This post is a reblog of a post by Candida Fink, MD.
I found it very interesting and hope you like it too! The post can be found on her blog: bipolar beat at psych central
Can the bacterial community that lives in your gut actually be related to psychiatric illnesses such as schizophrenia and bipolar disorder? Research on the human microbiome and its effects on health and illness has exploded into the worlds of medicine and research. It is increasingly clear that the microorganisms in the human intestinal tract, and the genes produced by all of these microscopic living things, play critical roles in an individual’s patterns of overall wellness — far beyond helping us digest food effectively.
Microbiota and Microbiome Defined
Microbiota is the ecological community of microorganisms (mostly bacteria, but also fungi, viruses, and so on) that live in a particular location, such as your gut. Microbiomerefers collectively to the genes harbored in these microorganisms. Researchers must understand the patterns of both the organisms and the genes to help clarify the roles these microscopic creatures play in the body’s health and function. So, if you read something about the microbiome that’s about only the bacteria and not the genes, you know it is an incomplete discussion. Also, while most of the discussions are about the gut microbiota and microbiome, humans actually have colonies of microorganisms living in other areas in and on their bodies, including their skin, reproductive tract, and the mouth and throat (which are technically part of the gut but sometimes are not thought of in that way).
A study in the journal Brain, Behavior, Immunology (May 2017), entitled “The microbiome, immunity, and schizophrenia and bipolar disorder,” summarizes some of the current research looking at the microbiome as it relates to schizophrenia and bipolar disorder. The article reports that many studies in animal models have shown that the gut microbiome could affect thinking and behavior through effects on the immune system. Some human studies have shown that people with psychiatric conditions took antibiotics more frequently than people without these disorders. Humans take antibiotics to kill off unwanted bacterial infections, but these medications also kill off some of the microbiota, changing the person’s microbiome. The question that comes up then is whether these microbiome changes were related to the development of the psychiatric conditions. This article also points to studies that found different microbiota in the mouths and throats (oro-pharyngeal microbiota) of people with schizophrenia compared to those without.
Babies are born with “sterile” guts; they don’t have any gut microbiota. But in the birth process, microorganisms colonize the baby’s mouth and intestine, starting off their process of building a microbiome that eventually looks like an adult’s. Many researchers are exploring how the developing microbiome might affect the developing brain and nervous system. While it seems clear that there are effects, the exact processes mediating the effects and what exactly gets changed or affected remains very unclear. While the immune system is thought to be one pathway, other mechanisms are also being investigated.
Many other areas of research show promising results when looking at the microbiota, microbiome, and illness. Autism researchers are looking at the “gut-microbiome-brain” connection, and there are strong indicators that the microbiota and microbiome have some relationship to autism. Obesity — not a mental illness but of concern to so many people living with mental illness — has been shown to have some very interesting connections to the microbiota in mouse studies. Changing the patterns of bacteria in mouse guts can transform the mouse from lean to obese and vice versa without changing diets. A study from China last month in the World Journal of Gastroenterologyreports a case of a 20-year-old with Crohn’s disease and seizures. They treated her with fecal microbiota transplantation — giving her the gut microbiota of a healthy person — and her gastrointestinal symptoms and seizures improved significantly.
The potential benefits to understanding how the microbiota and microbiome interact with the brain and central nervous system could be enormous. Understanding microorganism mechanisms that increase the likelihood of mental illness such as bipolar disorder or neurodevelopmental condition like autism would make room to build new interventions that target those mechanisms. The research in these areas is still in early stages, and there is much more to do, but this is an intriguing and promising story in the quest to understand and treat disorders of the brain.
I was in Budapest for five days. I attended a Hungarian wedding, and felt a bit isolated at first. Around me people were laughing, chatting in a language totally foreign to me. But then I met a British, wonderful man that managed to shift my perspective. That doesn’t happen everyday, especially not when you’re lost in translation, feeling like a bleep on the canvas of the universe.
We met after the wedding and he made my head spin. Being challenged in what you believe is unsettling, and for a moment there it felt like I was falling into a black hole. We talked about the universe giving you what you need, and also about space-time. The concept was somewhat familiar to me, but my head starts aching when I’m thinking about the mystery out there. I told him about particles being at two different spots at the same time, and he told a story about just that, but with humans: He was together with two friends, where one of them sat in the bed opposite him and the other friend. Suddenly this friend was in the bathroom at the other end, and they had not seen him walk over there. The friend who suddenly was at another space, did not understand he suddenly was there, too. I didn’t believe this story, so I will need verification from his friends, but it made me think about how little I know about this world. I recently read an article about consciousness where the author proposes a solution to the unfathomable mystery of our minds and souls. He compared ‘a common consciousness’ with dissociative identity disorder, where many personalities exists in the same body. He said that this might just answer the question related to how every human beings consciousness is completely unique: If consciousness exists all around us, even in other materials like plants, and it still can be unique for every creature, dissociative identity disorder might provide some answer to what scientists have struggled with for centuries.
Other than these discussions, I found a really good friend.
Am including some pictures from Budapest, a truly beautiful city.
Recovery Tips for the Optimal You
This is an article by Adam Cook that he wanted to share on my blog.
Adam Cook is the founder of Addiction Hub, which locates and catalogs addiction resources. He is very much interested in helping people find the necessary resources to save their lives from addiction.
