Neurotransmission

OR: DSM-V, how the American Psychiatric Association told me my mom was crazy, and how I found the true meaning of madness and sanity at the edge of neuroscience…

Welcome to NEUROTRANSMISSION: a blog on the meaning of madness. Let me explain why this topic fascinates me. As a teenager, I thought my mother was “mad.” The few friends to whom I confessed this description often replied, light-heartedly, that their mothers, too, were “mad.” The word “madness”, amongst fifteen year-old English schoolboys in the mid-1980s, had something of the resonance of “madcap”, or “zany” - amidst the oppressive conformity of Thatcherite Britain, it was almost a badge of pride. My friend Sean called himself “mad” to denote the crude delight he felt in eating a Snickers bar with his mouth wide open. Madness was the name of a popular band. But I had the feeling, in respect of my mother, that the madness I perceived in her was of an altogether distinct and distressing variety. Madness was my mother talking to herself; refusing to keep a bin in the house; screaming. Madness was her wide brown eyes staring straight through me as if I was not there; commissioning a professional wedding photographer to take a series of portraits of her posed in our back garden in a second-hand wedding dress; trying to smash my brother in the head with a metal clock. I sometimes fantasized that a white-coated doctor would come to our house and take her away in a straight-jacket, pronounce her “psychotic” or “schizophrenic”, feed her pills, and return her to the “normal” loving mother I remembered from my earlier childhood - but this never happened, and her madness went undiagnosed.

As I became an adult, I developed an interest in psychology and broadened my knowledge of clinical language. At first, this knowledge appeared to cast the inchoate misery of my adolescence in the comforting certainties of medical science. I soon discovered a book published by the American Psychiatric Association (APA) called the Diagnostic and Statistical Manual of Mental Disorders (DSM), which defined several hundred “mental disorders” in terms of their associated mental and behavioral characteristics. Confusingly, my mother did not seem to fit neatly into any of the categories, displaying features bridging psychosis, schizophrenia, and many of the so-called “personality disorders.” Further reading told me, however, that multiple diagnoses were not uncommon. So I decided that my mother likely had “Narcissistic Personality Disorder” with psychotic or schizotypal features. I wrote a memoir thus labeling her, feeling a duty, as a writer, to enlist the most accurate words I could find for the woman I remembered. Accuracy, as I then understood it, meant an aspiration to scientific objectivity. And the DSM, I assumed, was scientific. While I clarified in the memoir that, in contrast to the DSM labels, I actually preferred my father’s mythical explanation for what had occurred to my mother (he said, following Celtic folklore, that her soul had been abducted by the faeries and replaced with an evil spirit), I nonetheless deferred to the DSM as the repository of empiricism’s best account of the dark abyss of madness.

It was only after finishing my memoir that I began to study the DSM more closely. In the latter part of the six years it took me to write the book, I had experienced recurrent episodes of severe anxiety, profound hopelessness, and a pervasive obsession with the worthlessness of my existence, symptoms that both reflected the post-traumatic shadow of my mother’s quixotically abusive personality and partly formed the subject of the book. My psychiatrist gave me the diagnosis initially of “Generalized Anxiety Disorder” and then, as I became more distressed, “Major Depressive Disorder,” although he made clear that he did not take diagnostic categories very seriously, viewing them as a practical exigency for the purposes of medical insurance reimbursement (for which a DSM diagnosis is typically a pre-requisite), not an inviolable feature of biological reality. I was prescribed Paxil, Celexa, Lithium, Buspar, Klonopin, Trazodone, Effexor, Seroquel and Abilify, received psychotherapy, cognitive behavioral therapy, and a host of alternative treatments not covered by my medical plan (including, at my most desperate and vulnerable, a shamanic exorcism of my mother’s spirit), and my symptoms eventually faded. The modus operandi governing my treatment was a trial-and-error sequence of psychotropic interventions coupled with talk therapy. Whether my eventual recovery can be taken as corroboration for the effectiveness of selective serotonin reuptake inhibitors boosted by atypical anti-psychotics, or simply evidence that, given enough time, even the grimmest depression will resolve all by itself, I am no position to comment. In any case, recovering from my “dark night of the soul” (as theologian Thomas Moore poetically recasts the modern western clinical nomenclature of depression), I consoled myself with a stack of cheery self-help books with titles such as “There is Nothing Wrong With You” (Cherie Huber) before delving more deeply into the literature of madness. Since my own unhappiness had felt related to my mother’s condition, I hoped to find an answer to the mystery of her unusual behavior, and thereby feel a sense of closure in relation to my memory of her. Imagining that my own sanity lay in defining her madness, I began a journey that would take me to the frontiers of neuroscience and psychiatry. Ultimately, in attempting to define “madness”, I would be forced to reckon with the conundrum of what constitutes psychological health and the nature of the western Self. And ultimately I would need to understand my deep-seated need to find a psychopathological label for my mother, and the associated scope and limitations of western psychiatry’s classification of human thought and feeling.

