Preliminary Thoughts on a New Nomenclature of Psychotherapeutic Diagnosis and Practice

 

Above is one model of integrative psychotherapy (Erskine and Trautmann, 1996). What follows below are some preliminary thoughts on how I practice as a therapist and how I might change the existing nomenclature to reflect a more client-centered, relational model that rejects pathologizing language and structures (i.e., the DSM).

Premise: 

What counselors and psychotherapists have been taught to identify as symptoms of a corresponding condition pejoratively defined as "mental illness" should rather be understood as adaptations to experience.

All adaptations are at their genesis the best available mechanism for survival. As a person ages, these adaptations become either skillful (healthy) or unskillful (not supporting physical, emotional, mental, and spiritual health).

Disclaimer:

Short-term responses to challenging situations are not, in general, to be seen as adaptations to that experience (i.e., normal human emotional responses to life events such as death of a loved one, losing a job or promotion, surviving an accident, and so on). If, however, there are several similar experiences over a person's lifetime, with a corresponding response pattern that has solidified into what Carl Jung defined as a "complex," then this then can be seen as an adaption and not a response. 

Diagnosis:

When we join a new client on their healing journey, our task is to identify with them the somatic symptoms, affect dysregulation, cognitive distortions, lost spirituality, the core beliefs, and each domain's corresponding defense mechanisms that block an integrative experience of full health.

An integrative approach assesses from (at least) five domains, four of which are addressed by specific models of psychotherapy that contend their model is the only necessary model:

• Body - somatic symptoms and unconscious behaviors
• Affect - ability to regulate affect and for affect to match verbal and behavioral expression
• Cognitive - possessing rational and non-distorted self-concepts, lack or pervasive thinking errors, or other forms of unskillful cognitive and behavioral scripts
• Spiritual - a sense of purpose and meaning in one's life whether it's religious, spiritual, or atheist/humanist

The fifth domain is the Core Beliefs a person holds about who s/he is and what other people believe about him or her. These beliefs are deeply held and generally unconscious. They tend to originate in infancy and early childhood, making them difficult to uproot in order to plant new seeds for healthier core beliefs. Further, core beliefs tend to manifest in each of the four other domains listed above.

Multiplicity

We are all born (barring organic defects) with a whole and healthy Self-seed (our genetic and characterological template) that will become a mature sense of Self. However, no one escapes childhood without that Self being compromised in some way. Some children are so abused and/or neglected that they never develop a solid sense of self.

Consequently, parts of the self that are either overwhelming (emotional responses to trauma), unsafe (natural behaviors that are punished by caregivers), or not nurtured (for example, capacity for compassion or generosity) are split off from the Self and become self-fragments, ego states, parts, or subpersonalities that often remain unconscious and tend to show up in various forms of projection.

For each split off part, there is a part or parts that manages the outside world in some way to keep those "exiled" parts out of consciousness. Some of the common "managers" are the Pusher (focused on achievement and constant movement toward the next goal), Perfectionist (all or nothing thinking, a need for personal perfection, the failure of which brings intense shame), Pleaser (often middle children or first children who try to make everyone else happy, often at the expense of their own happiness), and the Inner Critic (a part who seeks to ensure the client is never criticized by others by being so hyper-critical of the client that any other criticism will be avoided). 

In order for splitting to become "hard-wired," there must be repeated episodes of the experiences that lead to the splitting. Normal misattunement between child and caregiver will not lead to splitting and, in fact, such misattunements are necessary for the development of resilience when they are quickly repaired by the caregiver.

Worldviews or Reality Frames

It is incumbant upon the therapist to be "experience near" (Kohut) with the client and be able to identify their basic worldview or reality model. This does not mean that the therapist necessarily supports the client's worldview, however, but it does require that the therapist be able to work within that reality frame.

It's also important that a client's worldview be held lightly - different parts of the client will possess alternate worldviews with anywhere from slight to profound variations.

Likewise, when a therapist encounters a new client whose worldview is unfamiliar (for example, someone from another country, or members of Tribal Nations, and so on), it is essential that therapists educate themselves as best they can and that they inquire with the client when they start to make assumptions about the client's experience that may not fit their reality frame.

Models of Psychotherapy

Successful therapeutic interventions require the all five domains are addressed. Here are a few examples of the therapeutic models that address the various domains:

Body - nutrition, exercise, somatic therapies (Somatic Experiencing, Bioenergetics, Yoga Therapy), behavioral psychotherapies, mindfulness-based therapies, Internal Family Systems Therapy (IFS - "parts work"), Hakomi, Eye Movement Desensitization, and Reprocessing (EMDR)
Affect - affective neuroscience, interpersonal neurobiology, intersubjective and relational psychotherapies, mindfulness-based therapies, IFS
Cognitive - cognitive behavioral therapies (CBT), dialectical behavioral therapy (DBT), neurolinguistic programming (NLP), rational emotive behavioral therapy (REBT), script analysis (Transactional Analysis), existential psychotherapy, narrative therapy, IFS
Spiritual - transpersonal psychotherapy, Jungian Analytical Psychotherapy, contemplative practices, meta-narrative therapies, existential psychotherapy, IFS (developing "Self-Leadership"), expressive therapies
Core Beliefs - cognitive therapies, relational psychotherapies, IFS, narrative therapies, creative visualization, soul retrieval, expressive therapies

Undoubtedly, there are other models I am not familiar with or that have slipped my mind at the moment, so this list should not be taken as my final position on this topic.

