it's obvious how the presence of "ADHD" in a small percentage of the population would have been beneficial in prehistoric human tribes).
Given this, our real challenge is to do a better job of interpreting and responding to these conditions, as several practitioners going back decades have already figured out how to do.
Almost every disease can be traced back to genes (as you said it doesn't matter how many of them). Of course how much those genes play a factor varies immensely based on many factors. And there absolutely is something genetically deterministic about your asthma - you just have found another way of shutting down the biochemical pathways that would normally lead you to have symptoms.
To anyone in research in the field, the distinction you are trying to make is moot. Huntington's is just as regulated as any of the "conditional diseases" you try to put in a separate category. Sure, it has a more deterministic ultimate fate, but it's gene expression likely varies by a lot of factors too, especially between different cell types. And with that exact differential view is how all diseases are studied.
> To anyone in research in the field, the distinction you are trying to make is moot
I wouldn't think this is true; it's about the most important distinction there could be in genetics - i.e., flaws/defects of specific genes vs traits/predispositions that have been selected for over the history of evolution.
If a trait has been selected for over tens/hundreds of thousands of years of evolution, it's a mistake to try and "cure" it; it's not something that can be cured, as it's there for an important reason. The right approach is to understand the conditions that trigger the symptoms, and create better conditions so the problem corrects, just as I've done.
> If that works for you I don't want you get you of that view, but that seems to romanticize illnesses too much for my taste.
This is an emotion-driven (and rather patronising) response, whereas I'm focused wholly on what is scientifically plausible and demonstrable.
I welcome new evidence to challenge the position I've put, but so far it hasn't been forthcoming.
Not sure if that's enough qualification for you, but I'm a biochemistry undergrad with the goal of contributing to drug development in the future. The viewpoints I express here come from regularly reading recent papers related to mechanisms of various diseases, as well as what I've learned by talking to our professors and how we talk about diseases in class. (I also have an irrelevant background in software engineering, so I'm probably not as young and unexposed to the world as you might assume).
> If a trait has been selected for over tens/hundreds of thousands of years of evolution
That's simply not true that all (or even most of) our genes have been selected for "for tens/hundreds of thousands of years". Most diseases that occur after reaching reproductive age are not strongly selected for (this also holds true for animals). On top of that human social structures also help to weaken/circumvent evolutionary pressure.
> it's a mistake to try and "cure" it; it's not something that can be cured, as it's there for an important reason
> create better conditions so the problem corrects, just as I've done.
Not everything is there for an important reason. I'm lactose intolerant (also only attained after turning 18, so evading evolution). There is a long outdated evolutionary reason for turning of milk consumption in adults. There is not a good reason that applies in this day and age to turn of additional ways of energy supply to the body.
Yes, we do also look at the evolutionary circumstances of a gene in drug development, but that's mostly to reduce side effects by finding out what pathways could be connected.
I also don't see a big distinction between "curing" it "creating better conditions". Isn't curing it a way to create better conditions? Coming back to lactose intolerance, I can obviously always try to avoid lactose - or I can sometimes take lactase pills when it's easier in social situations.
> I'm focused wholly on what is scientifically plausible and demonstrable.
I'd like to see scientific evidence that bodies develop diseases to get people "to clean up their diet" or be introspective. Everything I see in terms of how individual biochemical pathways can be turned on/off without far reaching repercussions points into the opposite direction of us being so complex and interconnected that nothing should be tinkered with.
As I said I'm happy for you (honestly!), that this is how it worked out for you, but there are also a number of different events/experiences that could've lead you on the better path you are on now. No need for diseases to trigger that.
Also as a response to something you said in one of your other comments:
> Like so much in medical research, efforts are governed by what research will be funded, and ideally what will lead to the discovery of a drug or intervention that can generate billions of dollars of revenues. Those researchers who figured this stuff out decades ago don't need to be considered.
While this is of course true, that's not the only reason why the vast majority of people prefer taking medication for their diseases. People are lazy and changing habits is hard. For the same reason, it's most efficient (not effective!) to prescribe drugs to their patients, because they can't start lifestyle coaching every patient to change their diet.
Just look at cardiovascular diseases! It's been a leading cause of death for a long time, even though we know that improving levels of exercise and adjusting your diet can improve the odds a lot. This doesn't mean we shouldn't put money towards e.g. funding a drug that removes plaque from arteries.
> That's simply not true that all (or even most of) our genes have been selected for "for tens/hundreds of thousands of years". Most diseases that occur after reaching reproductive age are not strongly selected for (this also holds true for animals). On top of that human social structures also help to weaken/circumvent evolutionary pressure.