Addiction recovery is difficult. Its success is not measured quickly, but rather over a long period of time. People often speak of beating addiction, but the real challenge is not defeating one’s substance abuse but being able to successfully contribute to your recovery. Relapse can happen anytime, but it is also quite possible to avoid if one works hard and surrounds oneself in the right kind of support. There are ways to bolster ones recovery to ensure success in the long run.
One way to help maintain sustainable sobriety is through a holistic perspective. Holistic refers to a whole-body approach to dealing with conditions such as addiction. A whole-body approach treats not only the addiction, but also its causes, while simultaneously providing comfort and support so that long-term change is possible.
Create a healthier you through diet and exercise
Optimal physical health is crucial to successful recovery. One can ensure health by eating right and increasing their physical activity. Those who have dealt with addiction also might find that they are nutritionally challenged. Substance abuse is so diametrically opposed to healthy living that addicts’ diets are often horrendous. Bodies are physically ravaged from addiction, too, so nutrition is needed to repair damage.
This year, focus on your diet by incorporating more vegetables and good fats. All vegetables and fruits are healthful, but adding avocados and olive oil can make you feel more full and satisfied. Believe it or not, doctors and nutritionists now advocate for bacon as a component of a healthy diet. So enjoy a salad with bacon and avocado and watch your health improve, little by little.
Exercise is another way to improve one’s health holistically. Fitness helps build strength that is crucial for stamina during recovery. Exercise also can help push addictive behaviors out of one’s life. Exercise triggers similar brain chemicals that result from using substances. When people work out, they feel senses of elation and stamina. Both of these characteristics help in managing addiction.
More importantly, exercise and diet foster healthy living. When someone exercises and eats better, they tend to make other decisions that support both of these components of their life. When you have a great day working out, you are less likely to eat junk food, go drinking or skip sleep or rest. The positive quality of exercise and diet can help those fighting addiction to persevere.
Get outdoors and benefit from nature
When exercising, try to incorporate some outdoor activities in the mix. As helpful as exercise is to managing addiction, outdoor exposure is linked to increased mood. When you feel better, you are much more likely to strive to be better. Outdoor exercises that are helpful include hiking, walking, running, cycling and swimming. Each of these exercises can also be done indoors to some degree, but the natural element simply takes the experience to another level. Treadmills and stationary bikes are boring. A beautiful mountain vista is anything but boring.
Keep sobriety going with a positive hobby
Another way to support addiction recovery is through finding a positive hobby. It doesn’t matter so much what the hobby is – just make sure that it is something that you enjoy. The overall goal is to fill your life with positive and rewarding activities. Hobbies can bring joy to anyone’s life, but are especially beneficial for someone going through recovery.
By combining a healthy diet, exercise, outdoor exposure and hobbies, anyone who is going through addiction recovery can help power through the tough days. This fuel is key to sustained addiction management.
When I open my mouth.
My whole heart comes out.
I don’t even care what the world thinks about how I sound
Christina Aguilera, Sing For Me
Anachronism (noun): an error in chronology; a person or thing that’s chronologically out of place
I put my hand under the faucet, letting cold water touch my skin, skin warmed up by my boiling mind. I am here. The really cold water reminds me of this simple fact that we often forget. I close my eyes a bit, to enjoy the sensation.
Closing my eyes brings back memories from other times when I was not in the here and now. When my chaotic life consisted of more tomorrows and yesterdays than life today. That was the time when my colors were grey, my mood black and my road consisted of an invisible color. I made no sound then, only some lamenting noises that I`d rather mute.
We come to this world from a watery place that feels safe like a warm, cozy house. There we are all alike, we know nothing more except what our fluid surroundings tell us. When we finally come out to our version of reality, we have to find our place in it. Some of us, never quite do. At one point we`d rather be at a mountain top, smoking plants with ancient monks, at another rather lie burrowed in the earth we supposedly come from. We swim upstream and downstream, seldom relaxing to just float. Bubbles burst, and shattered pieces remind us of who we once were.
Last year I got the chance to travel to dream-destinations of mine. China. It was my chance to be in my tomorrows, walk on my mountain-tops and my chance to just be. From early on, I feel in love with simple life-views portrayed in movies like Spring, Summer, Fall, Winter and.. Spring and books like “Eat pray, love”. The first steps to some of these philosophical views were mapped out by Asians, so the wish to walk at the same earth as they did, grew until the turning compass-needle in my heart pointed directly at Asia. What would I see in my own personal mirror?
One of the many places I got the chance to touch with my Norwegian shoes, was Hong Kong. There I enjoyed an extraordinary experience where I sure felt out of place constantly, silently enjoying it.
When you eat, do you taste every bit like it would be your last? When I was a child, I remember how I enjoyed a German chocolate after coming back to Norway. I saved it as long as I could, prolonging the joyful taste and thereby squeezing more happiness from it. I did this since I knew it would be long until next time a piece of Yogurette could melt on my tongue. The more grown-up and richer one gets, the less one savors what enters our senses. For this reason, “Dialogue in the dark” was just what my under-stimulated nerve-cells needed. Before I attended this unorthodox tourist-experience, I just knew that it was created by blind people, and that we would learn something from it. My inner owl hooted in satisfaction, even when someone put a blindfold over me over me and 9 other unknown people’s eyes. It was pitch dark, but the next hour were filled with so much color that it felt like I finally could see again.
I heard a classical piece of music that whirred up strong emotions, I touched objects that made my senses boomerang in wonder. I heard sounds never noticed before, and my body was drenched in water that almost crept under my skin. The excitement I felt was doubled by the mere presence of the strangers around me who had their own surprised exclaims and sounds. Although I`ll never meet those people again, their voices and laughter has left an imprint on my soul.
