Mental Health and the Brain: A Discussion Fall, 2008 a course at Bryn Mawr College and associated public conversation

Our eighth session and resulting on-line forum discussion completed our discussion of mental health therapies in general. This week, we will begin discussion of particular instances of mental health issues in the context of a variety of available therapeutic procedures and our earlier discussions of the brain.

Readings for this week

Depression (and anxiety?)

• Exploring depression: drugs, psychotherapy, stories, conflicts ...
• David Hume: a letter to a physician
• Depression from the inside
  

• Schizophrenia, "Just the facts". What we know in 2008. Epidemiology and etiology.
• Connections in schizophrenia

Relevant recent materials elsewhere

• Science Times last Tuesday on genes, including "Scientists and philosophers find that 'gene' has a multitude of meanings"
• In a novel theory of mental disorders, parents' genes are in competition (see comment for a perspective on this article different from that emphasized by the title)
• A special issue of Science on "Genes and Behavior," including a review on Genes and Social Behavior

Where we've been ...

I can't help but wonder, if our brains can, so to speak, "get us into these messes" ... shouldn't our brains alone be able to fix it? ... How can it create something, without having a way to undo it? It seems that if therapy and meds were always needed to fix whatever the brain had caused, then, evolutionarily, we'd be at a huge disadvantage, because what if these things were not available? ... I just find it hard to believe that we don't have the ability to will ourselves to get better ... kgins

Better than 80% of us have some experience with one or another form of mental health procedure ... Paul Grobstein

I'm glad we got to spend a little time talking about Freud and psychoanalysis on Monday ... the man and his thoughts are such a huge influence on pretty much everything we talk about in class every week ... As far as a comparison between CBT and psychoanalysis, I don't see much difference in the end goal - to develop a new story. It seems like CBT just gives you a more concrete method for doing this. More tools... It seems empowering to me ... ryan g

I find psychoanalysis fascinating ... I agree ... that CBT seems more like pharmacotherapy in that it treats the symptoms but may not treat the underlying cause. In my opinion psychoanalysis is more about self-discovery ... Paige Safyer

Pharmacotherapy and talk therapy provide us with a tools that may be more useful for some individuals than others. For example, individuals with clearly defined problems that they wish to address can appreciate the brief, cheaper, and more targeted approach of CBT. However, others are incapable of articulating a specific problem. That doesn’t mean that they don’t deserve help, need help, or are ready for help. It is possible that they are seeking professional help because of an inability to resolve dissatisfaction with their mental states through informal routes. Their lack of communication can be considered a symptom of their mental illness ... jrlewis

Who am I to say that any one therapy is ineffective or even inefficient? Who are we to say that one is better than any other? Do we even have a definition about what a "better" therapy would be? Is it cheaper? Quicker? Gets people off drugs faster? Do the patients "feel" better? I have no answers for these kinds of questions, and I haven't heard a cohesive argument from the class as of yet ... Ljones

I want to second akerle's comments ... social structures - for good and for bad have been eroded by modernity and city life. We have significantly more freedom and that freedom - can be both very helpful for people (especially people who do not "fit in") but it can also prove to be very isolating to people ... adiflesher

Since class, I have been trying to reconcile my emotions with my thoughts ... Emotional and mental pain seem mysterious, perhaps always will *be* mysterious, but if there were such things as antibiotics for depression, medications that consistently worked and lightened the brunt, would we advocate avoiding them? ... ysilverman

"the very moment I stopped thinking of my condition as “the enemy,” I made a turn and began to get better. I wasn’t cured, wasn’t forever well, but I was better. Metaphors matter." ... Siri Hustvedt

accepting something doesn't mean a resignation to it--and often in that acceptance can come the time and space to learn the true nature of that which we initially felt compelled to fight ... all illness, mental, physical, is part of our bodies, our brains, or stories, and so an appropriate relationship to it is not one of pure other/enemy, but of trying to figure what it's doing, how it got there, and how now to proceed in light of its presence ... It's very interesting to me to consider what the brain is trying to do through conflict and illness, and what we as patients and physicians may be doing to help or impede those responses and processes ... mstokes

Take off points - schizophrenia

Schizophrenia, "Just the facts".

descriptions of schizophrenia have been fairly consistent over the past two centuries and .... its occurrence has been relatively stable over the period 

worldwide prevalence with pockets of low and high prevalence 

• Heritability is high ...
• There is no "major" gene locus ... and a large number of candidate ... genes may contribute
• No gene appears to be either sufficient or necessary for the developent of schizophrenia

Although it appears that our understanding of the causation of schizophrenia has substantially increased during the past two decades, what we can confidently assert is essentially the same - both genetic and environmental factors are important, but ... how they cause schizophrenia is still unknown .... A reconsideration of our basic strategies and fundamental assumptions may be in order.

To paraphrase Mark Twain in this regard, "it ain't what people don't know that hurts them, it's what they know that ain't so".

We need to consider the possibility that there is no "one" schizophrenia.   

