Apr 24 2007

Mental Illness Denial Part II

Yesterday I wrote about my debate with Dr. Fred Baughman, who denies the existence of mental illness and the scientific legitimacy of the field of psychiatry. I laid out the basic foundation of modern neuroscience and how this leads to the conclusion that there must be mental illness, for the brain causes the mind and the brain is a biological organ like any other. Today I will discuss some of the specific arguing tactics that Baughman and others use to avoid this seemingly unavoidable conclusion.

All behavior is normal

Dr. Baughman’s points are more semantic arguments and misdirection than valid logic. He argues, for example, that the entire range of human behavior should be considered normal. All traits vary, he argues, and it is not valid to simply label the extreme ends of this variation as abnormal. To reiterate what I wrote yesterday, he returns to his position that only classic pathology can be considered a disease, he excludes all other criteria a-priori, and only disease can be considered a medical condition.

First, it is not clear if the traits that are considered symptoms of any particular mental illness are simply the ends of the bell curve. It may be, in some cases, that there is not a simple bell curve of variation, but the illness represents a bi-modal distribution – a separate group off the bell curve.

But even if we assume that, say, the ability to attend to a task varies on a bell curve (a matter of contention, but let’s grant this for hypothetical purposes) that does not mean that we should consider every point on the curve as equally normal or healthy. Let’s take blood pressure, for example. The upper end of biological variation of blood pressure is considered a disorder (more on this definition later). It is a risk factor for several diseases. Considering high blood pressure as unhealthy and worthy of treatment is not controversial. There are numerous examples of this in medicine. There are certain parameters for healthy biological function and if variation strays sufficiently outside of these parameters health or function is compromised.

There is no reason to exclude mental functions from this classification. For example, we evolved mood for a reason. It is adaptive to be depressed when bad things happen and happy when life is good. But when someone is extremely happy (manic) all the time, mood is no longer adaptive, it is disruptive. Some people are so depressed, and for no apparent reason, that they cannot get out of bed. Or they are so manic that they spend their money recklessly and destroy the practical necessities of their life. By what logic should such maladaptive extremes be considered healthy?

The response of the deniers is simply that without disease we cannot call something unhealthy – a return to their premise which is little more than an unsupported assertion.

Disease vs Disorder and Semantic Arguments

To avoid confusion of terminology the word “disorder” is often used to refer to the malfunction of some biological process when no underlying classical pathology is present. The term “disease” is reserved for a known pathophysiological process. Admittedly, the terms are sometimes carelessly interchanged, and this leads to confusion.

It is common for physicians to recognize that a constellation of signs and symptoms tend to occur together, with a characteristic natural history. Before anything is understood about the underlying cause, such clinical entities can be recognized and even well characterized. Methods can be developed to reliably diagnose them based upon the presence of enough of the typical signs and symptoms. It may be recognized as a medical disorder long before the underlying pathophysiology (disease) is identified. To qualify as a disorder, the symptoms must also cause demonstrable harm. To be considered a biological disorder, vs a purely psychological disorder, there needs to be evidence that the symptoms emerge from internal rather than only external factors.

So how do we know such disorders are real? Well, sometimes, admittedly, it can be tricky. For example, is Gulf War Syndrome a real medical disorder, or an illusion? Other disorders, like migraine headaches, have several specific symptoms and many identifiable epidemiological factors that allow it to be recognized and diagnosed with a high degree of confidence.

Many mental illness entities are disorders, like migraine, in that they can be reliably diagnosed, the diagnostic criteria have been validated, and they have a specific epidemiology and natural history. To dismiss the reality of all medical disorders where a specific pathology has not been identified is to reject much of modern medicine.

When applied to many psychiatric disorders the terms become a bit fuzzy. In my opinion, terminology has simply not kept up with the advance of neuroscience. If we can identify that a specific neurotransmitter is deficient in certain parts of the brain, is this a disease or a disorder? Well, it depends on whether or not you count brain structure and neurotransmitter function as a criteria for “disease.”

But this is all a semantic argument – it does not get to the real point, that the “soft” problems that can occur in the brain, problems with the pattern and strength of signaling, can result in real mental dysfunction. Baughman retreats to the semantic argument as a way of glossing over the real question. During the debate he argued that the terms disorder and disease are synonymous because psychiatrists use them that way. Even if true, which I do not accept, it is a non-sequitur.

But Baughman is operating within a very simple paradigm (no disease = normal) and must constrain all arguments to this narrow (and arbitrary) box that he has constructed. He cannot allow for any broadening of the definition of what counts as biological dysfunction, because then mental illnesses might sneak in.

During the debate I gave him the example of migraine headaches, as it is the closest non-controversial analogy for mental disorders. He was taken aback by this and did not have a good response. He eventually latched onto the notion that migraines are associated with visual scotoma (black spots) and that this was an objective finding. Mental disorders, he argues, have no objective findings. But this is patently untrue, and I find it hard to believe that Dr. Baughman, as a neurologist, does not know it. Not all patients with migraine have a scotoma, or any objective findings. I have diagnosed hundreds of patients with migraine – never on the basis of objective findings on neurological exam. The international classification of headache disorders (ICHD) diagnostic criteria for migraine does not even mention scotoma, and includes no objective exam findings, only reported symptoms.

To emphasize this point, migraine is a clinical syndrome, diagnosed on the basis of having a certain number out of a list of characteristic symptoms. This is exactly how most psychiatric illnesses are diagnosed. So by Dr. Baughman’s criteria migraine is not a legitimate medical illness (except for those minority with objective exam findings).

False Dichotomy

Dr. Baughman also created what is essentially a false dichotomy when he said that disease (classic pathology) leads to physical ailments, and psychological symptoms do not have underlying disease. But this is not true. All of the objective physical problems that can affect biological organs – infection, trauma, metabolic derangement, etc., when they affect the brain may cause psychiatric symptoms. In fact, when a patient presents with a new onset of psychiatric symptoms (anxiety, psychosis, etc.) it is typical for an underlying disease to be first ruled out before psychiatric treatment begins.

I personally have treated patients who presented with symptoms of schizophrenia and were then found to have a brain tumor. Removal of the tumor cured the schizophrenia. I have had numerous patients with frontal brain damage from a motor vehicle accident who developed, as a direct consequence of their brain trauma, mania, disinhibition, poor executive function, or apathy and depression.

Dr. Baughman wants a clean separation between classical disease and mental illness – but no such separation exists. Even the disease states he says are the only real medical problems are known to cause symptoms of mental illness.

Further, the same mental symptoms can result from more subtle dysfunction – such as poor development, a paucity of connections, or abnormal neurotransmitter activity. If we consider two hypothetical patients: patient A has a congenitally underdeveloped frontal lobe which can be demonstrated to have low physiological function, and patient B had a motor vehicle accident that caused trauma to his frontal lobes. Both patients may now exhibit the exact same clinical symptoms – namely poor executive function (the ability to inhibit one’s desires and act strategically for long-term goals). It seems clear that both patients have a mental illness but with differing underlying causes. The symptoms are the same because the same part of the brain is affected. Dr. Baughman would say that patient A is normal, and patient B has a neurological disorder, and that mental illness does not exist.

Tomorrow I will write about the objective scientific evidence for a biological basis for various mental disorders and how Dr. Baughman dismisses such evidence.

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