The exquisite meal we had at the end, felt like it must have done for the 12 disciples. With no sight and no disturbing white noise, I could fully appreciate what I tasted and how lucky I was to be there.
I sure felt the truth of this after we had touched, tasted, felt and walked in the dark, but shining, room in Hong Kong. In the loud silence of our journey through the dark, I could focus completely on how the food tasted and felt. I also had time to appreciate the fact that I sat there, completely free from inhibitions and restrictions, enjoying food some children never get to taste. I am one of the one percent of the population with this chance,
Even if this can be categorized under the most disorganized experiences of my life, I have never felt so clear about anything before.
Where have you arrived, and what is the sound of your symphony in the dark?
- What if I felt like I didn’t belong? (okaywhatif.com)
- Out of place (hopethehappyhugger.wordpress.com)
- Dialogue in the dark (An activity that puts people in the shoes of blind people)
- the one percent of us
If you want to read a book that will change your perspective, enlightenment now is the book for you. Even if you’re a skeptic, not believing that the world is actually getting better contrary to what the news tells us, you should read it. If it just is to argue about what he writes, that’s good too. We need good discussions, and the book gives you plenty of examples to impress others with. It’s so packed with new information that I used months reading it, just to digest everything before I continued with it. The trip to this surprising world, so much better than I though, was refreshing and showered me with hope and inspiration. Still not convinced? Why not check it out yourself ?
You can find the book here: Amazon.
If you want, I can even send it to a lucky follower of my book through audible. Just comment and it will be yours for free.
In my mid-20s, at the beginning of my training as a clinical psychologist, I was placed on a psychiatric day treatment ward in one of the poorer parts of Boston. One day, the experienced therapist with whom I led a men’s group was sick, and I was called on to do the group by myself. A ball of nerves, I decided to ask the men about their ancestry (with the helpful presence of a globe in the room) rather than risk silence. I briefly spoke of my Russian and Eastern European great-grandparents to set the tone and then spoke with each man in turn. After a few minutes of this exercise, there was a pause. A fellow from across the room looked at me and said softly, “You think you’re better than us, don’t you? You think this could never happen to you.”
I was stunned. Somehow I stammered a denial, but of course he was right. Perhaps I didn’t think I was better than them, but I certainly thought I was different from them. Like most of us in Western societies, I had grown up believing that psychiatric disorders were illnesses—diseases like any other—and there had been nothing in my training until then to convince me otherwise.
But learning about trauma, dissociation, and attachment in the ensuing decades has changed my mind. And I am not the only one.
PARADIGMS IN CONFLICT
Over the past several decades, the study of schizophrenia and the study of the dissociative disorders have been dominated by opposing paradigms. For schizophrenia, the assumption of a genetic basis and biological causation has reigned supreme. Adverse childhood experiences are viewed as irrelevant at best and adult stressful or traumatic experiences as only “releasing” underlying disease mechanisms. Symptoms are considered meaningless—unrelated to a person’s life circumstances—and psychotherapeutic approaches, when used at all, are limited to supporting medical interventions. In diagnosing schizophrenia for clinical or research purposes, posttraumatic and dissociative disorders are rarely considered or ruled out; indeed, in adherents to this paradigm, posttraumatic disorders are frequently disdained, discredited, or simply ignored.
In contrast, the overriding paradigm for the study of dissociative disorders has focused almost exclusively on life events—traumatic or otherwise—that are assumed to be meaningfully related to the symptoms a person experiences. A wide range of psychotherapeutic approaches to treatment are supported and advocated, whereas most medical interventions are viewed as anathema. At the same time, many trauma-oriented clinicians and researchers think of schizophrenia only as something dissociative disorders are not—but are often confused with; schizophrenia’s validity as a biologically based entity is rarely questioned.
Consider how these two paradigms deal with auditory verbal hallucinations. To persons adhering to the dominant biological paradigm (or “medical model”), voices are psychotic symptoms to be treated with medications or coped with using distraction techniques. As Colin Ross (2008 Ross, C. A. 2008. “Dissociative schizophrenia”. In Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology, Edited by: Moskowitz, A., Schäfer, I. and Dorahy, M. J. 281–294. London, , England: Wiley.) put it, from this perspective the notion of talking with someone’s voices would be as absurd as “asking a patient’s knee a question” (p. 284). In contrast, in a trauma/dissociation paradigm, voices are split-off parts of the personality that are ignored at one’s own peril—acknowledging and engaging these disowned parts, though often challenging, is typically advocated. The schizophrenia field views voices as biologically generated indications of a brain disorder, whereas the dissociation field views them as psychological indications of unresolved trauma or loss. Two more disparate perspectives cannot be imagined. Currently, these fields eye each other with considerable suspicion and, to a large extent, do not speak the same language or experience the world in the same way.