We have accumulated a significant amount of infomration pertaining to the causes of schizophrenia, but our comprehension of its etiology remains limited.  It is vital that we examine the reasons for this continuing gap between "findings" and "understanding." 

Connections in schizophrenia

"Only recently has much attention been given to white matter in schizophrenia.  The primary research focus has been on gray matter, where the neuronal cell bodies, dendrites, and synapses are located, not on the white matter, which provides the wiring between cortical regions ... the identification of morphological and neurobiological abnormalities in white matter lends further support to the hypothesis that there is a problem in brain connectivity in schizophrenia."

"If we interpret the increased white matter metabolism as an indication that the white matter is stressed, it would be helpful to better understand the nature and causes of this stress."

"Future advances in schizophrenia research will depend on examinations of connections at and across multiple levels, including cellular pathways, neuronal circuittry, brain regions, and different modalities and disciplines."

Take off points - depression (and anxiety?)

"These days, most people think of depression in terms of a contemporary pharmacology-based "medical model", the core of which is the idea that depression is an "illness" resulting from "chemical imbalances". From this perspective, the actual feelings and experiences that depressed individuals have are of relatively little interest, either therapeutically or in terms of trying to better understand depression, and the principle task is to find ways to "correct" the underlying disturbed pharmacological pattern ... My own guess has been and continues to be that while there are certainly pharmacological correlates to depression, the condition does not at all reduce to those, and that a fuller understanding of both depression and ways to treat it depends fundamentally on paying more attention to individual feelings and experiences, to observations made and reported "from the inside"" ... Exploring Depression

William Shakespeare, Hamlet

I have of late--but
wherefore I know not--lost all my mirth, forgone all
custom of exercises; and indeed it goes so heavily
with my disposition that this goodly frame, the
earth, seems to me a sterile promontory, this most
excellent canopy, the air, look you, this brave
o'erhanging firmament, this majestical roof fretted
with golden fire, why, it appears no other thing to
me than a foul and pestilent congregation of vapours.
What a piece of work is a man! how noble in reason!
how infinite in faculty! in form and moving how
express and admirable! in action how like an angel!
in apprehension how like a god! the beauty of the
world! the paragon of animals! And yet, to me,
what is this quintessence of dust? man delights not
me: no, nor woman neither, though by your smiling
you seem to say so.

Emily Dickinson

David Hume

"all my ardour seemed in a moment to be extinguished, and I could no longer raise my mind to that pitch, which formerly gave me such excessive pleasure ... I was continually fortifying myself with reflections against death, and poverty, and shame, and pain, and all the other calamities of life. These no doubt are exceeding useful, when joined with an active life, because the occasion being presented along with the reflection, works it into the soul, and makes it take a deep impression; but in solitude they serve to little other purpose, than to waste the spirits, the force of the mind meeting with no resistance, but wasting itself in the air, like our arm when it misses its aim ... Upon my mentioning it to my physician, he laughed at me and told me I was now a brother, for that I had fairly got the disease of the learned ... It is a weakness rather than a lowness of spirits which troubles me, and there seems to be as great a difference betwixt my distemper and common vapours, as betwixt vapours and madness. I have noticed in the writings of the French mystics, and in those of our fanatics here, that when they give a history of the situation of their souls, they mention a coldness and desertion of the spirit, which frequently returns and some of them, at the beginning, have been tormented with it many years. As this kind of devotion depends entirely on the force of passion, and consequently of the animal spirits, I have often thought that their case and mine were pretty parallel, and that their rapturous admirations might discompose the fabric of the nerves and brain, as much as profound reflections, and that warmth or enthusiasm which is inseparable from them"

Depression from the inside

Feeling everything to be heavy, things, even simple ones, are just too hard to do. Starting things, not being able to finish them, developing into a feeling that therefore nothing is worth starting.

Feeling that nothing will ever change, that one's discomfort is what has always been, will always be.

A profound inability to "will" change in either behaviors or mood

One is aware of one's own behavior/feelings, but can't do anything about them.

feeling very lonely and removed from everything. Being with people usually only intensifies the loneliness, making me more aware of how disconnected I feel.

It isn't that I don't deserve happiness, I just will never have it, and so it often seems best to give up and settle for something that isn't as wonderful as happiness but also isn't as terrible as depression.

There's always a voice that pops in and reminds me that anything I do become mildly interested is pointless because it will soon become unsatisfying, so no point in trying.

I have been FRUSTRATED and ANGRY at everything, small things, big things, and at nothing, and at myself. I am pretty sure I'm feeling better than before, but then sometimes I don't know. I feel good. Then I feel bad. Then I feel good. Then I feel bad again. It makes me feel overwhelmed. I feel, for lack of a better word, CRAZY. Maybe fragmented is a good word.

Without the mask of depression, my anxiety has returned.

I feel like I need there to be something wrong with me when nothing is. My story of myself, my identity, very much includes medications, depression, and anxiety. Without them, I don't know who I would be. They are my crutches. This is who I am. And sometimes I am unwilling for that to change.