Goals of Psychotherapy

First rule: Do No Harm. Second rule: It's not the therapy, it's the relationship.

If therapists can successfully follow these two rules, and hold a belief in the inherent ability of the client to heal, as well as a belief in the client's ability to know what therapeutic pace and which interventions are best for them, then the client becomes his or her own healer and the therapist simply "midwife" that process with them.

The goal is never to impose a therapist's sense of "mental health" but, rather, to explore with the client what their own sense of mental health looks like and feels like in their lives. Having done so, then it becomes easier for the therapist to identify with the client which areas or domains of their life are not functioning optimally.

Areas of less-than-optimal function are the adaptations defined as unskillful that therapy seeks to minimize while also helping the client learn skillful adaptations to replace those being minimized.

***

Okay then, that is my first-pass at a new model. Please share your thoughts, comments, and criticisms in the comments section here or at Facebook.

Jerome Wakefield - Psychiatric Diagnoses: Science or Pseudoscience?

 

This is an interesting podcast from the good folks at the Institute for Ethics and Evolving Technologies (IEET) on the validity of psychiatric diagnoses - a very relevant topic here at the Evolution of Psychotherapy Conference. Many of the speakers we have heard so far do not use the DSM diagnostic protocols because they have little to do with the clients we see in our offices.



Jerome Wakefield is the author of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (2007), All We Have to Fear: Psychiatry's Transformation of Natural Anxieties into Mental Disorders (2012), and several other books.

Psychiatric Diagnoses: Science or Pseudoscience?

Rationally Speaking
Posted: Dec 10, 2013 


Jerome Wakefield, DSW, PhD

The standard for diagnosis is the Diagnostic and Statistical Manual of Mental Disorders (DSM), which just released a 5th edition in 2013—but just how objective is it? This episode of Rationally Speaking features Dr. Jerome Wakefield, psychiatrist, PhD in philosophy, and author of "The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder." Julia, Massimo and Jerome talk about the arbitrariness of the DSM and the controversies around the boundaries of various mental disorders, including depression and sexual fetishes.



Jerome's pick: Bertran Russells's Autobiography

Listen/View

Vaughan Bell - Changing Brains: Why Neuroscience Is Ending the Prozac Era

Last week in The Observer (UK), Vaughan Bell took a brief but important look at the quiet shift occurring right now in the neuroscience world in relation to treating mental illness. The idea of being able to fix anything and everything with a magic bullet pill is ending. Now scientists are looking more closely at brain networks, hoping to learn more about how the brain is functioning in depression, or schizophrenia, or some other symptom collection.

The idea is that cannot understand a dysfunction until we understand the range of "normal" functioning. With this shift comes the Research Domain Criteria or the RDoC Project, which will sooner or later replace the current DSM model used by psychiatrists.


This is a step in the right direction - but it also is a step further away from the real source of nearly ALL mental illness symptoms - relational dysfunction in the family of origin, among caretakers, or in some other form. Everything else is life - sometimes it sucks and we feel like hell, but it's not a mental illness, it's grief, or loss, or sadness.

Changing brains: Why neuroscience is ending the Prozac era

The big money has moved from developing psychiatric drugs to manipulating our brain networks

Vaughan Bell
The Observer, Saturday 21 September 2013

Mice are used in research into optogenetics, which suggests that even finer control of the brain may be possible. Photograph: John B Carnett/Popular Science via Getty Images

The psychiatric drug age may have reached its peak. Although mind-altering medications are being prescribed in record numbers, signs of a radically new approach to understanding and treating mental illness are emerging from the deep waters of neuroscience. No longer focused on developing pills, a huge research effort is now devoted to altering the function of specific neural circuits by physical intervention in the brain.

The starkest indication that drugs are increasingly being thought of as yesterday's cutting-edge comes from the little mentioned fact that almost all the major drug companies have closed or curtailed their drug discovery programmes for mental and neurological disorders. The realisation that there has been little in the way of genuine innovation since the major classes of psychiatric drugs were discovered in the 1950s has made future sales look bleak. New drugs have regularly appeared since then, often with fewer side effects, but most are little better in terms of effectiveness.

This is largely because these drugs tend not to be very specific in their effects on the brain. For example, the medication fluoxetine (better known as Prozac) alters levels of the neurotransmitter serotonin in brain networks related to mood, but it has the same effect in brain networks involved in sexual response, leading to the common side effect of difficulty with orgasm. The pharmaceutical holy grail has been to develop drugs that are more selective in their effects, but this multibillion dollar dream has largely been ditched by Big Pharma as too difficult.

In its place is a science focused on understanding the brain as a series of networks, each of which supports a different aspect of our experience and behaviour. By this analysis, the brain is a bit like a city: you can't make sense of the bigger picture without knowing how everything interacts. Relatively few residents of Belfast who live in the Shankill spend their money in the Falls Road and this tells us much more about the city – as these are the key loyalist and republican areas – than knowing that the average income of each area is much the same. Similarly, knowing that key brain areas interact differently when someone gets depressed tells us something important that a measure of average brain activity would miss.

The idea is that we can better understand complex human emotion and behaviour by understanding neural networks. This is where a new wave of interest is beginning to rise within neuroscience. The surge of interest is not with the concepts, which, if truth be told, became common currency in the mid-20th century, but in the extent to which research and treatment are being driven by a desire to identify and modify key brain circuits.