EUGEN BLEULER: THE MARRIAGE OF DISSOCIATION AND SCHIZOPHRENIA
But it was not always this way. When Eugen Bleuler published his Dementia Praecox oder Gruppe der Schizophrenien (Dementia Praecox or the Group of Schizophrenias) 100 years ago, the construct of schizophrenia was infused with dissociative concepts (Moskowitz, 2008Moskowitz, A. 2008. “Association and dissociation in the historical concept of schizophrenia”. In Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology, Edited by: Moskowitz, A., Schäfer, I. and Dorahy, M. J. 35–49. London, , England: Wiley.; Moskowitz & Heim, 2011Moskowitz, A. and Heim, G. in press. “Affect, dissociation, psychosis: Essential components of the historical concept of schizophrenia”. In Psychosis and emotion: The role of emotions in understanding psychosis, therapy and recovery, Edited by: Gumley, A., Gilham, A., Taylor, K. and Schwannauer, M.London, , England: Routledge.). While insisting on an organic basis for the disorder, Bleuler recognized the symptoms his patients described as meaningfully related to their life experiences and used hypnotherapy and psychotherapy in his clinical work. He justified changing the name of the disorder largely on the basis that the “splitting” of the “different psychic functions” was central to its pathology (Bleuler, 1911/1950Bleuler, E. 1950. Dementia praecox or the group of schizophrenias, Edited by: Zinkin, J. New York, NY: International Universities Press. Original work published 1911, p. 8). Bleuler’s 1911Moskowitz, A. and Heim, G. 2011. Eugen Bleuler’s Dementia praecox or the group of schizophrenias (1911): A centenary appreciation and reconsideration. Schizophrenia Bulletin, 37(3): 471–479.“definition” of schizophrenia reads almost as a calling card for dissociative disorders:
If the disease is marked, the personality loses its unity; at different times different psychic complexes seem to represent the personality … one set of complexes dominates the personality for a time, while other groups of ideas or drives are “split off” and seem either partly or completely impotent. (p. 9)
The profoundly dissociative nature of Bleuler’s concept of schizophrenia has been ignored for many decades but should be apparent to any unbiased reader, as has been recognized by Colin Ross (2004Ross, C. A. 2004. Schizophrenia: Innovations in diagnosis and treatment, New York, NY: Haworth Press.) and myself (Moskowitz, 2008Moskowitz, A. 2008. “Association and dissociation in the historical concept of schizophrenia”. In Psychosis, trauma and dissociation: Emerging perspectives on severe psychopathology, Edited by: Moskowitz, A., Schäfer, I. and Dorahy, M. J. 35–49. London, , England: Wiley.; Moskowitz & Heim, in press).
However, Bleuler’s ideas about schizophrenia have little currency in today’s nosological world; all but the name has been jettisoned, and even that has been retained with considerable squeamishness—requiring constant vigilance against its interpretation as “split personality.” Instead, the architects of our current diagnostic system harked back to Bleuler’s predecessor, Emil Kraepelin, for inspiration.
EMIL KRAEPELIN, TAXONOMIES, AND GENERAL PARESIS
Despite Kraepelin’s experimental psychology pedigree (he studied with Wilhelm Wundt early in his career), his ideas on Dementia Praecox were far less informed by psychology than those of Bleuler (who used Jung’s word association experiments to aid his understanding), and he saw concepts of dissociation as irrelevant to diagnostic conceptualization. Rather, Kraepelin’s approach to parsing mental disorders was strongly influenced by biological classifications, such as Linnæus’s taxonomy of plants and the system developed by his own esteemed older brother, the biologist Karl Kraepelin (Weber & Engstrom, 1997Weber, M. M. and Engstrom, E. J. 1997. Kraepelin’s “diagnostic cards”: The confluence of clinical research and preconceived categories. History of Psychiatry, 8: 375–385.). In addition, the model on which Kraepelin based his concept of Dementia Praecox was General Paresis of the Insane—sometimes called Dementia Paralytica. General Paresis was a terminal condition that combined psychotic symptoms with paralysis and ultimately death and was widespread in Europe during the early part of the 19th century. The triumphant linking of its symptoms with a brain disorder caused by late-stage syphilitic infections in the mid-19th century clearly provided Kraepelin with a template or paradigm—a “model disease entity”—for mental disorders in general and dementia praecox in particular (Jablensky, 1995Jablensky, A. 1995. Kraepelin’s legacy: Paradigm or pitfall for modern psychiatry?. European Archives of Psychiatry and Clinical Neuroscience, 245: 186–188., p. 186).
THE NEO-KRAEPELINIAN PARADIGM OF MENTAL DISORDERS
The example of General Paresis, mental disorders were brain disorders but that any classification of psychopathology was best pursued through identifying brain pathology, not only drove Kraepelin’s typology but also still underpins that of the current diagnostic systems influenced by his thinking—the Diagnostic and Statistical Manual of Mental Disorders(3rd ed. [DSM–III]), the International Classification of Diseases–9, and their related progeny (Jablensky, 2007Jablensky, A. 2007. Living in a Kraepelinian world: Kraepelin’s impact on modern psychiatry. History of Psychiatry, 18: 381–388.). For the past three or four decades, the classification of mental disorders has been dominated by this approach, which came out of a group of primarily American psychiatrists self-identified as neo-Kraepelinian (frequently referred to as a movement or even a revolution).
As the neo-Kraepelinians set about revising the psychiatric diagnostic system in the 1970s, and reached their goal with the 1980 publication of the DSM–III, they were ostensibly creating an atheoretical system with improved reliability over its precursors. But in reality, they were clearly motivated by the belief that these conditions were medical disorders like any other; indeed, in a publication from that time, two prominent researchers spoke of “coveting” for schizophrenia the solid genetic grounding of “pellagra, paresis, tuberculosis, polio, and PKU [phenylketonuria]” (Gottesman & Shields, 1973Gottesman, I. I. and Shields, J. 1973. Genetic theorizing and schizophrenia. British Journal of Psychiatry, 122: 15–30., p. 15).
