Dealing with Physical and Mental Illness

Saturday, 02 April 2011 12:00

Dealing with Mental and Physical Illness

Any similarity between mental and physical illness resides solely in the language used to discuss them. It is the language of medicine, of physical causes, symptoms, syndromes, cures, and where the illness cannot be cured, management. We may talk about mental illness in terms of physical causes and cures and list the symptoms of mental illnesses such as depression, schizophrenia, mania, obsessions and compulsions, and phobias, but such language actually prevents us from understanding what is happening to the person concerned.

If we want to understand a particular physical illness all we have to do is refer to the results of the scientific research into the functioning of the body. We no longer have to rely on fantasies such as bodily humours or demonic spells to explain why we become ill. The causes and effects of physical illness can be readily demonstrated by various tests carried out on the body. The medical profession is extremely reluctant to decide that a set of phenomena is a disease if a physical cause cannot be demonstrated. It took some time to establish that Creutzfeldt-Jacob Disease (CJD) was a physical illness while whether chronic fatigue syndrome (ME) is a physical illness is still hotly debated.

In contrast, if we want to understand mental illness or, as it is now called, mental disorder, reference to the body is a complete waste of time. No physical cause has been found for any mental disorder. Psychiatrists may claim that depression is a result of the chemical imbalance of the brain, that mental disorders have a genetic cause, and that psychiatric drugs restore the chemical balance in the brain, but such claims are without any scientific basis.

The brain is the most complex object we have yet encountered in the universe. It operates differently from all other known objects. There are a great many differences between individual brains because the pattern of connections between the neurones in the brain is determined by the experiences the person has, and no two people ever have the same experience. Neuroscientists like Walter Freeman  recommend that we should not talk of 'the brain' but of 'brains', thus acknowledging that no two brains are ever completely alike. Such wisdom is completely ignored by those people who are not neuroscientists but who wish to appear to be authorities on the brain. They talk seemingly knowledgeably about direct connections between brain activity and behaviour, as if, a magnetic resonance scan of a brain can reveal what the person is thinking. David Healy , the psychiatrist who has shown how dangerous drugs like Prozac can be, calls such talk 'biobabble', in contrast to 'psychobabble', the nonsense which is talked by another kind of would-be authorities. Unfortunately biobabble often replaces proper care.

For instance, if you get depressed and consult a GP or a psychiatrist you are likely to be told that your depression is a result of a 'chemical imbalance in the brain.' What isn't mentioned is that nobody knows what a chemically balanced brain is, so no one can possibly say what a chemically imbalanced brain might be. 

You might also be told by your doctor that one feature of a chemically imbalanced brain is that there a lower levels of serotonin in the brains of depressed people than in the brains of non-depressed people. The Australian national depression initiative called beyondblue has a website to inform people about depression. There it states that, 'Severe depression appears to be associated with a reduction in the chemicals in the brain.'  Such a statement appears to be based on sound research but it is not. Because there are no physical tests for any psychiatric disorder all diagnosis is simply a matter of the opinion of the psychiatrists doing the diagnosing. There is immense individual variation in these opinions. As a psychiatric patient you can discover that one psychiatrist says you are depressed, another that you are anxious, another that you have a borderline personality disorder. Thus it is extremely difficult for researchers to establish that their research group are all suffering from the same disorder. The beyondblue website may refer simply to 'severe depression' but in the Diagnostic and Statistical Manual   used by most psychiatrists there are listed 39 different kinds of depression, including 'depression in complete remission'.

What can logically be deduced from the discovery that depressed people have lower levels of serotonin than non-depressed people? These lower levels and the depression occur at the same time. A correlation cannot be a cause. For instance, in the 1990s there was an increase in the number and size of the famines in Africa and an increase in the number of mobile phones. Can we conclude from that that mobile phones cause famine, or is it that famine causes mobile phones? To show that lower levels of serotonin cause depression it would be necessary to show that such lower levels occur before the person becomes depressed. To date no physical change has been shown invariably to precede depression.

The latest kind of anti-depressant drugs, the Selective Serotonin Reuptake Inhibitors (SSRIs), were created to replace the missing serotonin in the brains of depressed people. The beyondblue website states, 'Antidepressant medication is designed to correct the imbalance of chemical messages between the nerve cells.' When these drugs seemed to be successful in curing the depressed person the conclusion was drawn that this was further evidence that the cause of depression was a lack of serotonin. Drawing such a conclusion is the same as concluding that, because aspirin cures headaches, the cause of headaches is a lack of aspirin.