All the conditions we're talking about can very often express before reproduction happens; anxiety, depression, ADHD, bipolar, personality disorders, even schizophrenia (though that's later than most but still by the early 20s). And it's always been common for men to reproduce well into advanced age.
I gather you're arguing that mental "illness" hasn't actually been positively selected for by evolution, but in fact is just caused by crappy DNA that entered the gene pool by mistake and has stayed on for the ride.
It's a coherent claim, but doesn't really pass Occam's Razor.
For all the conditions I listed above, we can see how, in certain circumstances, they can be beneficial either to the individual or the group, so we don't need to conjure up an assumption that their emergence and persistence were undesirable accidents.
> I'm lactose intolerant
I'd be happy to research and debate this further at a later time if it turns out the topic materially hinges on this
> I also don't see a big distinction between "curing" it "creating better conditions". Isn't curing it a way to create better conditions?
It's a case of treating the symptoms vs the cause that pertain's to one's own life (their life experience and/or their environment).
Take the ADHD example. Current common treatment is to prescribe amphetamines. Future treatments according to this article might be to "switch off" the gene that causes ADHD-type behaviour. My "better conditions" approach is to look at the kid's overall personality and environment, investigate whether there's any trauma or distress underlying the behaviour (which is tragically often overlooked in the current treatment model), then once you've ensured the kid is in a safe and nurturing environment, if they're still hyperactive or unfocused, look at their whole personality and direct them towards activities that are suited to their talents and strengths (this happens sometimes but not nearly enough).
Using drugs or genetic treatments or anything else to "switch off" the ADHD is most likely to end up being somewhere between a lamentable underutilisation of talent/ability, and an egregious act of neglect/abuse.
When we treat genes as the "cause", we overlook so much in someone's life experience and environment that is highly controllable and that can have a far greater impact than by interfering with genes or biochemical pathways.
> I'd like to see scientific evidence that bodies develop diseases to get people "to clean up their diet" or be introspective.
The very existence of physical discomfort/pain or emotional distress is a demonstration of the biological signals we've developed to motivate changes to our conditions or behaviour.
We all know that eating too much of the wrong kind of food or drinking too much alcohol leads to physical and emotional pain/discomfort/distress that tells us to change.
Same goes for dysfunctional behaviour that leads to a relationship breakup or social rejection, leading to a period of introspection.
Sometimes the link between pain/illness and behaviour/environment is not so clear-cut, so we need to see a practitioner or do some research of our own.
But there's nothing in the least bit fringe or controversial about this concept.
> People are lazy and changing habits is hard
> we know that improving levels of exercise and adjusting your diet
I keep hearing this from experts on medicine and physiology. Some of them still dispute the "sugar is more harmful than fat" evidence (which I know is a separate issue that I don't want to start debating here/now).
I'm more optimistic about human potential.
People respond to incentives, and people will happily follow practices that clearly deliver benefits.
I know this from personal experience. I drank heavily, ate terribly, smoked and didn't stick to exercise. I tried doing everything mainstream health advocates recommended, but didn't get sustained results so I lost motivation and went back to bad old ways.
Then I found approaches that worked, and I've happily done them every day for over 8 years, because I've found that when I do, my life just keeps getting better.
Maybe to a researcher, sure, but to people predisposed to disease or mental disorders, that distinction is the most important of all.
Why? Because it means that you can do something about it, that you can deflect the trajectory of the disorder through your own actions.
Hopefully you accept statistics even if I cannot point to individual genes.
For for example ADHD I cannot give you a specific set of genes, but it is widely known and accepted to be very strongly related to if your ancestors had similar traits.
Do you have an explanation for this except the genes?
Yes of course - the environmental/experiential conditions in which the carrier of the genes find themselves.
Remember, ADHD is just a culturally defined description of behavioural tendencies, not a genetically hard-coded outcome like the shape of someone's face, so it's a mistake to think of them as being genetically determined in the same way.
Of course the genes someone inherits from their ancestors will influence their behaviour, but genes express differently depending on many conditions, and for behaviour it's highly contingent on one's own life experiences; indeed it's extremely important for survival and continued evolution that one can adapt their behaviour to the environment in which they live.
Even recent twin studies [1] don't find anything more than about 75-80% heritability of "ADHD" diagnoses, so you still need to explain the other 20-25%.
I was thinking about mentioning that because 75-80% is extremely high as far as I understand.