A fundamental task for the neo-Kraepelinians was to shore up the distinction between schizophrenia and manic depression, a distinction that had been blurred by Bleuler’s broad category. They accomplished this primarily by strongly emphasizing specific psychotic symptoms in the diagnostic criteria for schizophrenia (particular auditory hallucinations and delusions proposed by Kurt Schneider—so-called first rank symptoms) and by undermining the validity of the schizoaffective disorder category in a number of ways (Moskowitz & Heim, in press-a). The Kraepelinian dichotomy of schizophrenia and bipolar disorder has been explicitly seen as providing the foundation for a biologically based nosology; indeed, challenges to the clear differentiation of schizophrenia and bipolar disorder are often viewed as undermining the validity of the entire diagnostic system (Kendell, 1987Kendell, R. E. 1987. Diagnosis and classification of functional psychoses. British Medical Bulletin, 43: 499–513.). In addition, the neo-Kraepelinians have articulated a number of more general assumptions, including (a) that mental disorders are discrete from one another and from “normality” and (b) that advances in understanding mental disorders will come primarily from focusing on neurobiology (Klerman, 1978Klerman, G. L. 1978. “The evolution of a scientific nosology”. In Schizophrenia: science and practice, Edited by: Shersow, J. C. 91–121. Cambridge, MA: Harvard University Press.). This level of domination over research and practice (for example, DSM–IV diagnoses are required for insurance payments and frequently for journal article acceptance) clearly constitutes what Thomas Kuhn termed a scientific paradigm.
PARADIGMS AND SCIENTIFIC REVOLUTIONS
According to Kuhn (1970Kuhn, T. S. 1970. The structure of scientific revolutions, 2nd, Chicago, IL: University of Chicago Press.), in The Structure of Scientific Revolutions, the idea that science advances in a linear fashion with knowledge continually accruing so that “reality” or “truth” is more and more closely approximated over time is a myth. Rather, he argued, a field advances under the influence of a dominant paradigm, meaning both a particular past scientific achievement held up as a model or exemplar (as in the case of General Paresis and psychopathology) and the generally accepted beliefs and attitudes of a particular scientific community. A paradigm exerts an organizing influence on a field and guides research, determining to a large extent what types of research questions are considered legitimate and what sorts of answers are considered acceptable.
Kuhn (1970Kuhn, T. S. 1970. The structure of scientific revolutions, 2nd, Chicago, IL: University of Chicago Press.) argued that paradigms change and a scientific revolution ensues when three conditions are met: (a) a period of crisis develops in which the paradigm fails to adequately answer questions considered fundamental; (b) serious “anomalies” occur in which phenomena not clearly compatible with the paradigm are observed; and, importantly (c) a suitable alternative paradigm that explains many of the previous findings and at least some of the observed anomalies comes to light. Kuhn saw scientific revolutions as taking time to resolve; he argued that changing such strongly held beliefs involved a process of persuasion and fundamental reorganization not unlike that of religious conversion: “Conversions will occur a few at a time until, after the last holdouts have died, the whole profession will again be practicing under a single, but now different paradigm” (Kuhn, 1970Kuhn, T. S. 1970. The structure of scientific revolutions, 2nd, Chicago, IL: University of Chicago Press., p. 152).
Since the publication of the DSM–III in 1980, the ascendance of the neo-Kraepelinianparadigm in the psychiatric world has been paramount. It has driven our view of schizophrenia and marginalized acceptance of the dissociative disorders and posttraumatic stress disorder (PTSD). However, this paradigm is now under threat from many quarters—from within its ranks as well as from outside—and there is good reason to view it as a paradigm in crisis.
FAILURES OF THE NEO-KRAEPELINIAN PARADIGM
Evidence for fundamental tenets of the neo-Kraepelinian paradigm—that there are clear genetic or biological bases for schizophrenia and other mental disorders and that mental disorders are discrete from one another and from normal experiences—have not been supported.
Comorbidity of diagnoses, incompatible with viewing diagnoses as discrete categories, is rampant in the DSM–IV system and typically viewed as a major problem. Psychotic symptoms are now recognized as common to many disorders other than schizophrenia, and their presence in a significant portion of the community with no diagnosed mental disorder firmly suggests that the line between “normality” and “pathology” is not hard and fast (Van Os, Linscott, Myin-Germeys, Delespaul, & Krabbendam, 2008Van Os, J., Linscott, R. J., Myin-Germeys, I., Delespaul, P. and Krabbendam, L.2008. A systematic review and meta-analysis of the psychosis continuum: Evidence for a psychosis proneness—persistence—impairment model of psychotic disorder. Psychological Medicine, 39: 179–195.). In addition, evidence for the validity of schizoaffective disorder, a fundamental challenge to the Kraepelinian dichotomy, has accumulated over the years. The demonstrated existence of persons with prominent schizophrenic and affective symptoms undermines the core distinction between schizophrenia and bipolar disorder and provides an argument for viewing even severe psychopathology as a dimension or series of dimensions instead of as categories. Finally, the abject failure of genetic-based research to find any strong link with schizophrenia or bipolar disorder provides a further anomaly for the neo-Kraepelinianparadigm to explain or attempt to ignore (if anything, the genetic evidence points to a “shared neurobiology across the two disorders,” Thaker, 2008Thaker, G. 2008. Psychosis endophenotypes in schizophrenia and bipolar disorder. Schizophrenia Bulletin, 34: 720–721., p. 720).