If you consult a psychiatrist about your being depressed you are likely to be asked about your family history to see if depression runs in your family. You may recall that in your parents' and grandparents' generation there were relatives who went through unhappy periods in their lives but in those days people were not diagnosed with mental disorders as they are nowadays. It is on such flimsy evidence like this that psychiatrists interested in genetics have concluded that depression has a genetic cause. Things do run in families. My father voted Labor, I vote Labor, my son votes Labor. Obviously we have the Labor voting gene. Trouble is, it is an Australian Labor-voting gene and it doesn't get on well with the New Labour-voting gene in the UK.

If you are interested in the whole question of genetics and mental disorder I would recommend that you read Jay Joseph's book The Gene Illusion , published last year, which shows how unscientific and self-serving most of the research into genes and mental disorder has been. Alternatively, you can read geneticists like Professor Steve Jones of London University who is always pointing out that complex behaviour cannot be explained by the functioning of genes. He often says quite sadly that no one even understands the genetics of height or of eye colour so to talk of the genetics of depression or schizophrenia is a nonsense.

Many people, perhaps most people, get depressed and get over it. Some of these people are prescribed anti-depressants, some are not. However, current psychiatric dogma is that depression is a genetic disorder which must be managed by psychiatrists. Many patients are advised by their doctors that, even though they are no longer depressed, they should take anti-depressants to prevent themselves getting depressed again. The beyondblue website states, 'Once you have had an episode of depression you are likely to have further episodes,' and advises people to continue taking antidepressants long after they have ceased to be depressed, even for the rest of their lives. Long term research on the prophylactic use of antidepressants shows that, despite taking these drugs, some 30% of the people taking them get depressed again. This figure is hardly good, but it cannot be concluded that the drugs actually prevent depression since of that 70% who did not get depressed an unknown percentage would not have got depressed again whether or not they had taken any drugs.

From written history we know that depression and psychosis have always existed, but they were not defined as mental illnesses until the late nineteenth century when the German psychiatrist Kraepelin declared that they were. In describing them he said that depression and schizophrenia were life long illnesses. Once you got depressed, once you became schizophrenic, you were in that state for life. This belief still operates in psychiatric practice today. 

In diagnosing schizophrenia psychiatrists were always taught to regard auditory hallucinations as the front-rank or primary symptom of the illness. In a psychiatric examination a psychiatrist would seek to establish whether the person heard voices. It was not part of the examination to ask who these voices belonged to and what they were saying. A person who tried to talk to a psychiatrist about the ownership and content of the voices would be ignored. Psychiatric nurses were taught that if patients started to discuss their voices the nurse should distract them by, say, suggesting a game of scrabble. Many ex-psychiatric patients are experts at scrabble.

Then about ten years ago a woman called Patsy Hage got angry with her psychiatrist. She took him to task for never letting her talk about what her voices were saying. Her psychiatrist, Marius Romme, is a very kindly man and he dutifully conceded that he was wrong. He listened to what Patsy told him, and then he listened to other patients talk about their voices, and it soon became clear to him that these voices were not just random noise in the person's head but part of the way in which the person made sense of his life. Marius and his research assistant Sandra Escher set about doing some systematic research. They soon discovered that quite a significant percentage of the general population hear voices. Most of these people hear voices that are benign, even helpful. Only those people who hear horrible, persecutory voices earn the diagnosis of schizophrenia. These patients themselves, once given the opportunity, were able to work out ways of keeping their voices in order.  The voices are actually auditory memories that occur in the same way as we can hear music in our heads. The voices and the music will disappear as soon as you start to speak because the brain cannot do both tasks at once. Have you ever wondered how many of those people busy talking into their mobile phones are actually engaged in keeping their voices in order?

The Hearing Voices Movement was set up and run by psychiatric patients. Their work has been the greatest advance in mental health since the asylums stopped shackling their patients. Many people, once diagnosed as incurable, are now leading ordinary lives. Psychiatrists responded to the Hearing Voices Movement by allowing nurses to run Hearing Voices groups and by redefining auditory hallucinations as a not very important symptom of the mental disorder schizophrenia. 

Such a re-definition is an example of what Professor Bill O'Neill, my professor at Sydney University, used to call 'saving your hypothesis'. This is a technique which protects you from having to say that you were wrong. Another example of saving your hypothesis occurred in the 1990s with regard to depression.