Big money has already been committed. The Obama White House has promised $3bn to develop technology to help identify brain circuits, while the National Institute of Mental Health has promised to move its seven-figure funding away from research into conditions such as schizophrenia and depression towards a system that looks at how brain networks contribute to difficulties that are shared across diagnoses. This project, given the unspectacular name Research Domain Criteria or the RDoC Project, is being cited as an eventual replacement for the diagnostic system used by current-day psychiatrists.

Perhaps more surprising for some is the explosion in deep brain stimulation procedures, where electrodes are implanted in the brains of patients to alter electronically the activity in specific neural circuits. Medtronic, just one of the manufacturers of these devices, claims that its stimulators have been used in more than 100,000 patients. Most of these involve well-tested and validated treatments for Parkinson's disease, but increasingly they are being trialled for a wider range of problems. Recent studies have examined direct brain stimulation for treating pain, epilepsy, eating disorders, addiction, controlling aggression, enhancing memory and for intervening in a range of other behavioural problems.

New technologies such as optogenetics suggest that even finer control of brain circuits may be possible. While deep brain stimulation involves stimulating the brain with electrical currents, optogenetics involves injecting neurons with a benign virus that contains the genetic information for light-sensitive proteins. The brain cells then become light sensitive themselves and their activity can be controlled with millisecond flashes of light sent through embedded fibre optic cables. Until now, this has only been demonstrated in animals but there are high hopes that it could lead to precisely controlled treatments in humans that intervene only in carefully selected brain circuits.

Let's make this clear. The scientific revolution in identifying and manipulating brain circuits is already under way. Additionally, with billions committed to research over the next 10 years, the medical revolution is likely to follow in the decades after. But a more important change will occur. Advances in neuroscience are not just discoveries, they also shape, as they always have done, how we view ourselves. As the Prozac nation fades, the empire of the circuit-based human will rise, probably to the point where dinner party chatter will include the misplaced jargon of systems neuroscience. But these are tools to help us understand humanity, not our humanity itself. Grief remains the loss of a loved one, joy a fulfilment of life's desires, and neither could be explained just by neural circuits. Life will still stretch beyond the confines of our inner worlds.

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 FORA.tv

Why Life in America Can Literally Drive You Insane (Hint: It's not just Big Pharma)

Interesting and important article, found at AlterNet.

Why Life in America Can Literally Drive You Insane

It's not just Big Pharma

By Bruce E. Levine
July 30, 2013

In “The Epidemic of Mental Illness: Why?” (New York Review of Books, 2011), Marcia Angell, former editor-in-chief of the New England Journal of Medicine, discusses over-diagnosis of psychiatric disorders, pathologizing of normal behaviors, Big Pharma corruption of psychiatry, and the adverse effects of psychiatric medications. While diagnostic expansionism and Big Pharma certainly deserve a large share of the blame for this epidemic, there is another reason.

A June 2013 Gallup poll revealed that 70% of Americans hate their jobs or have “checked out” of them. Life may or may not suck any more than it did a generation ago, but our belief in “progress” has increased expectations that life should be more satisfying, resulting in mass disappointment. For many of us, society has become increasingly alienating, isolating and insane, and earning a buck means more degrees, compliance, ass-kissing, shit-eating, and inauthenticity. So, we want to rebel. However, many of us feel hopeless about the possibility of either our own escape from societal oppression or that political activism can create societal change. So, many of us, especially young Americans, rebel by what is commonly called mental illness.

While historically some Americans have consciously faked mental illness to rebel from oppressive societal demands (e.g., a young Malcolm X acted crazy to successfully avoid military service), today, the vast majority of Americans who are diagnosed and treated for mental illness are in no way proud malingerers in the fashion of Malcolm X. Many of us, sadly, are ashamed of our inefficiency and nonproductivity and desperately try to fit in. However, try as we might to pay attention, adapt, adjust, and comply with our alienating jobs, boring schools, and sterile society, our humanity gets in the way, and we become anxious, depressed and dysfunctional.

The Mental Illness Epidemic

Severe, disabling mental illness has dramatically increased in the Untied States. Marcia Angell, in her 2011 New York Review of Books piece, summarizes: “The tally of those who are so disabled by mental disorders that they qualify for Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) increased nearly two and a half times between 1987 and 2007—from 1 in 184 Americans to 1 in 76. For children, the rise is even more startling—a thirty-five-fold increase in the same two decades.”

Angell also reports that a large survey of adults conducted between 2001 and 2003 sponsored by the National Institute of Mental Health found that at some point in their lives, 46% of Americans met the criteria established by the American Psychiatric Association for at least one mental illness.

In 1998, Martin Seligman, then president of the American Psychological Association, spoke to the National Press Club about an American depression epidemic: “We discovered two astonishing things about the rate of depression across the century. The first was there is now between ten and twenty times as much of it as there was fifty years ago. And the second is that it has become a young person’s problem. When I first started working in depression thirty years ago. . . the average age of which the first onset of depression occurred was 29.5. . . .Now the average age is between 14 and 15.”

In 2011, the U.S. Centers for Disease Control and Prevention (CDC) reported that antidepressant use in the United States has increased nearly 400% in the last two decades, making antidepressants the most frequently used class of medications by Americans ages 18-44 years. By 2008, 23% of women ages 40–59 years were taking antidepressants.