All of this is taking its toll on the medical model. As the neo-Kraepelinian edifice begins to crumble, adherents resort to stronger and stronger biological language, as though words such as neuropsychiatry and endophenotypes have the power to restore its once shining façade. The emphasis on endophenotypes is particularly telling, as this concept involves exploring putative underlying biological variables that may have only an indirectrelationship to the signs and symptoms of mental disorders. For example, a recent large-scale twin and family study focused on apparent genetic impairments in memory and intelligence as conveying liability for schizophrenia (Toulopoulou et al., 2010Toulopoulou, T., Goldberg, T. E., Mesa, I. R., Picchioni, M., Rijsdijk, F., Stahl, D.and … Murray, R. M. 2010. Impaired intellect and memory: A missing link between genetic risk and schizophrenia?. Archives of General Psychiatry, 67: 905–913.). The strong emphasis on endophenotypes, arising from a failure to find clear connections between genetic makeup and psychiatric diagnoses or symptoms, suggests that the neo-Kraepelinianstalwarts have beaten a strategic retreat; at the same time that psychological approaches to treating and understanding psychiatric symptoms, including delusions and hallucinations, have made great strides, the dominant paradigm has given up the traditional territory of mental disorders—the signs and symptoms that people suffer from and that treatments target.
So, the neo-Kraepelinian, categorical, medically based diagnostic system clearly seems to be in a state of crisis. But, as Kuhn has noted, a discipline such as psychopathology will not loosen its grip on a paradigm unless a suitable alternative is available to take its place. What is the evidence that one is appearing?
THE EMERGING TRAUMA/DISSOCIATION PARADIGM
In recent years, evidence has accumulated that traumatizing events are strongly linked to psychopathology in general and psychotic symptoms in particular. Kenneth Kendler, a prominent psychiatric geneticist, concluded from a carefully designed large-scale twin study that childhood sexual abuse was “causally related” to the development of psychiatric and substance abuse disorders (Kendler et al., 2000Kendler, K. S., Bulik, C. M., Silberg, J., Hettema, J. M., Myers, J. and Prescott, C. A. 2000. Childhood sexual abuse and adult psychiatric and substance use disorders in women: An epidemiological and cotwin control analysis. Archives of General Psychiatry, 57: 953–959., p. 953). In a subsequent commentary, he noted that the more than threefold increase in major depression attributable to severe sexual abuse was “much greater” than the odds ratios associated with any gene putatively linked to schizophrenia or bipolar disorder (Kendler, 2006Kendler, K. S. 2006. Reflections on the relationship between psychiatric genetics and psychiatric nosology. American Journal of Psychiatry, 163: 1138–1146., p. 1140); he soberly concluded, “The project to ground our messy psychiatric categories in genes … may be in fundamental trouble” (Kendler, 2006Kendler, K. S. 2006. Reflections on the relationship between psychiatric genetics and psychiatric nosology. American Journal of Psychiatry, 163: 1138–1146., p. 1145). Psychotic symptoms in particular appear to be strongly linked to trauma, both adult trauma (particularly when associated with PTSD; e.g., Scott, Chant, Andrews, Martin, & McGrath, 2007Scott, J., Chant, D., Andrews, G., Martin, G. and McGrath, J. 2007. Association between trauma exposure and delusional experiences in a large community-based sample. British Journal of Psychiatry, 190: 339–343.) and childhood interpersonal traumas (including in longitudinal studies such as Arseneault et al., 2011Arseneault, L., Cannon, M., Fisher, H. L., Polanczyk, G., Moffitt, T. E. and Caspi, A. 2011. Childhood trauma and children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study. American Journal of Psychiatry, 168: 65–72.). These studies are becoming increasingly well designed, typically controlling for many potentially confounding variables, even apparently genetic ones. Furthermore, psychological trauma has been strongly linked to the development of delusions and hallucinations (Moskowitz, Read, Farrelly, Rudegeair, & Williams, 2009Moskowitz, A., Read, J., Farrelly, S., Rudegeair, T. and Williams, O. 2009. “Are psychotic symptoms traumatic in origin and dissociative in kind?”. In Dissociation and the dissociative disorders: DSM–V and beyond, Edited by: Dell, P. and ’Neil, J. O. 521–533. New York, NY: Routledge.), and dissociation has been found to consistently and powerfully predict auditory hallucinations (but not delusions) in a range of populations (Moskowitz & Corstens, 2007Moskowitz, A. and Corstens, D. 2007. “Auditory hallucinations: Psychotic symptom or dissociative experience?”. In Trauma and serious mental illness, Edited by: Gold, S. N. and Elhai, J. D. 35–63. Binghamton, NY: Haworth Press.; several recently published studies have supported this relationship). Finally, brain changes long assumed to indicate a core genetic or biological neurodevelopmental disturbance in schizophrenia have been linked with chronic stressful or traumatic childhood experiences (Read, Perry, Moskowitz, & Connolly, 2001Read, J., Perry, B., Moskowitz, A. and Connolly, J. 2001. The contribution of early traumatic events to schizophrenia in some patients: A traumagenic neurodevelopmental model. Psychiatry: Interpersonal and Biological Processes, 64: 319–345.; Teicher et al., 2003Teicher, M. H., Andersen, S. L., Polcari, A., Anderson, C. M., Navalta, C. P. and Kim, D. M. 2003. The neurobiological consequences of early stress and childhood maltreatment. Neuroscience and Biobehavioral Reviews, 27: 33–44.). And these trauma-based brain changes are entirely consistent with emerging evolutionary-based explanations for psychotic symptoms (Grace, 2010Grace, A. A. 2010. Ventral hippocampus, interneurons, and schizophrenia: A new understanding of the pathophysiology of schizophrenia and its implications for treatment and prevention. Current Directions in Psychological Science, 19: 232–237.; Moskowitz, 2004Moskowitz, A. 2004. “Scared stiff”: Catatonia as an evolutionary-based fear response. Psychological Review, 111: 984–1002.).