Looking at the ADHD example, aside from the genes, consider what else is consistent: same gestational environment (mother's food, air, water, emotions, microbiome), possibly the same living environment in early life (I'm not clear on how many of these twins were separated, and if so, at what age), but even if they were separated, they're still living in the same time in history, likely the same city/country, likely at a similar socioeconomic level, they have the same appearance/height (so people respond to them similarly) and if they were separated, both experiencing trauma of separation (both from a sibling, and one or both from parents).
So there's a whole lot going on that can explain the high heritability figure.
But even if you disregard all of that, you still have to explain the other (at least) 20-25%.
While this has been true in our past, we as a species have completely diverged from this. We do everything in our power to save every life no matter what the disorder or weakness. So it is no longer survival of the fittest in the traditional sense.
Whereas in the past someone with schizophrenia or major depression would not likely live a “normal” life and have children, now obviously it is very likely.
And the fact that they're widespread means they're selected for, not just not selected out.
It can also mean that the normal state of the brain exists near a small number of other stable modes, and that a wide variety of small nudges would have similar effects. The article mentions that a study of schizophrenia found that it was characterized in part by extremely rare mutations, suggesting that the brain is at an unstable local maximum, vulnerable to degrading into schizophrenia if unbalanced in any direction. Schizophrenia may in a sense be a much hardier fallback mode of brain operation.
Think about the condition we currently call the "disorder" ADHD.
We can easily imagine how the behavioural tendencies ascribed to it would have been beneficial in hunter-gatherer times; i.e., it would be beneficial to the tribe for a certain number of people to be restless and explorative, rather than being conformist and content doing repetitive tasks. Same goes for bipolar; think about how many of our leading writers, inventors, musicians are diagnosed bipolar, and how useful it would always have been to have had a few people with that kind of creativity and propensity for bursts of novel productivity in the tribe.
And I can easily think of ways depression and anxiety are adaptive and supportive of survival, rather than not (for depression it's the ability to contemplate/reform a troubled life, and anxiety it's the avoidance of danger). Even schizophrenia in certain circumstances.
And of course when we invoke Occam's razor, it makes far more sense that these genes are there because they're beneficial, rather than being there due to a historical accident.
For example, schizophrenia. It doesn't generally show itself until one's early 20's: there are many college students who find their studies halted because of it. It is really easy to have children before this. Depression can render itself after having children, especially in women. We treat it now.
Lots of non-psychiatric disorders are similar: no problems until early-to-mid adulthood. Plenty of time to have children beforehand.
The difference now isn't that genes aren't passed along to children, but more that we try to give folks a more normal life and less misery. And we frown upon the abusive practices that were so commonplace in asylums of yesteryear.
This line of argument is flawed because:
1) Plenty of depression, anxiety and of course ADHD occurs in childhood, while bipolar and schizophrenia more commonly occurs in late adolescence or early adulthood. Plenty of reproduction happens - particularly by men of course - at ages later than these when these illnesses can manifest (we can even see how some men with ADHD or bipolar tendencies have reproduced at higher rates than other men, and rationalise why this would have been the case through evolutionary history).
2) The suggestion that such widespread tendencies are in the gene pool only as an undesirable accident doesn't pass Occam's razer. We must assume they are there because they have been selected for, unless there is evidence to the contrary, which nobody in this whole thread has been able to offer.
3) We can easily see reasons why it has been beneficial to have some level of propensity for tendencies like depression, anxiety, ADHD, bipolar and even some schizophrenia in the gene pool.
It is enough for them to not be much of obstacle or to not manifest symptoms all the time. That is enough for them to stay.
First, the logic assumes the genetic coding for these conditions is never helpful to survival/replication, which as I've pointed out in several other comments, is demonstrably false.
But even if that coding really was never ever helpful, the theory relies on the notion that unhelpful DNA just keeps hanging around on the genome anyway.
Though I can't find a big amount of research on this (particularly regarding humans), there is evidence of "genome streamlining" where genes that serve no purpose get stripped out of the genome. This is necessary because it there is a cost in retaining DNA (continuing to transcribe it and modulate it), so it's far more efficient and thus helpful for survival to remove it.
The main research I've found on this pertains to birds and bats [1] (in which it is particularly important due to the metabolic cost of flying), but it would be reasonable to expect it also happens in primates, including humans, at least to some degree.
I concede this is speculative, but it's compelling.
Even still, the validity of my main point doesn't rely on this being true. We know that most mental "illness" tendencies are sometimes useful for survival/replication. That's what matters most here.
[1] https://www.sciencedaily.com/releases/2017/02/170206155949.h...
What are those unconventional approaches ?
Evolution is not proactive. It's passive. Genes introduce possibilities, so are beneficial, so are not.