The CDC, on May 3, 2013, reported that the suicide rate among Americans ages 35–64 years increased 28.4% between 1999 and 2010 (from 13.7 suicides per 100,000 population in 1999 to 17.6 per 100,000 in 2010).

The New York Times reported in 2007 that the number of American children and adolescents treated for bipolar disorder had increased 40-fold between 1994 and 2003. In May 2013, CDC reported in “Mental Health Surveillance Among Children—United States, 2005–2011,” the following: “A total of 13%–20% of children living in the United States experience a mental disorder in a given year, and surveillance during 1994–2011 has shown the prevalence of these conditions to be increasing.”

Over-Diagnosis, Pathologizing the Normal and Psychiatric Drug Adverse Effects

Even within mainstream psychiatry, few continue to argue that the increase in mental illness is due to previous under-diagnosis of mental disorders. The most common explanations for the mental illness epidemic include recent over-diagnosis of psychiatric disorders, diagnoses expansionism, and psychiatry’s pathologizing normal behavior.

The first DSM (Diagnostic and Statistical Manual of Mental Disorders), psychiatry’s diagnostic bible, was published by the American Psychiatric Association in 1952 and listed 106 disorders (initially called “reactions”). DSM-2 was published in 1968, and the number of disorders increased to 182. DSM-3 was published in 1980, and though homosexuality was dropped from it, diagnoses were expanded to 265, with several child disorders added that would soon become popular, including oppositional defiant disorder (ODD). DSM-4, published in 1994, contained 365 diagnoses.

DSM-5 was published in May, 2013. The journal PLOS Medicine reported in 2012, “69% of the DSM-5 task force members report having ties to the pharmaceutical industry.” DSM-5 did not add as many new diagnoses as had previous revisions. However, DSM-5 has been criticized even by some mainstream psychiatrists such as Allen Frances, the former chair of the DSM-4 taskforce, for creating more mental patients by making it easier to qualify for a mental illness, especially for depression. (See Frances’ “Last Plea To DSM-5: Save Grief From the Drug Companies.”)

In the last two decades, there have been a slew of books written by journalists and mental health professionals about the lack of science behind the DSM, the over-diagnosis of psychiatric disorders, and the pathologizing of normal behaviors. A sample of these books includes: Paula Caplan’s They Say You’re Crazy (1995), Herb Kutchins and Stuart Kirk’s Making Us Crazy (1997), Allan Horwitz and Jerome Wakefield’s The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder (2007), Christopher Lane’s Shyness: How Normal Behavior Became a Sickness (2008), Stuart Kirk, Tomi Gomory, and David Cohen’s Mad Science: Psychiatric Coercion, Diagnosis, and Drugs (2013), Gary Greenberg’s The Book of Woe: The DSM and the Unmaking of Psychiatry (2013), and Allen Frances’ Saving Normal (2013).

Even more remarkable than former chair of the DSM-4 taskforce, Allen Frances, jumping on the DSM-trashing bandwagon has been the harsh critique of DSM-5 by Thomas Insel, director of the National Institute of Mental Health (NIMH). Insel recently announced that the DSM’s diagnostic categories lack validity, and that “NIMH will be re-orienting its research away from DSM categories.” And psychiatrist Robert Spitzer, former chair of the DSM-3 task force, wrote the foreword to Horwitz and Wakefield’s The Loss of Sadness and is now critical of DSM’s inattention to context in which the symptoms occur which, he points out, can medicalize normal experiences.

So, in just two decades, pointing out the pseudoscience of the DSM has gone from being an “extremist slur of radical anti-psychiatrists” to a mainstream proposition from the former chairs of both the DSM-3 and DSM-4 taskforces and the director of NIMH.

Yet another explanation for the epidemic may also be evolving from radical to mainstream, thanks primarily to the efforts of investigative journalist Robert Whitaker and his book Anatomy of An Epidemic (2010). Whitaker argues that the adverse effects of psychiatric medications are the primary cause of the epidemic. He reports that these drugs, for many patients, cause episodic and moderate emotional and behavioral problems to become severe, chronic and disabling ones.

Examining the scientific literature that now extends over 50 years, Whitaker discovered that while some psychiatric medications for some people may be effective over the short term, these drugs increase the likelihood that a person will become chronically ill over the long term. Whitaker reports, “The scientific literature shows that many patients treated for a milder problem will worsen in response to a drug—say have a manic episode after taking an antidepressant—and that can lead to a new and more severe diagnosis like bipolar disorder.”

With respect to the dramatic increase of pediatric bipolar disorder, Whitaker points out that, “Once psychiatrists started putting ‘hyperactive’ children on Ritalin, they started to see prepubertal children with manic symptoms. Same thing happened when psychiatrists started prescribing antidepressants to children and teenagers. A significant percentage had manic or hypomanic reactions to the antidepressants.” And then these children and teenagers are put on heavier duty drugs, including drug cocktails, often do not respond favorably to treatment and deteriorate. And that, for Whitaker, is a major reason for the 35-fold increase between 1987 and 2007 of children classified as being disabled by mental disorders. (See my 2010 interview with him, “Are Prozac and Other Psychiatric Drugs Causing the Astonishing Rise of Mental Illness in America?”)