IS THERE A SCIENTIFIC REVOLUTION IN THE HOUSE?
The failures of the current dominant medically based neo-Kraepelinian paradigm, coupled with the successes of an alternative paradigm focusing on adverse life experiences (including attachment disturbances) and dissociation, could herald the approach of a scientific revolution. Evidence that this may be occurring includes the increased willingness of prominent medical journals such as the American Journal of Psychiatry and Archives of General Psychiatry to publish studies supportive of this view (e.g., Arseneault et al., 2011Arseneault, L., Cannon, M., Fisher, H. L., Polanczyk, G., Moffitt, T. E. and Caspi, A. 2011. Childhood trauma and children’s emerging psychotic symptoms: A genetically sensitive longitudinal cohort study. American Journal of Psychiatry, 168: 65–72.; Kendler et al., 2000Kendler, K. S., Bulik, C. M., Silberg, J., Hettema, J. M., Myers, J. and Prescott, C. A. 2000. Childhood sexual abuse and adult psychiatric and substance use disorders in women: An epidemiological and cotwin control analysis. Archives of General Psychiatry, 57: 953–959.; Scott et al., 2007Scott, J., Chant, D., Andrews, G., Martin, G. and McGrath, J. 2007. Association between trauma exposure and delusional experiences in a large community-based sample. British Journal of Psychiatry, 190: 339–343.). As more and more psychiatrists are shifting paradigms, it must be recognized that many medically trained individuals within the trauma and dissociative disorders field have long championed this perspective (of course, there are psychologists and other non-physicians who continue to firmly embrace the “medical model” as well, but these paradigms to a large extent do map onto disciplinary distinctions and tensions).
Should a new paradigm emerge, it will be a genuine biopsychosocial one, recognizing that genetics plays a role in psychopathology, likely in providing vulnerability to certain broad forms of mental disorders or to mental disorders in general. It will also recognize that life experiences from gestation on play a major role not only in the expression of psychiatric symptoms but also in the expression of the genes that underlie vulnerability to mental disorders. This new paradigm must also recognize some form of dimension or dimensions across apparently different types of mental disorders (evaporating the comorbidity “problem”) and between pathology and so-called normality. It will require recognition of the extent and severity of childhood trauma, a reality that has long faced considerable resistance from adherents to the medical model. Finally, the presence of dissociative conditions, with the corollary that such individuals are radically different at different times, must be taken into account not only clinically but also in the design of research—something to which the current paradigm has been blind.
The DSM–5 committees appear to have some awareness of these challenges. Dimensional perspectives are being considered for personality disorders and possibly as an axis alongside other categories. What is striking is that the schizophrenia committee is recommending the elimination of the (currently pathognomic) first rank symptoms (voices conversing or commenting, delusions involving intrusions or withdrawals of thoughts or behavior), belatedly recognizing that they have “no unique diagnostic specificity” for schizophrenia (American Psychiatric Association, 2011American Psychiatric Association. (2011). Schizophrenia.http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=411# (http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=411#)). This is obviously welcome news (an early indication of a paradigm shift?), as the association of these clearly dissociative symptoms with schizophrenia has led to substantial misdiagnosis of dissociative identity disorder patients. But it also reminds us of the enigma that practically every attempt to define schizophrenia, from Bleuler to the present day, has invariably called forth dissociative identity disorder. That the paradigmatic biological disorder can be so easily confused with the paradigmatic environmental disorder should already be shaking the rafters of this house (but of course, as the dominant paradigm does not recognize dissociative identity disorder, it does not recognize this enigma!). The explanation for this puzzle should help us to understand the nature of schizophrenia—until then, we can firmly state that whatever schizophrenia is, it is not psychotic symptoms and certainly not auditory hallucinations. Unfortunately, the DSM–5 schizophrenia committee has not gone this far and continues to emphasize psychotic symptoms, even as the head of that committee, William Carpenter, warns against this approach (“Psychotic experience is to the diagnosis of mental illness as fever is to the diagnosis of infection—important, but non-decisive in differential diagnosis,” Fischer & Carpenter, 2009Fischer, B. A. and Carpenter, W. T.2009. Will the Kraepelinian dichotomy survive DSM–V?. Neuropsychopharmacology, 34: 2081–2087., p. 2081).
If a new paradigm does emerge, we can be sure that Kraepelin’s paradigmatic disease entity—General Paresis of the Insane—will be replaced. Perhaps it may not be possible to find a new exemplar for mental disorders in general, but PTSD would seem a worthwhile candidate for at least some of them—those clearly linked to trauma and characterized by dissociation (as, for example, has been proposed by Van der Hart, Nijenhuis, & Steele, 2006Van der Hart, O., Nijenhuis, E. and Steele, K. 2006. The haunted self: Structural dissociation and the treatment of chronic traumatization, New York, NY: Norton., in their structural dissociation model). And the possibility that schizophrenia, or at least some form of psychotic disorder, could fit this model should not be rejected outright. Even Bleuler, the progenitor of schizophrenia, despite his commitment to an organic etiology, seemed to recognize this. A growing appreciation of this possibility could, quite literally, trigger a scientific revolution in our view of mental disorders altogether.