The mind is plastic. Human "conform" to the world around them. Perhaps the commonness of disorders are the result in common patterns in the human condition, as well as a finite number of genetic contributions?
And of course, there's gut bacteria. A wonky gut often leads to a wonky mind. Perhaps diseases of the mind are actually symptoms of other abnormalities?
It specifically mentions co-morbidities and such. It mentions that hundreds if not thousands of genes are involved and that this was pointed out by a study which contrasted the obviously genetic conditions of epilepsy and multiple sclerosis with disorders like bipolar or schizophrenia.
> This article reveals the folly of viewing a complex system (the mind) through a mechanistic lens.
Nobody is saying that current research views the mind through a mechanistic lens. The article is explicitly saying, "hey, this is a complex problem – let's observe and analyse the phenomena"
> We want to be able to look at the mind the way we look at a malfunctioning car ("ah, the timing belt's out") or computer ("one of the memory sticks died"), repair/replace that component and expect it to carry on as "normal".
Says who? The article is not saying this. The argument that researchers have an unsophisticated model of the brain/mind and its corresponding disorders is frequently put forward to justify a rejection of conventional therapy – which is what you end up doing, surprise surprise.
> The discussion in this article seems astonishingly simplistic and naïve to anyone who has read/heard any of the many researchers who have spent years examining mental "illness"
That's a gross mischaracterization of the article, which says:
“Researchers are also drastically rethinking theories of how our brains go wrong. The idea that mental illness can be classified into distinct, discrete categories such as ‘anxiety’ or ‘psychosis’ has been disproved to a large extent. Instead, disorders shade into each other, and there are no hard dividing lines — as Plana-Ripoll’s study so clearly demonstrated”
So when you say
> So, trying to categorise "disorders" into discrete definitions with distinct "causes" in order to restore the mind to some "normal" state cannot possibly work.
Yeah, nobody's trying to do that. Researchers are clearly aware of that.
I'm happy for you that whatever mental disorders you were suffering from seem to be receding but the attitude that mental health researchers are stuck is a conventional rut needs to be put to bed. If you're going to refute an article at least refute what the article says and not what you claim it says.
My point is that they're still largely making the same mistakes; yes they're blurring the distinctions between "disorders", but they're not going back to first principles, nor giving due consideration to the coherent and compelling work of other eminent figures in their field.
> > So, trying to categorise "disorders" into discrete definitions with distinct "causes" in order to restore the mind to some "normal" state cannot possibly work.
> Yeah, nobody's trying to do that. Researchers are clearly aware of that.
They are still focused on identifying biological causes for disorders, rather than seeing variations in behaviour – even extreme ones – as adaptations that have been selected for by evolution.
It's articulated here:
> They have a few theories. Perhaps there are several dimensions of mental illness — so, depending on how a person scores on each dimension, they might be more prone to some disorders than to others. An alternative, more radical idea is that there is a single factor that makes people prone to mental illness in general: which disorder they develop is then determined by other factors. Both ideas are being taken seriously, although the concept of multiple dimensions is more widely accepted by researchers.
I sigh at that statement, when several prominent figures in the field, all with advanced qualifications in mainstream medicine or psychology, have been offering coherent explanations and effective treatment approaches for years or decades.
Point being... what appears to be a major weakness sometimes turns into a significant advantage.
So my theory is that some of our evolution is not at the individual level but the societal.
I recently finished Hidden Valley Road and one of the interesting things mentioned was the use of nicotine/anabaseine to improve attentional gating. Apparently due to the acetylcholine release in the PFC. Similar effect to modafinil for attentional switching and alertness.
Philosophically, I think it is true that noone can save someone from the torments of a wayward mind. The trick is to overcome this "powerful elephant" with the intelligent use of the mind in the first place, and tranquilize it by studying scripture, satsanga, and renouncing desire/hope. We must identify not with the mind or thoughts, but with what Kant called the noumenal world, the solar existence, pure consciousness.
Having hit my head quite a few times over the past years, I've dug into cutting-edge mTBI (concussion) research pretty hard.
What I learned was that the long-term effects of concussion are now fundamentally thought of as neurometabolic in nature. That is, the loss of metabolic homeostasis within the brain due to an initial trauma. Unless this process arrests, what you're left with is neurodegeneration. How much really depends on the circumstance and patient.
The most striking takeaway I had, was that much of the latest research is suggesting that different etiologies lead to the same pathology in many instances. For example, it may be that you can acquire Alzheimer's Disease, or Parkinson's Disease, or even ALS via way of: chronic poor sleep quality (poor glymhpatic performance), history of frequent subconcussive head trauma (CTE), history of concussive or severe head truama (mTBI/TBI), neuroimmune factors, and of course genetic factors. Often times a combination thereof. That example isn't even remotely comprehensive on either the etiology or pathology side.