Whitaker’s explanation for the epidemic has now, even within mainstream psychiatric institutions, entered into the debate; for example, Whitaker was invited by the National Alliance for the Mentally Ill (NAMI) to speak at their 2013 annual convention that took place last June While Whitaker concludes that psychiatry’s drug-based paradigm of care is the primary cause of the epidemic, he does not rule out the possibility that various cultural factors may also be contributing to the increase in the number of mentally ill.

Mental Illness as Rebellion Against Society

"The most deadly criticism one could make of modern civilization is that apart from its man-made crises and catastrophes, is not humanly interesting. . . . In the end, such a civilization can produce only a mass man: incapable of spontaneous, self-directed activities: at best patient, docile, disciplined to monotonous work to an almost pathetic degree. . . . Ultimately such a society produces only two groups of men: the conditioners and the conditioned, the active and passive barbarians." — Lewis Mumford, 1951

Once it was routine for many respected social critics such as Lewis Mumford and Erich Fromm to express concern about the impact of modern civilization on our mental health. But today the idea that the mental illness epidemic is also being caused by a peculiar rebellion against a dehumanizing society has been, for the most part, removed from the mainstream map. When a societal problem grows to become all encompassing, we often no longer even notice it.

We are today disengaged from our jobs and our schooling. Young people are pressured to accrue increasingly large student-loan debt so as to acquire the credentials to get a job, often one which they will have little enthusiasm about. And increasing numbers of us are completely socially isolated, having nobody who cares about us.

Returning to that June 2013 Gallup survey, “The State of the American Workplace: Employee Engagement,” only 30% of workers “were engaged, or involved in, enthusiastic about, and committed to their workplace.” In contrast to this “actively engaged group,” 50% were “not engaged,” simply going through the motions to get a paycheck, while 20% were classified as “actively disengaged,” hating going to work and putting energy into undermining their workplace. Those with higher education levels reported more discontent with their workplace.

How engaged are we with our schooling? Another Gallup poll “The School Cliff: Student Engagement Drops With Each School Year” (released in January 2013), reported that the longer students stay in school, the less engaged they become. The poll surveyed nearly 500,000 students in 37 states in 2012, and found nearly 80% of elementary students reported being engaged with school, but by high school, only 40% reported being engaged. As the pollsters point out, “If we were doing right by our students and our future, these numbers would be the absolute opposite. For each year a student progresses in school, they should be more engaged, not less.”

Life clearly sucks more than it did a generation ago when it comes to student loan debt. According to American Student Assistance’s “Student Debt Loan Statistics,” approximately 37 million Americans have student loan debt. The majority of borrowers still paying back their loans are in their 30s or older. Approximately two-thirds of students graduate college with some education debt. Nearly 30% of college students who take out loans drop out of school, and students who drop out of college before earning a degree struggle most with student loans. As of October 2012, the average amount of student loan debt for the Class of 2011 was $26,600, a 5% increase from 2010. Only about 37% of federal student-loan borrowers between 2004 and 2009 managed to make timely payments without postponing payments or becoming delinquent.

In addition to the pain of jobs, school, and debt, there is increasingly more pain of social isolation. A major study reported in the American Sociological Review in 2006, “Social Isolation in America: Changes in Core Discussion Networks Over Two Decades,” examined Americans’ core network of confidants (those people in our lives we consider close enough to trust with personal information and whom we rely on as a sounding board). Authors reported that in 1985, 10% of Americans said that they had no confidants in their lives; but by 2004, 25% of Americans stated they had no confidants in their lives. This study confirmed the continuation of trends that came to public attention in sociologist Robert Putnam’s 2000 book Bowling Alone.

Underlying many of psychiatry's nearly 400 diagnoses is the experience of helplessness, hopelessness, passivity, boredom, fear, isolation, and dehumanization—culminating in a loss of autonomy and community-connectedness. Do our societal institutions promote:

Enthusiasm—or passivity?
Respectful personal relationships—or manipulative impersonal ones?
Community, trust, and confidence—or isolation, fear and paranoia?
Empowerment—or helplessness?
Autonomy (self-direction)—or heteronomy (institutional-direction)?
Participatory democracy—or authoritarian hierarchies?
Diversity and stimulation—or homogeneity and boredom?

Research (that I documented in Commonsense Rebellion) shows that those labeled with attention deficit hyperactivity disorder (ADHD) do worst in environments that are boring, repetitive, and externally controlled; and that ADHD-labeled children are indistinguishable from “normals” when they have chosen their learning activities and are interested in them. Thus, the standard classroom could not be more imperfectly designed to meet the learning needs of young people who are labeled with ADHD.

As I discussed last year in AlterNet in “Would We Have Drugged Up Einstein? How Anti-Authoritarianism Is Deemed a Mental Health Problem,” there is a fundamental bias in mental health professionals for interpreting inattention and noncompliance as a mental disorder. Those with extended schooling have lived for many years in a world where all pay attention to much that is unstimulating. In this world, one routinely complies with the demands of authorities. Thus for many M.D.s and Ph.D.s, people who rebel against this attentional and behavioral compliance appear to be from another world—a diagnosable one.

The reality is that with enough helplessness, hopelessness, passivity, boredom, fear, isolation, and dehumanization, we rebel and refuse to comply. Some of us rebel by becoming inattentive. Others become aggressive. In large numbers we eat, drink and gamble too much. Still others become addicted to drugs, illicit and prescription. Millions work slavishly at dissatisfying jobs, become depressed and passive aggressive, while no small number of us can’t cut it and become homeless and appear crazy. Feeling misunderstood and uncared about, millions of us ultimately rebel against societal demands, however, given our wherewithal, our rebellions are often passive and disorganized, and routinely futile and self-destructive.

