Monday, September 09, 2013

Biological Psychiatry and the New Science of Mind (Yeah, Not So Much)

At Frontiers in Theoretical and Philosophical Psychology, Henrik Walter (Research Division of Mind and Brain, Department of Psychiatry and Psychotherapy, Charité Universitaetsmedizin Berlin, Germany; Berlin School of Mind and Brain, Humboldt University) offers a theory article on a proposed third wave of biological psychiatry. From Walter's abstract:
A look at current conceptualizations in biological psychiatry as well as at some discussions in current philosophy of mind on situated cognition, reveals that the thesis, that mental brain disorders are brain disorders has to be qualified with respect to how mental states are constituted and with respect to multilevel explanations of which factors contribute to stable patterns of psychopathological signs and symptoms.
Full Citation: 
Walter H. (2013, Sep 5). The third wave of biological psychiatry. Frontiers in Theoretical and Philosophical Psychology; 4:582. doi: 10.3389/fpsyg.2013.00582

As a little bit of background, Walter offers a brief sketch of each of the first two waves of biological psychiatry:
The first wave in the second half of the nineteenth century can be best understood as a new research agenda. It was not so much characterized by the idea that the mental and the nervous system are closely linked – this was already believed by ancient philosophers – but rather by the ambition to uncover the relation between mind and brain by doing systematic research linking neuropathology and mental disorder and by using the experimental method in animals and humans. Wilhelm Griesinger (1817–1868), one of the most important figures of this first wave, famously declared: mental disorders are disorders of the brain.
And . . .
The second wave of biological psychiatry started only in the second half of the twentieth century and was, according to Shorter, driven by two new discoveries. The first was genetics, which could show that severe mental disorders, in particular schizophrenia, have a strong genetic component. The second was the discovery of efficient medication for various mental disorders (1949 lithium, 1952 chlorpromazin, 1957 imipramin, 1958 haloperidol, 1963 diazepam). They quickly became a major pillar of psychiatric treatment and contributed strongly to the opening and later disappearance of the large mental asylums in the second half of the last century. Soon, the concept of a neurochemical imbalance of neurotransmitters became the favored explanatory model for psychiatric disorders.
Walter argues that there have been two recent (in the last two decades) developments that signal the transition into a Third Wave - (1) the advances in if the molecular neurosciences, and (2) the development and advances in the fields of cognitive neuroscience and neuroimaging. In support of the first point:
It became increasingly clear that the effects of psychiatric drugs are not primarily exerted via the level of neurotransmitters in the synaptic cleft, but that there is up- and down-regulation of receptors, effects on intracellular cascades, and even regrowth of neurons in the hippocampus. The picture of the neurobiological changes underlying psychiatric disorders and treatment thus became much more complex and differentiated and it became apparent that different levels of brain organization are important which interact in a complex way. 
In support of his second point:
With the first human study published in 1991, fMRI has today become a major research tool in psychology as well as in psychiatry. This development could not have taken place without a large increase in computational power. In fact, computational neuroscience which tries to develop mathematical models of brain function, has become an important tool in explaining neurocognitive processes and recently the program of computational psychiatry has begun to evolve (Montague et al., 2012). Further methods and technologies have become available to investigate the interplay of genetics, experience and environment in the etiology and neural explanation of psychiatric disorders like imaging genetics, epigenetics, optogenetics, or deep brain stimulation.
Rightly, Walter comments in this section of the paper on the ways popular media reporting misrepresents the findings from these new technologies (he offers as examples: “love is in the ACC,” “the God spot,” “gene for schizophrenia discovered”). With this over-reach in interpreting results, the new field of critical neuroscience (see [article] Slaby, 2010, Steps towards a Critical Neuroscience, Phenomenology and the Cognitive Sciences, 9(3); or [book] Slaby and Choudhury, 2011, Critical Neuroscience: A Handbook of the Social and Cultural Contexts of Neuroscience). 