Point being, your brain is like a washing machine. If it goes out of balance, sometimes it will only oscillate further out of balance unless the process is arrested.
Psychiatric disorders are much the same way. I suspect it is for this reason that comorbidity is so commonplace.
The interesting part about psychiatric disorders however, is to a degree they can self-reinforce in a unique way. Your behavior and thought literally influence your brain's neurochemical state. Likewise, your brain's neurochemical state influences behavior and thought. I suspect this is why behavioral intervention in conjunction with medication generally works better than medication alone in treating psychiatric disorders.
Of course, it's not as simple as brain chemistry affecting thought and vice versa. You brain chemistry (and as such your behavior and thought) is still subject to effects of neurodegeneration, neurostructural changes, neuroinflammation, immune activation, and so forth.
So what we have is a very, very complex puzzle wherein you have many different factors—often vastly different in mechanism—each affecting the other.
If it's acute (TBI), then almost certainly yes.[1] It's no longer considered a concussion at that point however.
[0] https://www.neuroskills.com/brain-injury/mtbi-and-concussion...
Turbofan engines are a far more dramatic example.
That's a great metaphor. Thanks :)
I'd naively think we're more likely to get a useful theory by trying to push a Predictive Processing approach too far for a while and then find a way to incorporate the signaling impact of hormones & ambient levels of neurotransmitters on various feedback loops.
I certainly found https://slatestarcodex.com/2017/09/12/toward-a-predictive-th... useful for overcoming my writing anxiety and issues with motivation.
One thing to understand about this is that they're not making up these dimensions from thin air. The dimensions are found in a data-driven manner using one of several techniques, most of which fall under the umbrella of factor analysis[1]. If you're familiar with principal component analysis or singular value decomposition, it's a pretty similar idea: you find the dimensions that explain as much variance as possible.
Then, once you have the dimensions, you try to make sense of them in some way. You may do something called factor rotation, which will change what these dimensions are, but you always have the same information among those five factors. Next, you have to give the factors arbitrary names. The names are usually given for the purpose of making it easy to discuss the factors. (This is the same way that the "Big 5" personality scale [2] was developed.)
For instance, if you had a factor which included the survey questions "Do you have trouble sleeping at night?" "Does it take you a long time to fall asleep?" and "Do you wake up not feeling refreshed?", you might name this an "insomnia" dimension. Really, it's just making it easier to discuss the math and data (though the names do end up having a big impact on how people think about the factors).
You can do this with survey data, brain imaging data, genetic data, etc. There are many different ways to find these. That means you can look at how they line up with each other. There are many theories and structures, but a popular one is about the "p factor" mentioned in the article which boils it down to a single dimension. I haven't read the literature for a few years, though, so I can't comment on current thinking about factor structures beyond what the article discusses.
But in the end, the idea is trying to find statistics which are useful and meaningful, either in the clinic or else for guiding future basic research. So when they say "how many dimensions are there?", what they really mean is "how many dimensions can we find that are useful?". It's not a perfect solution, but it is a good start.
[1] https://en.wikipedia.org/wiki/Factor_analysis
[2] https://en.wikipedia.org/wiki/Big_Five_personality_traits
Although this may not seem like a crazy idea, some proponents suggest that essentially everything the brain does works in this way. For example, that the cause of schizophrenic symptoms may be due to them holding a very loose predictive model with weak priors; basically that they don't have pre-existing high-confidence predictions about anything, on every level. You and me likely would predict with very high confidence that we are not and can't be a god, but someone with schizophrenia may not predict that with as much certainty due to a general issue with neural prediction.
I am oversimplifying it and may be partially wrong, but I think that's the general. I'd highly recommend reading that blog's series on predictive processing for a much better explanation. The linked post also discusses schizophrenia.
If this theory is correct then one could use it to guide one's own life?
Here's something I don't understand when trying to look at it through the lens of this theory:
I've had mostly success when it comes to software development. Whether it be new languages, new projects, what have you... If I sit down, focus, and do the work, it comes out well and succeeds. This is in stark contrast to other areas of my life btw, where I've worked very hard at things but made minimal progress.
So if I understand correctly, my internal prediction machine should be predicting success, and thereby providing a jolt of motivation, whenever I think about a new cool project.
Take VR development. I really want to learn Unity and make a cool VR game. But every time I start, I putter out. I get distracted, I don't make progress fast enough, I just.... end up stopping, and doing something else. Why?