In the early 1960's when the first anti-depressants were being prescribed widely with good results psychiatrists' view of depression changed. Instead of seeing depression as a life-long illness they saw it as a short-term disease which psychiatrist could cure with drugs. This was the view of depression held by Professor Alec Jenner and his colleagues at the professorial in-patient unit in Sheffield, UK, where I went to work in 1968. They could see no point in having a psychologist there but they had no objection to my talking to the patients. At this clinic depressed patients were treated with drugs and electroconvulsive therapy (ECT). There was common pattern. People would come in to the clinic depressed and go out some months later not depressed. Then six or so weeks would pass and they would be back, depressed. I took to calling the front door of the clinic a revolving door, something which did not endear me to my colleagues. 

By the early 1990s the evidence from long-term studies supported my observations and could no longer be ignored. It showed that for those depressed people who were treated only with drugs and ECT a certain group of them would get depressed once and not get depressed again but for the majority depression recurred. The best predictor of further depression was the occurrence of an episode of depression. Here is a curious contrast with physical medicine. If, say, an antibiotic repeatedly fails to cure an infection most doctors would conclude that the antibiotic does not work. Not so with psychiatrists. It is not that the anti-depressants do not cure depression. It is that there is a kind of depression which is impervious to anti-depressants. This is now known as chronic depression. There's a lot of it about.

Also by the end of the 1990s evidence was accumulating that depression need not be chronic and lifelong . Depressed people who went into therapy rather than take drugs stood a very good chance of not only ceasing to be depressed but also not get depressed again. Very reluctantly psychiatrists began to take account of this. They particularly liked Cognitive Behaviour Therapy (CBT) because it does not ask difficult questions about family life, or old age and death, or what is the purpose of living. The originator of CBT was a psychiatrist Aaron Beck. There is no doubt that CBT, in the hands of a competent therapist, can be extremely effective. However, Aaron Beck was very careful not to offend his psychiatrist colleagues by showing that CBT was more effective than drugs. He and his followers always use the language of illness and never say that drugs are unnecessary. As a result cognitive therapists have never developed a coherent model of depression which shows why changing how we think can bring depression to an end.

Psychiatrists have not succeeded in developing a coherent model of depression or of any of the mental illnesses. They have been forced to acknowledge that, as they say, social and psychological factors play a part in mental disorders, and they acknowledge the success of CBT not just in depression but in all the mental disorders, but they shie away from examining the question of why changing how you think can bring a mental disorder to an end but changing how you think will not cure cancer or even the common cold. Having a positive attitude can be helpful in the course of a physical illness but thought alone will neither cause nor cure a physical illness.

Psychiatrists want to hang on to their belief in the physical causes of mental illness because it is this belief which justifies the existence of their profession. Thus on the beyondblue website the model of depression which is presented includes every possible aspect of a person's life but it explains nothing. 

Where therapy is concerned the beyondblue website gives the greatest space to drugs, followed by CBT and behaviour management. Therapies where the person and the therapist explore the relationship between childhood experience and adult life are given short shrift with the advice, 'Most people with depression do not need this kind of in-depth and prolonged re-evaluation of their life.'

What psychiatrists and many of the CBT therapists ignore is what actually determines our behaviour. Studies of the brain - our brains - by neuroscientists show clearly that physiologically we are not capable of seeing reality directly. All we can perceive are the structures which our brain learns over time to construct. These structures are theories, guesses, about what is actually happening. The structures which we create come from our past experience, and, since no two people ever have the same experience, no two people ever see anything in exactly the same way. What determines our behaviour is not what happens to us but how we interpret what happens to us. 

All of the structures or meanings we create cohere together to form a structure which we experience as our sense of being a person. But the ideas which form our sense of being a person can easily be disconfirmed, and when this happens we feel ourselves falling apart. We cast around for some ideas which will defend us and hold us together. The most desperate of these defences are those behaviours which psychiatrists call mental illnesses. People turn to these when they have completely lost confidence in themselves .

However, if we understand that when we suffer a major disconfirmation of our ideas, such as happens when we suffer a disaster, our ideas have to fall apart so that we can construct ones that better fit our situation, we can ride out the chaos and uncertainty of such changes without having to resort to any of the desperate defences. If the disaster we have suffered has undermined our self-confidence we can rebuild it with the knowledge that, as we have created our ideas we are free to change them.

The cause of mental illness is ignorance and the cure lies in knowledge of ourselves.