The Third Wave

Walter offers a concise definition of his proposed third wave as it relates to mental disorders in this single sentence:
According to the third wave of biological psychiatry, mental disorders are relatively stable prototypical, dysfunctional patterns of experience and behavior that can be explained by dysfunctional neural systems at various levels. 
Representative of this model (Walter calls it a paradigmatic example) is Thomas Insel's research domain criteria (RDoC), the development of which he has overseen in his role as Director of the National Institutes of Mental Health (NIMH). Insel generated a lot of discussion when he announced that the NIMH would not be using the American Psychiatric Association's the DSM-5, claiming that:
the weakness (of DSM-5) is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment (Insel, 2013, Transforming Diagnosis).
Rather than using the DSM categories as the "gold standard," Insel argues that we need to move away from the symptom-based approach that has been dominant for more than 100 years in Western psychology and, instead, seek to understand the causal explanatory structures that underlay the symptoms.

Walter offers this summary of the basic philosophy of the RDoC model:
RDoC can be regarded as a generalization of these initiatives being constructed for application to all mental disorders. It is based on three central assumptions: (1) mental disorders are presumed to be disorders of brain circuits. (2) Tools of neuroscience, including neuroimaging, electrophysiology and new methods for measuring neural connections can be used to identify dysfunctions of neural circuits. (3) Data from genetics research and clinical neuroscience will yield biosignatures that will augment clinical signs and symptoms for the purposes of clinical intervention and management.
These three central objectives smell a lot like a methodology for developing pharmaceutical interventions (which is my belief). However, there are also environmental and developmental factors considered as orthogonal dimensions (a way to graphically display large amounts of information) that will inform the neurological findings derived from the RDoC organization structure.

In this case, the data is organized as a 2-dimensional schema:
One dimension includes constructs that represent five core domains of mental functioning: Negative valence systems, positive valence systems, cognitive systems, systems for social processes and attention/arousal systems. Each of these domains includes subconstructs (around five). For example the negative valence systems include: active threat (“fear”), potential threat (“anxiety”), sustained threat, loss and frustrative non-reward. To take another example: the cognitive systems domain comprises attention, perception, working memory, declarative memory, language behavior, and cognitive (effortful) control. The second dimension consists of units of levels of organization on which the constructs can be measured. These levels are defined as follows: genes, molecules, cells, circuits, physiology, behavioral, self-reports, and paradigms. The “circuits” unit of analysis refers to measures that can index the activity of neural circuits, either through functional neuroimaging or through recordings previously validated as circuit indices (e.g., fear-potentiated startle). “Physiology” refers to well-established measures that have been validated by assessing various constructs, but that do not measure brain circuit activity directly (e.g., heart rate, cortisol). “Behavior” may refer either to systematically observed behavior or to performance on a behavior task such a working memory.
As powerful as is the NIMH (grant proposals not adhering to their new framework will not be funded), there are still many researchers, including neuroscientists, who offer objections to the RDoC model. Here is a summary of the four most common objections to the third wave perspective, as suggested by Walter:
(1) It could still be argued that the framework favors the neurobiological over other factors, as it entails the idea that psychiatric disorders are brain disorders. It will make no difference if you call psychiatric disorders “disorders of the brain” or “disorders of brain circuits” and thus do not justice to the mental within the concept of mental disorders. 
(2) The third wave does not include a solution to the normativity problem, namely the question of when a constellation of psychological signs and symptoms is already a disorder or when it is still part of “normal experience,” so it will still promote a medicalization of life problems. 
(3) Even if we somehow could solve the first two problems, it might be argued that a focus on the brain will lead to inefficient resource allocation because the outcome for patients is not worth the effort be put in. History has shown that all general claims that we will in the near future know “the” causes of mental disorders have failed, and the continuous failure of neurobiology (with some exceptions) to sufficiently explain or predict mental disorders shows that it cannot account for such complex phenomena. 
(4) We should rather focus on the well-known psychosocial factors contributing to the development or sustainment of psychiatric disorders which are much more relevant in practice.
I tend to agree with these basic objections. Fundamentally, the third wave model (and especially the RDoC) is premised on the unproven and highly questionable proposition that the mind is equivalent to the brain.