You need something to point out which bits of X to pay attention to. Thats why teachers are valuable -- the indicate where to pay attention.
---------
Consider going onto http://codementor.io/ and hiring someone to pair-program with you for a while. If you were at the office and spent 4 hours getting nowhere with a problem, you'd ask a colleague for help.
> All such sweeping hypotheses are premature, says Hyman. “I think it’s a time for much more empirical research rather than grand theorization
So I think it is best to consider this a theory that we all hope is true, which has a slight chance of being true.
The point of models such at this isn't to 'cleave reality at its joints', it's to provide useful frameworks to reason about disease (or politics).
High level concepts such as schizophrenia attempt to given a human understandable account of what Schizophrenia is, why it emerges, and what treatments we may form.
Reductionism of the sort of, "we've looked at every neuron and figured out that 12301231723 of your 3782328372832 brain cells are out of whack" has no explanatory power. The goal of inquiry into mental illness is not to give some physical account of what is wrong with the brain, it is to give an account of what is wrong with the mind.
These brain chemistry accounts of psychological illness really have glaring problems. By definition they exclude all ecological or cultural factors by focussing on some individual's brain. But this is almost tautological, all psychological illness manifests in some sense in the brain.
When some local company pours lead into the river and everyone loses 20 IQ points then that manifests in the brain, like anything else does. However the right framework in that case is ecological.
An ADHDer who repeatedly finds that their distractibility leads to them to fail at obvious tasks and disappoint the people around them can very easily develop symptoms of depression. Would that require having the biological underpinnings of depression?
(I wish they’d change the name of CD to something that avoids the layperson’s concept of “depression” - that alone would help the well-meaning but ignorant people who think it’s just a matter of finding a way to cheer oneself up and certainly nothing to do with serotonin...).
There is nothing in the original post that was wrong about clinical depression.
ADHD and Clinical Depression are sometimes co-morbid for exactly the reason you just strongly asserted they are not.
I really struggle to understand where that comes from so I can handle it better. I do believe it developed over time, though. I think it can be reversed. Perhaps that's just a lingering thread of optimism.
I started to think that I was a fucking idiot for being incapable of doing what was expected of me, and what I wanted to do. All my grand plans and projects and ideas seemed to just slip through my fingers, despite best efforts I couldn't (and still struggle to) get out of bed in the morning and get to work on time. It was frustrating.
For me it started when I finished university and I realised I had me entire life ahead of me, and no idea what to do with it. As a kid, sure I had plenty of screwups and a tough time, but I always saw the light at the end of the tunnel, I just had to get through my assignments and exams, finish school, finish university, get a job. Once I had done all that I sort of lost all purpose and identity, I had no idea who I was supposed to be. I had grown up with the concept that I was going to get my degree and find a job, then marry some girl, buy a house and have some kids and I'd live happily ever after, like I thought my parents did. Turns out that's not what I wanted in life, and I really struggled to find a purpose.
I think this is incredibly common for all sorts of people with different mental health issues, not just ADHD, I know plenty of people who've experienced the same descent into a hopeless state. Some turn to Jesus, some to drugs, others just say fuck it and kill themselves.
The treatment for depression caused by other mental health conditions (e.g. ADHD) and Clinical Depression are very different, although they are often comorbid. Generally successful treatment of the underlying condition also makes the depression go away. Giving antidepressants to someone who has ADHD with depressive symptoms (without treating the ADHD, i.e. it's undiagnosed) generally doesn't alleviate the depressive symptoms.
It isn't strictly depression that's a diagnostic criteria for a lot of disorders/conditions, but rather a negative impact on normal functioning and everyday life. Some people are just rendered incapable due to their mental health, unable to hold a steady job or impulsive to the point of committing assault or other crimes. Some people just take it on the chin without getting depressed about it, but others (those with the biological underpinnings of depression I suppose) get depressed or anxious. There's plenty of chronically underachieving people with ADHD who are perfectly happy, and others who experience significant distress.
You have captured my point exactly.
> Clinical Depression is a state of depressed mood without clear cause.
Sure. It is easy to have a depressed mood without clear cause if you just fail at identifying the cause.
Back when I didn't know how to identify aircraft, I saw unidentified flying objects pretty often.
1. People who are doing okay don't seek out diagnosis. One big example is Bill Gross, the "Bond King" who manages mutual funds - he happened to read the description of Asperger's and realize he had it in his seventies. Psychologists do not see a representative sample of society. If diagnosis A and B are both mild enough to cause some people with it to not seek treatment, but everyone with both to do so, you'll see a correlation between A and B.