When we have hope, energy and friends, we can choose to rebel against societal oppression with, for example, a wildcat strike or a back-to-the-land commune. But when we lack hope, energy and friends, we routinely rebel without consciousness of rebellion and in a manner in which we today commonly call mental illness.

For some Americans, no doubt, the conscious goal is to get classified as mentally disabled so as to receive disability payments (averaging $700 to 1,400 per month). But isn’t that too a withdrawal of cooperation with society and a rebellion of sorts, based on the judgment that this is the best paying and least miserable financial option?


~ Bruce E. Levine, a practicing clinical psychologist, writes and speaks about how society, culture, politics and psychology intersect. His latest book is Get Up, Stand Up: Uniting Populists, Energizing the Defeated, and Battling the Corporate Elite. His Web site is www.brucelevine.net

AV Horwitz and JC Wakefield - All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders

Over at Evolutionary Psychology (a journal), Dieneke Hubbeling (Consultant Psychiatrist, and Wandsworth Crisis and Home Treatment Team, South West London) reviews the newish book from AV Horwitz and JC Wakefield, All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders (2012).

These passages offer a bit of a nutshell synopsis of the book, although the review itself is very interesting and the book, despite its flaws, seems to be a move in the right direction.

All We Have to Fear is an interesting book and, at times, shocking findings are presented, such as the problems Rind and co-authors experienced after suggesting that childhood sexual abuse did not always have dramatic consequences. The authors also make clear how the incidence of anxiety disorders increased because of watered down criteria. However, the fact that many people are suffering from a disease is not as such a reason to change criteria. The chance of experiencing a common cold at least once during one’s life is higher than 50% in certain climates, but people still call it a disease and the authors do not address this issue. 

The main weakness of the book in my view is that the authors present a very simplified version of evolutionary theory. The authors mention as uncontroversial that the snapping of a septuagenarian’s femur is a disorder because femurs are biologically designed to support movement (p. 29). However, evolutionary processes are selected for a particular life-span. There is not much point in designing organs which can function for a thousand years if an organism is likely to be eaten beforehand (Kirkwood and Austad, 2000).

And with that, on to the review . . . .

Book Review: Is Fear Good for You?

A review of A. V. Horwitz and J. C. Wakefield, All We Have to Fear: Psychiatry’s Transformation of Natural Anxieties into Mental Disorders. Oxford University Press: New York, 2012, 304 pp., US$29.95, ISBN # 978-0-19-979375-4 (hardcover).

Reviewed by Dieneke Hubbeling, Consultant Psychiatrist, Wandsworth Crisis and Home Treatment Team, South West London and St. George’s Mental Health NHS Trust, Email: dieneke@doctors.org.uk.

Evolutionary Psychology
www.epjournal.net – 2013. 11(2): 436-441 

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After writing the highly acclaimed The Loss of Sadness: How Psychiatry Transformed Sorrow Into Depressive Disorder (2007), Horwitz and Wakefield have now written a book about anxiety disorders with a similar theme, namely that anxiety symptoms are too often classified as a disorder or disease and that referring to evolutionary theory is useful for rectifying this. The authors describe anxiety as a naturally designed emotion (p. ix), which enhanced survival in ancestors. Feeling anxious is often a healthy response to a difficult situation and not a sign that there is something wrong in one’s brain. This is not particularly controversial, but it is far more complicated to use evolutionary theory for establishing the difference between disorder and normal functioning than the authors assume, as I will explain in this review.

The authors introduce the topic in chapter 1, The Puzzle of Anxiety Disorders. They explain how, according to the literature, the incidence of anxiety disorders has increased dramatically from an estimated 2-4% in 1980 to an empirically established 49.5% in 2010. This increase is at least partially explained by the different methodology in epidemiological studies. Most studies asked what kind of problems people had in the past and then between 25% and 33% of the population reported symptoms of an anxiety disorder from memory. In a prospective study, whereby participants were assessed every three years, the incidence increased to 49.5% (Moffitt et al., 2010). However, broad criteria for anxiety disorder are used in these studies and Horwitz and Wakefield question this. In the rest of the chapter the authors’ signpost to their main argument that feeling anxious is often an appropriate response and not a disorder.

One of the authors, Wakefield, developed a definition of disorder years ago. According to him a disorder is a harmful failure of mechanisms to perform the functions they were biologically designed to do (Wakefield, 1992). In order to be suffering from a disorder, two requirements have to be fulfilled: The condition has to be harmful and the condition has to be caused by the breakdown of a function, which has been selected for in the past. The rationale behind this definition is clarified in Chapter 2, An Evolutionary Approach to Normal and Pathological Anxiety. The authors start with ruling out various alternatives to Wakefield’s definition. Differences in brain functioning as demonstrated by, for example, fMRI-scans cannot be a criterion for disorder because there is no difference in fMRI-scans between pathological and normal anxiety, i.e., a level of anxiety appropriate to the circumstances. Everybody should get anxious standing in front of a dangerous snake. Similarly, both normal and pathological anxiety can be learned, both normal and pathological anxiety can be constructed by societies as negative events, both normal and pathological anxiety can be outside the normal statistical range, and both normal and pathological anxiety can cause social impairment.