To his credit, Walter addresses this fundamental issue, that all we need to do in understanding the mind is look at the brain. He brings in the philosophical idea of situated cognition:
There is not yet a consistent or complete theory of situatedness, rather there are several strands of research and theorizing that can be subsumed under the catchword “the 4Es”: the embodied, extended, embedded and enacted mind (Lyre and Walter, 2013). The main idea is that in order to understand what cognition (the mental) is, it is necessary to take into account that cognitive capacities of a system may depend on the fact that those systems (our brains) are (i) embodied, i.e., coupled to our bodily constitution and that it therefore is necessary to regard the bodily realization of cognitive abilities as an integral part of the cognitive architecture; (ii) situationally embedded, i.e. are dependent in a specific way on their environment, i.e., cognitive systems exploit the specific circumstances of their environmental context in order to increase their performative abilities, (iii) extended, i.e., extend over the boundaries of our body into the technological or social environment and thus are constituted not only by internal factors but also by external, environmental factors and (iv) enacted, i.e., arise only by the active interaction of an autonomous systems with its environment (Walter, 2010).
I have long been arguing that all four of these types of situatedness are essential to any definition of mind or consciousness. If we do not even know how the mind is generated, and why, how can we ever begin to say that specific brain  circuits or brain states are pathological?

The New Science of Mind?

In an opinion article in the Sunday (Sept. 8, 2013) New York Times, Dr. Eric Kandel (2000 Nobel Prize in Physiology or Medicine for his research on the physiological basis of memory storage in neurons) outlines his perspective on the currently emerging "new science of mind."

In the first part of the article, Kandel outlines four key findings that have emerged over the course of our increasing exploration of neuroscience and the brain-based correlates of mental distress:
  • First, the neural circuits disturbed by psychiatric disorders are likely to be very complex.
  • Second, we can identify specific, measurable markers of a mental disorder, and those biomarkers can predict the outcome of two different treatments: psychotherapy and medication.
  • Third, psychotherapy is a biological treatment, a brain therapy. It produces lasting, detectable physical changes in our brain, much as learning does.
  • And fourth, the effects of psychotherapy can be studied empirically. Aaron Beck, who pioneered the use of cognitive behavioral therapy, long insisted that psychotherapy has an empirical basis, that it is a science. Other forms of psychotherapy have been slower to move in this direction, in part because a number of psychotherapists believed that human behavior is too difficult to study in scientific terms. 
Numbers three and four here are crucial to any forward movement we are going to make in our understanding of non-invasive ways to alter unhealthy psychological functioning. Unfortunately, he goes on in the second half of the article to espouse the mainstream materialist view, although he stops just short of saying the brain = mind.
This new science of mind is based on the principle that our mind and our brain are inseparable.
Inseparable? Yes - when the brain dies, we cease to exist. But identical? No.

There really is a new science of mind, but it is not the RDoC model of Thomas Insel and the NIMH, nor is it the third wave of biological psychiatry. Rather, it is a field known as interpersonal neurobiology, proposed and named by Daniel Siegel and co-developed with Allan Schore, with support form Louis Cozolino, Marco Iacoboni, Stephen Porges, Pat Ogden, Daniel Stern, and Diana Fosha.

From Dan Siegel's personal site, here is a long definition of interpersonal neurobiology:

About Interpersonal Neurobiology

An Introduction to Interpersonal Neurobiology

An Interdisciplinary Field:  Seeking Similar Patterns 
Daniel J. Siegel, M.D. is a pioneer in the field called interpersonal neurobiology (The Developing Mind, 1999) which seeks the similar patterns that arise from separate approaches to knowledge. This interdisciplinary field invites all branches of science and other ways of knowing to come together and find the common principles from within their often disparate approaches to understanding human experience. Sciences contributing to this exciting field include the following: 

  • Anthropology
  • Biology (developmental, evolution, genetics, zoology)
  • Cognitive Science
  • Computer Science
  • Developmental Psychopathology
  • Linguistics
  • Neuroscience (affective, cognitive, developmental, social)
  • Mathematics
  • Mental Health
  • Physics
  • Psychiatry
  • Psychology (cognitive, developmental, evolutionary, experimental, of religion, social, attachment theory, memory)
  • Sociology
  • Systems Theory (chaos and complexity theory)
Interpersonal neurobiology weaves research from these areas into a consilient framework that examines the common findings among independent disciplines.  This framework provides the basis of interpersonal neurobiology. The mind is defined and its components necessary for health are illuminated.  