2. All mental health diagnostic criteria share a clause that sounds like "and these symptoms cause a significant amount of distress or ill-functioning to the patient." This is similar to the first factor, but happens after people seek treatment; if you tell a psychologist that you aren't having any problems in your life, they do not diagnose you with depression, anxiety, ADHD, etc. It almost doesn't matter what you have going on, if it doesn't cause problems its not worth using medical care on, so it doesn't get diagnosed. And again, if you only have one kind of thing causing you problems, it's more likely to not be severe enough to warrant some kind of diagnosis.
3. Similar to the previous factor, mental health diagnoses are used to gatekeep medical care and social support. So, people who need more resources than they currently have are going to push more for additional mental health diagnoses, while people who are more okay are going to be fine with the first one proffered. Eg, a young woman who is extremely anxious and whose mom yells at her all the time goes in, gets diagnosed with anxiety and prescribed anxiolytics, things are still bad because her mom keeps yelling, so she goes back and gets a depression diagnosis and anti-depressants. Or a school can offer accommodations for ADHD and not autism, or vice versa, so someone with one goes back and asks the psychologist for the other.
In short, there's a general willingness-to-seek-diagnosis that's an obvious latent variable for mental health diagnoses. I'd be more surprised to not find a positive correlation between two arbitrarily picked mental health diagnoses. If there's an outright negative correlation, that's something that would be actually indicative of a biological link of some sort - either the biochemistry of one complex protects against the other, or they're a pair of under/over-activity of a system, or the like.
I went to the doctor in my mid-20s to get treated for ADHD, as it was causing me significant problems in my life, having gone through bouts of anxiety, depression, and suicidal ideation for the year or two prior, which the manifested itself in an inability to manage the negative traits of my ADHD. I've had it all my life, but only realised I likely had it a couple of years prior, but it was never something that caused big enough problems to go to a doctor about, mostly just report cards stating "easily distracted and distracters others".
At the same time I was diagnosed with ADHD, the doctor said it was likely I also had high functioning autism. I guess maybe I have it, but it's not something that's ever caused me any particular problems in life, so the doctor basically said not to worry about it and only to seek treatment (therapy or counselling) if I felt like I needed it. Same story for the ADHD too, he said there was no need to continue seeking treatment if I felt like I didn't need it at any point in the future.
On the other hand, being put on medication for ADHD (clonidine and dexamphetamine) has made a world of difference for me, and I've seen vast improvements in quality of life. Most importantly though has been recognising and accounting for the fact that my mind functions in a different way than most people, and making accomodations (and asking others to accomodate) for this.
Interestingly enough, he also mentioned the possibility of having bipolar disorder as well, but said that it was likely the symptoms were actually ADHD masquerading as bipolar and decided to treat the ADHD first and see if the symptoms remain. Diagnosing mental health issues is a difficult task, a lot of people with ADHD are misdiagnosed with bipolar, or people with bipolar diagnosed with clinical depression. If it wasn't for the fact that I was fairly certain that I had ADHD when I went to the doctor, I wonder what I would've been diagnosed with.
I think the language around mental functioning and disorders isn't great.
If you have Asperger's or ADHD and don't experience distress or difficulty in life from it, then it's not really a mental illness or disorder, it's just a different way your mind works. ADHD has a particularly bad name, it's not an attention deficit to begin with, but rather an inability to chose what your attention is on (you should see me if I'm in a hyperfocus/flow state, it's definitely not a deficit of attention), and it's not always hyperactive. I have primarily inattentive-type ADHD, you wouldn't pick me as having it just from looking at me, I display barely any "typical" traits of ADHD, it's mostly mental for me (mood swings, inattentiveness, impulsiveness, poor working memory, no concept of time, rejection sensitivity and a lack of emotional permanence). I don't think it's intrinsically a disorder either, it's been hugely beneficial in parts of my life, and I don't really want to be labelled as disordered or broken for the entirety of my life, it only became a disorder at a certain point in my life, largely due to external factors at the time. Often it's helped me function above and ahead of neurotypical people.
I know plenty of people with ADHD who don't take any medication and don't feel the need to, and get by perfectly fine in life. My father very likely has ADHD (it's hereditary, and he displays a lot of traits), and has never seeked treatment for it, and he's a very successful man. Same for people with bipolar, autism, or other neurodiverse minds.
I have always thought that mental disorders are no different to physical disorders. We all know some people who are robustly healthy while others seem to get a bewildering array of different diseases. Illness is not randomly distributed.
But then I saw a psychiatrist who inquired about my use of psychoactive drugs. And based on my love of stimulants, he diagnosed me as having bipolar disorder, manifesting primarily as depression. And so he prescribed modafinil, with lamotrigine to reduce the risk of mania.