The Head Doctors
Medical explanations for the vicissitudes of human behavior stretch back to antiquity, if not earlier. The ancient Greek physician Hippocrates categorized dispositional abnormalities in terms of the unseen operations of four internal substances, or “humors” (black bile, yellow bile, blood, and phlegm), a concept whose legacy lives on today in the notion of a “phlegmatic” personality (and arguably even underpins the popular idea that mental disorders are caused by “chemical imbalances” in the brain.) By the middle ages, materialism had been overtaken in the west by a harshly judgmental theological paradigm in which marginal or transgressive beliefs and behaviors were reified as the workings of Satan; “witches” were burnt to death or drowned. But in the wake of the Enlightenment, the zeitgeist again recast madness in materialist terms, as essentially a malfunction of Reason. Significant advances in medical science, such as Leeuwenhoek’s discovery of microscopic organisms, the subsequent emergence via Koch and Pasteur of the “germ” theory of disease, and the development of the hospital, then compounded a widespread understanding of sickness as rooted in mechanistic terms.

A countervailing paradigm, sprung from ancient eastern religious notions of the “soul,” then resurfaced in post-Enlightenment terms in the shape of G.W Leibniz’s insistence that consciousness was not reducible to the mechanical operations of its biological substrate. While philosophers throughout Europe then continued to analyze the idea of mind as a phenomenon whose quality of reflexive self-awareness rendered it categorically distinct from the material world, their peers in medicine initiated the period described by French sociologist Michel Foucault as “the Great Confinement,” in which vast numbers of “madmen” (and women) were detained against their will in institutions such as the Hopital General in Paris and London’s Bethlem Royal Hospital. Madness to early modern medicine was thus a sickness no less rooted in hidden physical agents than leprosy, and hence no less imperiling the healthy population unless the mad were locked behind stone walls. Yet western thought’s ambivalent stance on its predominant theory of the mind (and thus of madness) remained split between consciousness conceived as an epiphenomenon of grey matter, and mind regarded as a substance unto itself, at minimum a special sort of matter or at most a hologram of some sacred totality.

This split persisted even into the ascendance of a certain Viennese neurologist, Sigmund Freud, who although speculating in his Project for a Scientific Psychology (1895) that all psychological phenomena would ultimately be understood in neurobiological terms, also made the paradoxical assertion that his work was, in fact, not really scientific at all. “Everybody thinks that I stand by the scientific character of my work,” Freud said in a 1934 interview with Giovanni Papini, “and that my principal scope lies in curing mental maladies. This is a terrible error that has prevailed for years and that I have been unable to set right. I am a scientist by necessity, and not by vocation. I am really by nature an artist…And of this there lies an irrefutable proof: which is that in all countries into which psychoanalysis has penetrated it has been better understood and applied by writers and artists than by doctors. My books, in fact, more resemble works of imagination than treatises on pathology.” Freud the writer of the imagination arguably survived in the therapeutic treatment, in classical psychoanalysis, of patient speech as a form of elliptical symbolic text, pregnant with hidden meanings whose exegesis the astute analyst was tasked to illuminate, but it was Freud the psychopathologist whose legacy was to prove more influential as the medical men co-opted the “germ” theory of disease for psychological purposes, and the “disease model” of modern scientific psychiatry was born.