The Mindsight Approach Exists Within the Field of Interpersonal Neurobiology 
Under the umbrella of interpersonal neurobiology, Dr. Siegel’s mindsight approach applies the emerging principles of interpersonal neurobiology to promote compassion, kindness, resilience, and well-being in our personal lives, our relationships, and our communities. At the heart of both interpersonal neurobiology and the mindsight approach is the concept of “integration” which entails the linkage of different aspects of a system—whether they exist within a single person or a collection of individuals.  Integration is seen as the essential mechanism of health as it promotes a flexible and adaptive way of being that is filled with vitality and creativity. The ultimate outcome of integration is harmony. The absence of integration leads to chaos and rigidity—a finding that enables us to re-envision our understanding of mental disorders and how we can work together in the fields of mental health, education, and other disciplines, to create a healthier, more integrated world.

Integration:  At the Core of Our Well-Being 
Integration is at the heart of both interpersonal neurobiology and Dr. Siegel’s mindsight approach. Defined as the linkage of differentiated components of a system, integration is viewed as the core mechanism in the cultivation of well-being. In an individual’s mind, integration involves the linkage of separate aspects of mental processes to each other, such as thought with feeling, bodily sensation with logic. In a relationship, integration entails each person’s being respected for his or her autonomy and differentiated self while at the same time being linked to others in empathic communication.

What Does Integration Mean for the Brain? 
For the brain, integration means that separated areas with their unique functions, in the skull and throughout the body, become linked to each other through synaptic connections. These integrated linkages enable more intricate functions to emerge—such as insight, empathy, intuition, and morality. A result of integration is kindness, resilience, and health. Terms for these three forms of integration are a coherent mind, empathic relationships, and an integrated brain.

Focus Your Attention:  Actually Change Your Brain 
This highly integrative field is not a division of one particular area of research, but rather is an open and evolving way of knowing that invites all domains of both academic and reflective explorations of reality into a collective conversation about the nature of the mind, the body, the brain, and our relationships with each other and the larger world in which we live. This emerging approach is fundamental to exploring a range of human endeavors, including the fields of mental health, education, parenting, organizational leadership, climate change intervention, religion, and contemplation. Knowing about the way the focus of attention changes the structure and function of the brain throughout the lifespan opens new doors to healing and growth at the individual, family, community, and global levels.

"Inspire to Rewire" 
 By combining the exciting new findings of how awareness can shape the connections in the brain toward integration together with the knowledge of how interpersonal relationships shape our brains throughout the lifespan, we can actively “inspire each other to rewire” our internal and interpersonal lives toward integration. 
 Dr. Siegel edits the Norton Series on Interpersonal Neurobiology, from W.W. Norton Publishers. For counselors and psychotherapists, this series offers some of the most useful books available.

When Dr. Kandel mentioned that psychotherapy is a biological approach because it literally can change and even rewire the brain, he was referring primarily to Aaron Beck's cognitive behavioral therapy (CBT). I have not seen any evidence that CBT can effectively rewire the brain, but there is a growing body of evidence that suggests that depth psychology, specifically psychodynamic and relational psychoanalytic approaches, can rewire the brain through the repair of faulty attachments schemas.

If we are to be healthy and functional human beings, we will by necessity be in relationship with others.
Relational-needs are present throughout the entire life cycle from early infancy to old age. People do not outgrow their need for relationship. These needs are the basis of our humanness. Even as adults we attach to others because we perceive them as being able to satisfy our variety of needs. (Erskine, Attachment, Relational-Needs, and Psychotherapeutic Presence, 2011).
Relational psychoanalysis is based on the premise that much of who we are as human beings is formed by our relationships to primary caregivers, our environment, and our peers. By this measure, then, dysfunction is based in unhealthy relationships and/or coping strategies in one of these areas. The psychotherapeutic process is also a relationship, and it is in the relationship more than the theory employed that allows for healing to occur.

According to Mikulincer and Shaver (2007, Attachment in Adulthood: Structure, Dynamics, and Change), some clients (many more so in trauma work) experience relational bonds with their therapists that are similar to infant attachment bonding patterns.
Specifically, some clients: (i) regard their therapist as stronger and wiser; (ii) seek proximity through emotional connection and regular meetings; (iii) rely upon their therapist as a safe haven when they feel threatened; (iv) derive a sense of felt security from their therapist, who serves as a secure base for psychological exploration; and (v) experience separation anxiety when anticipating loss of their therapist. [Cited in Mallinckrodt, 2010, Journal of Social and Personal Relationships; 27(2)]
In concluding the article, which has turned out to be much longer than I had anticipated, here is a video of David Wallin talking about Attachment in Psychotherapy (2007).

Attachment in Psychotherapy from Books Inc on
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