So I wonder if bipolar disorder is actually relatively common. I mean, I was self medicating primarily with caffeine, and for many years used nicotine to take the edge off. Maybe that's fundamentally why coffee, tea, etc are so popular.
Edit: typo
There's a milder form of bipolar disorder called cyclothymia that is rarely diagnosed unless a patient seeks psychiatric care for a different reason. Estimates suggest it's fairly common, potentially up to 1% of the population.
I was diagnosed with ADHD, with the possibility of bipolar, and also have a sweet tooth for stimulants, both legal and not (I'm basically fuelled on caffeine, nicotine, and amphetamines).
I've also never heard of modafinil being prescribed as a treatment for bipolar disorder either, do you happen to have any resources on this?
Since then I've thought a fair amount about mental illness in general and have a few theories.
1) Diet. Get the right materials into your body so it can do with them what it needs to. Especially early in life while brain is still forming.
2) Exercise. Make sure your body can get sufficient blood / oxygen to all parts of the body so it can function properly.
3) The brain, IMO, should be viewed as a TOOL Sure it is already part of our body but this is why I think it's so overlooked as a perspective. If I decided to do some landscaping and needed an excavator, I would need to learn how to use it, and practice in order to become efficient and effective with my use of it. I think it's same with the brain. New circumstances come up all the time and sometimes the people who experience them have not trained their brains to deal with them in an effective / efficient way. There should be more focus on this sort of perspective / reflection / learning and perform these generally-applicable exercises early in life. Not just math, science, english, etc.
-- There is no doubt in my mind there are going to be SOME genetically relevant issues. But I would be surprised if, once this stuff gets fleshed out further, we don't come to realize most of it was preventable.
I think you're probably right to a large degree. To paraphrase you're basically saying yes, there for sure is a very real genetic and environmental component, however if we simulate a reality where everyone runs their bodies and minds in an optimal manner we'd be far less likely to see all forms of disease including mental illness/psychiatric disorders.
The takeaway is if you're struggling with it, they are both important components that ought to be a part of a wholistic treatment plan.
I was watching something on Health Theory the other day and she psychiatrist being interviewed said they start with an elimination diet and the nutritionists have more success than the psychiatrists.
Food for thought.
Reducing the complexity of the bio-psycho-social model down to "exercise" and "eat better" isn't great.
Parent post is clear: get exercise, eat better, prevent mental illness.
But there is a percentage of the population that, even with correct diet, exercise, and general mental hygiene, are incapable of surmounting their mental health problems.
Everybody is different, and you can't really apply your personal anecdote to everyone who's suffered from depressive bouts or other mental health issues.
It's incredibly frustrating when people tell me I just need to eat right, or do yoga, or align my chakras and all my mental health problems will go away. It's borderline accusing me of being lazy or stupid for feeling and functioning the way I do.
Meanwhile, the Dodo Bird theory [0] has yet to be disproven, and there are good reasons to suspect that humans are merely smart mammals, rather than special animals who have no peers throughout the rest of the kingdom, which means that psychology and psychiatry are only the tip of a much bigger comparative discipline which handles humanity as a special case rather than as the main system of study.
Your example of SSRIs is an especially poor one, as SSRIs are well-understood to have been developed by the pharmaceutical industry as part of a panpsychic wellness package which is meant to be sold pill-by-pill to the public [6][7]. SSRIs today are like sugar in the past [8], with a corporate army of compensated scientists ready to study the noise and find useful results from harmful chemicals.
[0] https://en.wikipedia.org/wiki/Project_MKUltra
[1] https://en.wikipedia.org/wiki/Edgewood_Arsenal_human_experim...
[2] https://en.wikipedia.org/wiki/Crack_epidemic_in_the_United_S...
[3] https://en.wikipedia.org/wiki/CIA_involvement_in_Contra_coca...
[4] https://en.wikipedia.org/wiki/Homosexuality_and_psychology
[5] https://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Man...
[6] https://en.wikipedia.org/wiki/Selective_serotonin_reuptake_i...
[7] https://twitter.com/jcbonthedl/status/1159823784242753537
[8] https://en.wikipedia.org/wiki/Sugar_marketing#Influence_on_h...
The solution is ML. Neural networks with appropriate architectures effectively perform a change of basis, mapping the data basis to an output coordinate system. When properly trained they can automagically orient their internal representation with the true data bases.
The difference is whether the process can be automated, and that is where the problem of the black box comes in. With the current system, we know why the drug was prescribed. With an ML system, we would have no clue.