In 1883, Emile Kraepelin, the German doctor generally credited with “discovering schizophrenia and manic depression,” published the first edition of his seminal Lehrbuch der Psychiatrie, a volume that by 1915 in its eighth edition had swollen to 2, 818 pages, purporting to establish for the mind sciences the type of classificatory system that Carl Linnaeus had created in zoology a century earlier. Echoing Kraepelin, the DSM, first published in 1952 as a slim volume and covering a modest 108 disorders, had undergone a similar lexical and nosological ballooning to over 300 disorders and 934 pages by its fourth edition of 1994. Accounting for such a radical expansion in the putative knowledge base supporting the science of the mind in four short decades, with the known ecology of mental disorder apparently proliferating like species of Amazonian butterflies, demands that we accept either a version of Moore’s Law applying to medical science (for which no evidence exists), or speculate that non-scientific forces were afoot: perhaps it was Freud the writer of the imagination, not Freud the doctor, whose legacy was holding sway after all, with “scientific” psychiatry propelled by some form of imaginative agency. And if the DSM is thus partly a speculative work, its purpose, assumptions and sub-textual implications are presumably susceptible to critical analysis like any text, however sacred…

The Good Book
The DSM is often described as the “psychiatric Bible,” and it is oddly instructive, in reflecting upon the manual’s fiftysomething year history, to contrast the APA’s influential publication with the compositional backstory of the Judaeo-Christian tradition’s long-venerated tome. Literal readers of both books tend to ignore their bases in the limits of individual human decision-making, and often prefer to quote from an idealized version of their iconic text that conforms to their own prejudices, rather than the real texts with all their irksome inconsistencies. For instance, when Beverly LaHaye, founder of Concerned Women for America (the Christian conservative group that in January criticized Mary Cheney, Dick Cheney’s openly gay daughter, for getting pregnant) commented in a 1987 interview with Ms magazine that “America is a nation based on Biblical principles,” the text to which she presumably referred was not a version including the Song of Solomon’s homage to sexual love; neither, presumably, does LaHaye find her midnight prayers to the Almighty restlessly disrupted by reports of the Gnostic “heresies,” such as the Alexandrian philosopher Valentinius’ foundation myth that a primordial ur-being known as the Demiurge created the universe by accident, or indeed any of the contentious and often bizarre scriptures that failed to make the cut when Bishop Cyril of Jerusalem presided over the synthesis of the first Christian Bible in the year 350.

For fundamentalists of any religious stripe, indeed, the hermeneutic controversies implicit for sophisticated readers in the three major monotheistic religions’ canonical texts are typically subsumed by faith in the works’ unmediated transmission of the word of God. Consequently, what the Ten Commandments and the Sermon on the Mount represent for sincere Christian believers, regardless of these textual discrepancies, is a prescription for living, and while the Good Book apparently falls silent on the questions of stem-cell research or Britney Spears’ vagina, Christian conservatives typically appear to presume that Christ Himself has spoken disapprovingly upon these matters. Such prejudicial posturing equally characterizes much of the psychiatric profession, which often pretends to speak from a vantage-point of ex cathedra infallibility when the objective evidence underlying their opinions is often ambiguous.

The early history of the DSM was no less constructed by committee than the early Christian Bible, and equally the result of internecine schisms, political horse-trading, and negotiation with outsider factions – the APA’s 1973 decision to cave to gay activist pressure and remove homosexuality from its list of mental illnesses being perhaps the most salient and notorious case in point. There, as in the case of “Post-Traumatic Stress Disorder” (included as a result of a committee vote, after pressure from Vietnam veterans), the “Religious or Spiritual Problem” code appended to DSM IV (after a campaign by psychoanalyst David Lukoff and colleagues), and the repositioning of “Pre-Menstrual Dysphoric Disorder” from the manual’s body text to an epigraph describing topics requiring “further study” (after pressure by Paula Caplan and other feminist psychologists), it is hard to avoid the suspicion that the purported “disorders” do not exist in the same way as “Mount Rushmore” or “chicken McNuggets” can be said to exist. Equally, the tired hypothesis that not existing in the same sense as “Mount Rushmore” perforce implies that the item in question, in this case mental illness, is therefore “socially constructed” – that is, purely subjective - would have provided little reassurance, for instance, to me during the suicidal phase of my own severe depression, when the unwelcome and unrelenting visitation by the “noonday demon” certainly did not feel like simply a matter of cultural convention.