The stronger the affects, the less pronounced the dissociative tendencies need to be in order to produce the emotional desolation. Thus, in many cases of severe disease, we find that only quite ordinary everyday conflicts of life have caused the marked mental impairment; but in milder cases, the acute episodes may have been released by powerful affects. And not infrequently, after a careful analysis, we had to pose the question whether we are not merely dealing with the effect of a particularly powerful psychological trauma on a very sensitive person, rather than with a disease in the narrow sense of the word. (Bleuler, 1911/1950Bleuler, E. 1950. Dementia praecox or the group of schizophrenias, Edited by: Zinkin, J. New York, NY: International Universities Press. Original work published 1911, p. 300; Sünje Matthiesen, translation)
Lost connections by Johann Hari is simply the best book I’ve ever read. It asks all the right questions and it also provides many possible answers. I hope this will be a book that ultimately will change our society and the way we think about mental illness. Working as a psychologist myself, it felt like somebody finally provided solutions that will work in therapy and possibly change.
This synopsis is copied from goodreads:
From the New York Times bestselling author of Chasing the Scream: The First and Last Days of the War on Drugs, a startling challenge to our thinking about depression and anxiety.
Award-winning journalist Johann Hari suffered from depression since he was a child and started taking antidepressants when he was a teenager. He was told—like his entire generation—that his problem was caused by a chemical imbalance in his brain. As an adult, trained in the social sciences, he began to investigate this question—and he learned that almost everything we have been told about depression and anxiety is wrong.Across the world, Hari discovered social scientists who were uncovering the real causes—and they are mostly not in our brains, but in the way we live today. Hari’s journey took him from the people living in the tunnels beneath Las Vegas, to an Amish community in Indiana, to an uprising in Berlin—all showing in vivid and dramatic detail these new insights. They lead to solutions radically different from the ones we have been offered up until now.
Just as Chasing the Scream transformed the global debate about addiction, with over twenty million views for his TED talk and the animation based on it, Lost Connections will lead us to a very different debate about depression and anxiety—one that shows how, together, we can change
Some stories bury themselves deep into your soul, leaving marks and holes. When the marks are gone, scars appear to remind you not to forget. This story did that to me. From now on, I will not forget. I will not forget that there is always hope, no matter how terrible your life was. Because this book is about extreme abuse. This post might be triggering, so refrain from reading further if you can be triggered.
I have just read Scared Selfless by Michelle Stevens. It is hard to describe how important this book was to me. Working as a psychologist myself, this was like finding the famous needle in the haystack. When I stumbled upon it on audible, i knew it was about trauma, but I had no idea that it also was about multiple personality disorder and that the author (a psychotherapist) was the one sharing her story. When I first listened to it, my boyfriend heard the first chapter too. Unfortunately, he couldn’t stomach the horrible abuse Stevens has experienced as he started to think about his own daughters. For me, it was impossible to stop listening. It was such an emotional journey, taking me from despair to horror and then hope. There has been such a long time since a book managed to evoke these feelings in me, and I realized one thing: Humans must keep searching for stories like these, that reminds us there’s always hope; That we truly are survivors, no matter what we’ve experienced. I will take this book with me in all conversations with my lovely clients from now on. And if I ever feel hopelessness, or that I can’t offer anything more, I shall remember that is just not true. By loving what you do and remembering why you do it, we can all change lives. Ourselves and others.
“A riveting memoir that takes readers on a roller coaster ride from the depths of hell to triumphant success.”—Dave Pelzer, author of A Child Called “It”
Michelle Stevens has a photo of the exact moment her childhood was stolen from her: She’s only eight years old, posing for her mother’s boyfriend, Gary Lundquist—an elementary school teacher, neighborhood stalwart, and brutal pedophile. Later that night, Gary locks Michelle in a cage, tortures her repeatedly, and uses her to quench his voracious and deviant sexual whims. Little does she know that this will become her new reality for the next six years.
Michelle can also pinpoint the moment she reconstituted the splintered pieces of her life: She’s in cap and gown, receiving her PhD in psychology—and the university’s award for best dissertation.
The distance between these two points is the improbable journey from torture, loss, and mental illness to healing, recovery, and triumph that is Michelle’s powerful memoir, Scared Selfless.
Michelle suffered from post‐traumatic stress disorder, anxiety, and depression, and made multiple suicide attempts. She also developed multiple personalities. There was “Chelsey,” the rebellious teenager; “Viscous,” a tween with homicidal rage; and “Sarah,” a sweet little girl who brought her teddy bear on a first date.
In this harrowing tale, Michelle, who was inspired to help others heal by becoming a psychotherapist, sheds light on the all-too-real threat of child sexual abuse, its subsequent psychological effects, and the best methods for victims to overcome their ordeals and, ultimately, thrive. Scared Selfless is both an examination of the extraordinary feats of the mind that are possible in the face of horrific trauma as well as Michelle’s courageous testament to their power.
Thank you Stevens, for sharing your story.
If you are a survivor of abuse yourself this homepage might be of help. Finding a good therapist can help too. Don’t be afraid of trying to find help, it can help you to heal.