Wakefield and Horwitz argued that there can only be a disorder if an individual’s internal processes are not performing the functions they were biologically designed to perform. We are no longer living in the EEA (environment of evolutionary adaptedness) and there are many things we no longer need to avoid such as spiders, darkness, open spaces, etc. If we are becoming anxious in those conditions, there is no disorder or illness, as our brains are performing a function they were selected for. The authors also mention that there are cultural and individual differences in anxiety and these differences have at least partially been selected for. Different levels of anxiety can be equally adaptive as people can find different niches, and it can also be advantageous for a population to have variation in anxiety proneness because a different level of anxiety might be more adaptive in the future.

In Chapter 3, Normal, Pathological and Mismatched Anxiousness, the authors further explore the differences between normal and pathological anxiety. They emphasized that the boundary between normal and pathological is not always clear, like there is no clear boundary between child and adult. The authors repeated that mismatched anxiety is not a disorder and mentioned the analogy with taste preferences for fat and sugar. This taste preference has been selected for and can cause obesity and early death in societies with plenty of sweets available, but it is not a disorder according to Wakefield’s definition. The authors further explain that anxiety can even be not pathological in situations when there is no danger either currently or in the EEA, because anxiety functions according to the smoke detector principle. Similar to a smoke detector, it is better to give a number of false alarms than not to notice something dangerous once (Nesse, 2005).

In Chapter 4, A Short History of Anxiety and its Disorders, the authors explain that anxiety as a phenomenon was recognized at least since the ancient Greek civilization, but it was not considered a separate disorder. Maudsley, for example, classified phobias as a subtype of melancholic disorders. Freud made a distinction between realistic anxiety and anxiety neurosis, whereby realistic anxiety could be divided into primary anxiety (in which somebody experiences fear because of the actual situation) and signal anxiety (in which something threatening might happen in the future). The authors are following Freud in thinking that both realistic and neurotic anxiety can have the same symptoms and the same amount of distress. The context has to be taken into account, if one wants to make the distinction between disorder and normal experience. Horwitz and Wakefield explained that classification systems in psychiatry have tried to clarify whether symptoms are contextually appropriate or not. The Feigner criteria used patients’ own beliefs about reasonableness as the distinction between normal and pathological anxiety. The American classification system DSM mentioned objective contextual standards as well.

How to classify anxiety disorders is further discussed in Chapter 5, The Validity of the DSM Diagnostic Criteria for Anxiety Disorders. The authors mention various attempts to delineate pathological anxiety from normal anxiety, with specific phobias, social phobia, and generalized anxiety disorder as examples. Attempts in terms of intensity, number, and duration of symptoms were unsuccessful and one tried to add criteria as unreasonableness given the context or clinical significance. The authors claim that the current threshold for disorder is far too low and that too many people are considered suffering from an anxiety disorder. They suggest some improvements, such as narrowing role impairment to dysfunction in activities that have been selected for. For example, social phobia is a disorder if it stops somebody having intimate relationships, but it should not be a disorder if somebody only has difficulties with speaking in public.

In chapter 6, Fear and Anxiety in the Community, the authors explain how the criteria from the DSM-IV and other classification systems which were already too broad were also applied in rather loose way, for example by using a scale designed as a first stage screening instrument as a stand-alone assessment. Horwitz and Wakefield are particularly critical of asking people whether they were anxious when they were young. According to the authors, many anxieties in childhood disappear and one should not call them disorders. The authors also disapprove of using screening instruments after disasters, such as Hurricane Katrina, because screening scales measure symptoms and do not take the context into account. On page 167 they state “...in the attempt to create a scientific approach to psychiatric disorder, psychiatry is instead coming perilously close to transforming itself into a pseudoscience that has rendered its own domain of mental disorder meaninglessly broad.”

Post-traumatic stress disorder only entered official psychiatric classification systems after 1980 as the authors explain in Chapter 7, PTSD, but nowadays many people claim to be suffering from it and health professionals specialize in treating PTSD. Horwitz and Wakefield argued that during evolution humans must have dealt with horrific and shocking experiences. They must have learnt to avoid them, if possible. Having intrusive memories – one of the key symptoms of PTSD – might well have been helpful in doing this. The authors express again their worry that many normal responses might well have been labeled pathological.

PTSD entered the DSM classification system under the pressure of Vietnam veterans and it seems to be a diagnosis people like to have, unlike most other conditions. The authors also described the meta-analysis by Rind, Tromovitch and Bauserman (1998), who found that child sexual abuse did not always have such detrimental effects as generally assumed and how these authors were severely criticized because of the outcome of their study. Horwitz and Wakefield rightly remark that this is very worrying and that psychiatry and psychology as a science should be open to new facts, even if they go against lay opinion and current scientific views.

Nowadays more people are treated for anxiety than for depression, unlike the 1950s and 1960s. The authors explain this change in chapter 8, The Transformation of Anxiety into Depression. any people started to have health insurance, and just “being anxious” was not sufficient to have treatment costs reimbursed. Patients had to suffer from a specific disorder. Anxiety disorders were defined more restrictively than depression; for example, the duration of anxiety disorders had to be at least 6 months, and they came lower in the DSM-III hierarchy. Also for anxiety there was at least some attempt to rule out normal anxiety by stating that the fear had to be irrational, whereas with depression only recent bereavement was accepted as an exception.