But if “mental disorders” are neither fully “natural kinds” (to quote philosopher Ian Hacking’s term) nor fully “human kinds” - neither entirely independent of human observation for the ground of their being (like fish or forests) nor, at the other end of the epistemological spectrum, entirely dependent on human observation (like catwalk fashion or the dance of the Dow Jones index) – if “mental disorders” are perhaps more properly understood as fuzzy sets, constituted by a dizzying array of biological, psychological and social factors with wildly heterogeneous symptom patterns and prognoses, then it perhaps should come as no surprise that the DSM has emerged not as an unambiguous taxonomy of mental maladies but a hodge-podge of clinical supposition and heuristic compromise. In other words, we should fully expect the DSM, like the Christian Bible, to represent the fallible opinions of flesh-and-blood men and women (albeit, mostly men). If the Bible is not really the word of God, the DSM is not really the facts of madness. The difference is that one might imagine that “the facts of madness” could, at least in principle, be determined as a matter of empirical record for any and all to scrutinize (like the oblate-spheroidal shape of the Earth), whereas determining the reality of the “the word of God” is contrastingly only possible to the faithful. Madness is fact, God interpretation, or so popular wisdom might speculate.

But the enigma at the heart of madness is that the matter of interpretation is actually far more problematic than a literal reading of a Zyprexa advertisement would otherwise tend to suggest. Yet since we live in a surface-obsessed culture with an insatiable hunger for quick fixes for every ailment, an aversion to pain, and a narrow, Cartesian conception of the self, the predominant reading of the DSM is as an encyclopedia of mental diseases, with “bipolar disorder” presumed to exist in the same sense as “influenza” or “osteoarthritis.” Thus imagined as holy psychiatric writ, the DSM looms large amidst medical insurers, lawyers, mental health practitioners and patients as a lexicon of psychic suffering, cited and critiqued not only for what it actually says but also for the literal significance with which some of its readers rush to impart it, both positive and negative. Like the Bible, the DSM has inspired busy parallel industries of believers and apostates, and the manual has acquired, intentionally or otherwise, the appearance not merely of helpfully outlining some common psychological pitfalls for the benefit of the needy but of prescribing what it means to be “normal.” The APA never officially intended its manual to be read, like the Christian Bible, as a guide for living, but is it, I wonder, perhaps an unconscious implicit purpose precisely to this pedagogical effect that renders the book so divisive, so inflammatory? The DSM ostensibly defines disorder, not order – sickness, not health – but despite the absence of explicit guidelines for what constitutes the Good Life in 21st Century America, doesn’t the very categorization of illness effectively insinuate a corresponding paradigm of wellness, a model of “sanity” elliptically inscribed within the nomenclature of disease as its sub-textual shadow? In addition to the official DSM, it is hence this shadow DSM, the APA’s “Guide to the Good Life”, with whose hidden directions I become intrigued as I make my first foray into the “PsyComplex,” hoping to disentangle the visible book from its spectral twin, and learn the lessons of each as they relate to my mother’s madness and my own…

Extreme Overwhelm
Sometime in 1977, Harvard undergraduate David Oaks began to feel alienated and to find his extracurricular work as a social activist overwhelming. One day, after smoking cannabis, he entered an “altered state” in which he came to believe that his neighbor worked for the CIA and that his television was talking to him. He was variously diagnosed as “schizophrenic”, “bipolar”, and “psychotic”- terms which, to this day, he entirely refutes as applicable to his former experience, preferring the phrases “extreme overwhelm” or “crisis.” Oaks went on to found MindFreedom, an organization at the forefront of the psychiatric “survivor” movement. Experiences that one can be said to have “survived” are typically understood as dreadful - one survives cancer, a car wreck, a concentration camp – and by thus nuancing his movement’s self-definition in such graphically post-traumatic terms, Oaks is clearly not shrinking from a starkly antagonistic stance in relation to the APA and the DSM, it strikes me. But while it is clear that David Oaks has survived something, I am not ultimately sure whether that something was mental illness, malpractice at the hands of sub-standard clinicians, or some combination of the two, and wonder about the extent to which the pain of “extreme overwhelm” perhaps informs and colors his perception of the allegedly “fascistic” APA.

On the phone, Oaks thanks me several times for writing about the DSM, a “human rights” issue that he said has been “ignored” thus far by the media, and scarcely pauses in a forty five minute diatribe against North American psychiatry’s record of clinically and ethically dubious activities in the past few decades, from forced electroshock treatments and court-ordered psychotropic medications to the undue influence exercised upon the profession by profiteering pharmaceutical companies and the undemocratic, subjective nature of the DSM’s composition.

Now, let me be clear that I am in no doubt of the gravity of the evidence corroborating Oaks’ indignation in regard to certain activities of the APA. In April 2006, the Washington Post reported that of the 170 experts who contributed to DSM IV, more than half had ties to drug companies that sell psychiatric medications, including 100 percent of the experts who worked on mood disorders and psychotic disorders. How is the average person supposed to take his diagnosis seriously, when half the “experts” who came up with those diagnoses are on the Pharma payroll? As Oaks argues, the collusion between medicine and drug money renders the prospect that non-drug alternatives will be seriously considered by the psychiatric establishment far less likely. And, yes, there is the fundamental issue of the DSM’s problematic empirical validity. “It’s completely unscientific!” says Oaks. “Now, I’m not denying that there are people going through extreme distress, but the point of any crisis is that it can also lead to growth, and locking people up with the power of law on the basis of a scientifically dubious document is simply wrong.”

I ask Oaks what he thinks of the Church of Scientology, which, through an unassumingly named subdivision called the Citizen’s Commission on Human Rights (CCHR), has campaigned vigorously against the APA and psychiatry in general (an “industry of death”) on the grounds, inspired by maverick psychiatrist Thomas Szasz, that mental illness is a “myth.” (Possessing the status of “myth” does not, we should note, prevent Scientologists from believing in the idea that an extra-terrestrial dictator called Xenu brought billions of aliens to Earth 75 million years ago and blew them up in volcanoes with hydrogen bombs, but the religion expects a different standard of truth-telling of the psychiatric profession, apparently). Oaks replies that he thinks CCHR has “done some good work,” but insists that he is “pro-choice” rather than “anti-psychiatry,” and applauds “progressive” psychiatrists who allow patients to “chose their own diagnostic labels.”

If one assumes the validity of the disease model, this patient-centric model of psychiatry would be scandalously akin, in physical medicine, to permitting a brain cancer patient to believe he was actually only suffering from a headache. Oaks does not believe in the disease model, of course, but I feel that his preferred euphemistic alternatives (“overwhelm” etc.) sidestep the essential questions of whether madness exists, and if so in what forms and for what reason, and how, as a society, we might best respond to it. Even if it is meaningful to conflate every variety of psychological suffering, from severe anxiety to paranoid delusions to arachnophobia to dementia, under the single term “emotional distress,” what about the more fundamental questions of what is actually occurring for the sufferer, whether at the level of molecules and neurotransmitters or in his romantic and work life? Assuming that a suicidal crack addict is clinically distinct from a panic-prone investment banker, what words can we most effectively use to distinguish their definition and treatment, if the language of psychiatry is off limits? Surely it is not enough just to say that the addict and the banker are both “distressed.”

So, is even a bad DSM better than no DSM at all? And, even supposing that mental illnesses are not “natural kinds” like tigers or tuberculosis, is it really practical to imagine attempting to treat the vast panoply of “emotional distress” on a purely ad hominen basis, providing a customized therapy for everyone, without reference to some form of consensually-determined criteria? When he was not fulminating against the APA, Oaks concedes the problem.

Don’t Prolong Your Grief
“Let me stop you right there,” the APA public relations person curtly interrupts me, as I try to explain my interest in speaking to Dr. Michael First, editor of the DSM’s revised fourth version (DSM IV-TR) and the director of an APA group that is doing the ground-work for DSMV. “You know that DSMV isn’t coming out for several years?” she says, as if rapping me on the knuckles for not doing my homework. I explain that, yes, I am well aware from the APA’s website that DSMV is not scheduled for publication until 2011 at the earliest, but that I am nonetheless interested in examining the issues surrounding the potential future of psychiatric diagnosis that the lengthy DSMV composition process promises to examine. “Oh, in that case…” I never hear back from the PR person, but a few days later, Dr. First calls me. Now, the DSM has been the subject of intense flack for so long, and the APA equally such a longstanding target of animus, that my instinct as an interviewer is to spin the true scope of my interest as far as justifiable, short of lying, towards a semblance of the anodyne. So I do not mention David Oaks.

(And I certainly do not mention my mother. Dr. First has never met my mother. Possibly, she would like to meet him – she routinely sends letters and poems to Bill Clinton, Tony Blair, Queen Elizabeth II and other dignitaries, so an eminent American psychiatrist would not be out of place in her address book. But I do not plan on showing this article to my mother, or furnishing her with First’s email address, so this meeting is unlikely to occur, and First thus highly unlikely to ever know my mother outside the palimpsest of my own fallible recollections; inviting his comment on the topic therefore seems quite futile.)

I think it especially unwise to betray my interest in David Oaks and the “survivor” movement since such a confession, prior to my interview, would surely be equivalent, I speculate, to boasting of militant atheism prior to meeting the Pope. Better to get on First’s good side with some credulous noises about the “exciting prospects” for an “etiologically-based neurobiological and genetic psychiatry.” What I mean by those noises is my feigned credulity in the APA’s potential fulfillment, in DSMV, of Freud’s Project for a Scientific Psychology: the idea that science will soon propel psychiatry to the point where it can identify specific disease processes, even specific genes and neurological mechanisms, that are causally related to specific mental illnesses in the same way that the HIV virus causally relates to AIDS. If so, would Dr. First then be able to analyze my mother’s fMRI scan and identify the tell-tale malfunction that once led her to wake up my brother in the morning by spraying an aerosol deodorant in his face?

Perhaps I go too far with my fake credulity, because Dr. First is quickly at pains to dispel any delusion under which I may have been laboring that Freud’s Project is anywhere close to realization. “It’s very unlikely that we’ll see any sort of paradigm shift in DSMV,” says First. “The research base just isn’t there, yet, and I can’t imagine it appearing in the three years before we write the DSMV draft in 2010.” Even in the case of dementia, a hitherto clear-cut case where the evidence of neuronal “plaques” and “tangles” in post-mortem brain tissue samples was presumed to suggest a straightforward causal relationship between an organic diagnostic marker and an associated psychopathology (Alzheimer’s disease), the plot has recently thickened, and the plaque-tangle correlation no longer appears to represent a diagnostic “gold standard.” And in the far more ambiguous case of schizophrenia, the research is even less promising. (Paul Hammersley, a psychologist at the University of Manchester, England, has proposed abolishing the word “schizophrenia” altogether, because the “disease” denotes a hugely heterogeneous set of bizarre behaviors with no common etiology). Indeed, Dr. First seems to be striking such a tone of humility in the face of his profession’s patchy scientific research base that I begin to wonder why David Oaks and the “survivors” were still so angry with the APA. (Probably because neither First nor any of the other APA big cheeses have deigned to respond to MindFreedom’s emails; although, given Oaks’ militant tone, First’s disregard for the “human rights” activists who oppose him is hardly incomprehensible.)

We discuss the changes in DSMV and I try and establish whether the APA is shifting the manual onto new ground. First commits the APA to a stringent new conflict-of-interest policy to avoid repeating the embarrassment of the DSM IV drug company links scandal. He is going to insist on a “very high [research] threshold” for the inclusion of controversial new diagnoses such as Compulsive Shopping Disorder, to mitigate the timeworn allegation that the APA is responsible for the continued “medicalization” of what Thomas Szasz called “problems in living.” (There is a chance, though, that Prolonged Grief Disorder will make the cut in DSMV, apparently, putting the APA in the peculiar position of being authorized to determine exactly how long the grief-stricken are permitted to mourn before a shrink can pronounce them sick in the head). The DSM will remain a strictly “clinical document,” not a “statement of what mental health is” – even if, on my analysis, one cannot exist without the other.

In essence, DSMV is going to be APA business-as-usual. The manual will almost certainly retain the controversial “categorical” model that defines mental disorders as discrete entities that a person either does or does not have (like a virus) as opposed to the “dimensional” approach (favored by many researchers) that presents psychological phenomena on a continuum with no arbitrary cut-offs between “normal” and “abnormal.” An exception might be in the area of “personality disorders,” where the categorical approach is so wildly at variance with both the research and clinical picture that “some element of dimensionality” will probably be adopted. So, First is neither arguing bullishly for the likely realization of the Freudian Project, nor is he conceding to the invalidity of the disease model and committing the APA to an earnest search for alternatives. Far too much is at stake, I assume, to abandon the disease model: think of all the labor needed to revise the insurance industry paperwork, the millions of dollars in APA publishing revenue, the billions of dollars in drug money…

In Oaks and First, I have met the psychiatric equivalents of both the Apostate and the Believer (although Oaks confessed to a smidgeon of belief, and First to an almost heretical degree of doubt) – but I am still no closer to understanding the nature of madness, whether it is a disease or not, and in any case how it can best be defined and treated. If Oaks is right, my mother was just “emotionally distressed” when she took me on a skiing holiday in Austria but refused to let me ski; if First is right, even if my mother still fits into a DSM category, my bizarre Alpine holiday wasn’t likely to be explicable by a brain scan, at least not any time soon. I decide I need to meet an Agnostic, a thinker sensitive to mental illness as both “natural kind” and “human kind,” to therapy as both psychopathology and imaginative dialog. Perhaps, I speculate, madness is explicable in this interzone where science meets Soul, and perhaps here I will find some answers not just about the nature of sickness but the meaning of mental wellness - clues to the “Guide to the Good Life” which First argues the DSM never purported to be and which Oaks and the “survivors” suspect is the APA’s hidden agenda (conscious or otherwise) in advancing a certain model of mental “disorder” and its implicit vision of “order.” Or perhaps I have simply been grieving my mother too long, should add Prolonged Grief to my list of troubles, and take the right pill to dispel my unhealthy fixation…

Mother, you had me…
If there could be said to be a single figure pioneering a new paradigm in the sciences of the mind that bridges the divide between the neurobiological determinism of the disease model and the fuzzier, subjective realm of psychoanalysis, it is Allan N. Schore, a professor on the clinical faculty of the Department of Psychiatry and Biobehavioral Sciences at the UCLA David Geffen School of Medicine. A pioneer of the nascent field of “neuropsychoanalysis,” Schore has integrated the research on neurobiology, neuroscience, psychiatry, psychoanalysis, developmental psychology, pediatrics, and trauma, serving on the editorial board of 28 journals in six scientific fields, in addition to running a private clinical practice. Schore’s work proceeds on the premise that the “single skull” view of the human psyche that has effectively served as the dominant framework for the western understanding of the mind (and mental illness) since Hippocrates is essentially incorrect. We have been looking for clues to the riddle of madness inside one head, when the answer really lies in the connections between two heads (or more).

In particular, the development of the mind (whether “healthy” or pathological) depends critically on the infant brain’s interrelationship with its primary caregiver. Between birth and the age of one year, the average brain expands in weight from 400 grams to 1000 grams, with much of this expansion contingent upon the nature of infant-mother interactions. In particular, the neurological mechanisms responsible for our emotional development depend on a consistent, loving interplay between mother and child. So far, so familiar, but the awe-inspiring features of Schore’s work is that he has shown how this understanding of the importance of effective parenting plays out at the neuronal level, and demonstrated empirically that “good enough” mothers actually create the neurological make-up of their children through unconscious intrapsychic processes.

The revolutionary impact of this new model is that it no longer makes sense to try and understand madness solely as a malfunction of a single brain. Instead, it is more accurate to think of madness as a disturbance in the interpersonal links between two brains, with its origins almost certainly located in the early mother-infant relationship. Early parental neglect or abuse develops a brain wired with the potential for later pathologies such as “Borderline Personality Disorder” (BPD). The good news is that the brain retains a degree of “plasticity” even into adult life, allowing therapists and other caring people to rewire the brain of the abused individual through empathic interactions. “This is why we have intimate relationships,” Schore tells me, “so one unconscious can homeostatically regulate another unconscious. The core of most human problems is emotion – one thinks of violence, for instance – and the development of qualities like empathy is critically related to attachment patterns in the early mother-infant relationship. But just as pathology can result from poor affect regulation by the mother of the infant, later psychotherapy can actually rewire those affective circuits in positive ways.” Schore is currently studying the fMRI scans of mother-infant pairs involving mothers with BPD in order to study the intergenerational transmission of BPD at a neurological level with an ultimate view towards developing new therapies to help people with BPD.

My mother was adopted at the age of one. I do not know why her biological parents, who were married and ultimately went on to have three more children, decided to give their first child away, or what kind of early interactions she had with her biological mother. I can imagine that the early separation was traumatic. Perhaps her sensitive infant limbic system never recovered from this primal blow. I can also imagine that her developing neo-cortex probably took quite a hit when her adopted mother left her alone by a primus stove one day and she badly burnt her face. The sense of betrayal she felt, aged eight, when she learnt through playground gossip, rather than from her mother, that she was adopted, must equally have made its presence distressingly manifest in her proliferating synapses. So, who can then say what was going on her head two decades later when she gave birth to me? Taking Schore’s work into account, I find myself wondering about the time, aged seven, when I stole some change from my mother to buy candy, and her subsequent reprimand was so severe I sobbed for hours unconsoled. Was the intolerable level of shame I experienced then in some sense an intergenerational echo from my mother’s own primal trauma? If Schore were to capture my mother’s brain in dialog with my own through a fMRI scan, would traces of our mother-infant shame still be partly visible even now, her abusive personality and my later depression mutually encoded in a common limbic injury? My desire to answer these questions is the ulterior motive behind my interview with Schore on the rapprochement between science and psychoanalysis.

But just as I had refrained from introducing my mother to Michael First, neither I do not burden Allan Schore with my personal story. Yet I feel clearer, having spoken to him and read his work, that a new way of understanding the mind and madness is emerging, a paradigm that straddles the gap between the crude determinism of the disease model and the loose subjectivism of the “survivors,” between the Freud of the Project and Freud the imaginative writer, between “natural kinds” and “human kinds.” His work, it strikes me, has suggestive parallels with the Buddhist teaching of “anatta” (“no-self”), the idea that the individual self can only be said to have existence in relation to other selves. In Buddhism, neither “madness” nor “sanity” has any ultimate reality; the point of living is not to achieve “sanity”, or indeed any quality in relation to the individual self, but to reduce the suffering of others. And while it is valuable to develop the means to help others in distress – let us imagine a DSM, free of stigma, purely conceived for practical purposes to guide treatment– a “mental disorder” is neither entirely solid nor entirely fluid. Madness is instead a “practical kind ” (to quote philosopher Peter Zachar’s term) – a useful map that does not pretend to the status of territory. Thus the important question, in relation to my mother’s strange personality and my later melancholia, is not which diagnostic category to put them in, but how their attendant pain can be eased, and how I can prevent their underlying cycle of intergenerational trauma from affecting my nine month-old daughter as she grows up.

According to Schore, my daughter’s brain and my own are unconsciously intertwined, just as my own behavior mirrors my mother’s imprint. Her developing brain cannot thrive outside of that fluid intertwining. (Perhaps, like a quantum state, her brain cannot even be said to exist outside of the brains that interact with her and consequently influence her?) A DSM that thus fails to recognize this sensitive interdependence of dual psyches, that reifies mental disorders as static disease entities, has not fundamentally advanced on the medieval paradigm in which psychoses were interpreted as the presence of evil spirits. A fundamentalist “psychiatric Bible” insists on “mental disorder” and the self as no less solid than Mount Rushmore; their implied vision of psychic “order” is a humdrum, etiolated vision of life with its eccentricities cauterized, a life in which Van Gogh and Virgina Woolfe would have zoned out on Haldol as teenagers; a vision of America populated by legions of obedient consumers, anxiously siloed from one another behind gray office cubical walls and a solitary myth of the “single skull” psyche. By contrast, an enlightened paradigm of psychological health starts from the assumption that the smallest sub-division of homo sapiens is not one person but two; that sanity and synapses are similar because they both depend on connection. I may still not have a satisfactory label for my mother’s madness, but I know that at some point the links between her and those closest to her were painfully disrupted. To be mad is to be alone. Sanity starts in the communion of one self with another. “Mother, you had me, but I never had you,” as Lennon sang. Time to hug my daughter.