In Chapter 9, Setting Boundaries between Natural Fears and Anxiety Disorders, the difficulty in establishing the presence of a disorder is reiterated and the authors emphasize the importance of using dysfunction of activities that have been selected for as an essential condition for disorder. However, the authors also state that there is a lack of knowledge of evolutionary theory and that nobody currently knows whether treatment results differ between pathological anxiety and mismatched anxiety. The authors also mention that sometimes treatment can still be useful, even if there is no disorder according to their definition.

All We Have to Fear is an interesting book and, at times, shocking findings are presented, such as the problems Rind and co-authors experienced after suggesting that childhood sexual abuse did not always have dramatic consequences. The authors also make clear how the incidence of anxiety disorders increased because of watered down criteria. However, the fact that many people are suffering from a disease is not as such a reason to change criteria. The chance of experiencing a common cold at least once during one’s life is higher than 50% in certain climates, but people still call it a disease and the authors do not address this issue.

The main weakness of the book in my view is that the authors present a very simplified version of evolutionary theory. The authors mention as uncontroversial that the snapping of a septuagenarian’s femur is a disorder because femurs are biologically designed to support movement (p. 29). However, evolutionary processes are selected for a particular life-span. There is not much point in designing organs which can function for a thousand years if an organism is likely to be eaten beforehand (Kirkwood and Austad, 2000).

The authors mention that different levels of anxiety have been selected for, because one can find different niches. However, there might be no niche available and there is frequency dependent selection. The authors would probably classify this as a kind of mismatch, because the current environment has too many people with the same level of anxiety, but they do not clearly state this.

There are different forms of anxiety, namely anxiety for a specific stimulus (phobias) and also general anxiety. An idea from evolutionary psychology is that in a dangerous environment it might be better to have a low threshold for all forms of anxiety and in a less dangerous environment it might be evolutionarily advantageous to be only anxious for specific stimuli (Bateson, Brilot, and Nettle, 2011). If this is true, the view of Horwitz and Wakefield would become even more complicated, namely that not only can somebody have a disorder because of a mismatch between current environment and environment of evolutionary adaptedness, but people can also have the wrong type of anxiety response.

If one wants to use malfunctioning of an activity that has been selected for as criterion for disorder, it is unlikely that one can easily find empirical evidence. One needs to determine not only what has been selected for, but also whether it is a mismatch with the environment, either in general or the wrong type of disorder, whether it is a quick response because of the smoke-detector principle, whether it is frequency dependent selection, etc. However, the problems are even bigger. Wakefield and Horwitz do not mention treatability as a possible criterion in Chapter 2 and they are very explicit in Chapter 9 that sometimes conditions, which are not disorders, should still be treated. One of the problems of a broad definition of anxiety disorders is that treatment costs are very high and that costs of people not being able to work are probably even higher. However, it is very counterintuitive to offer insurance-reimbursed treatment to people who are anxious because of some biological dysfunction and not to others because of a mismatch, even if they are equally dysfunctional in their social environment. Wakefield stated in another publication that using treatability as a criterion was getting things backwards (Wakefield, 1999), but this seems to be incorrect. Evolution does not really play a role in deciding whether the treatment of a patient should be paid for out of public funds (Bolton, 2008). In the rationing of health care funds, in-vitro fertilization is seen as something one can do without and cancer treatment not, but from an evolutionary perspective it would be the opposite.

At the time of writing this review, Nature published a news item about the health problems of local residents after the Fukushima disaster (Brumfiel, 2013). Many local residents suffer from anxiety and nobody can really predict the effects of radiation for particular persons in the next decades, and the argument was made for further psychological support. One could argue that it is normal to feel anxious under those circumstances, but it does influence people’s life and, if they want help for psychological difficulties, why not? Fear is not always good for you and can be extremely unpleasant.

References

• Bateson, M., Brilot, B., and Nettle, D. (2011). Anxiety: An evolutionary approach. Canadian Journal of Psychiatry, 56, 707-715.
• Bolton, D. (2008). What is mental disorder? An essay in philosophy, science, and values. Oxford: Oxford University Press.
• Brumfiel, G. (2013). Fallout of fear. Nature, 493, 290-293.
• Horwitz, A. V., and Wakefield, J. C. (2007). The loss of sadness. New York/Oxford: Oxford University Press.
• Kirkwood, T. B. L., and Austad, S. N. (2000). Why do we age? Nature, 408, 233-238.
• Moffitt, T. E., Caspi, A., Taylor, A., Kokaua, J., Milne, B. J., Polanczyk, G., and Poulton, R. (2010). How common are common mental disorders? Evidence that lifetime prevalence rates are doubled by prospective versus retrospective ascertainment. Psychological Medicine, 40, 899-909.
• Nesse, R. M. (2005). Natural selection and the regulation of defenses: A signal detection analysis of the smoke detector principle. Evolution and Human Behavior, 26, 88-105.
• Rind, B., Tromovitch, P., and Bauserman, R. (1998). A meta-analytic examination of assumed properties of child sexual abuse using college samples. Psychological Bulletin, 124, 22-53.
• Wakefield, J. C. (1992). The concept of mental disorder on the boundary between biological facts and social values. American Psychologist, 47, 373-388.
• Wakefield, J. C. (1999). Mental disorder as a black box essentialist concept. Journal of Abnormal Psychology, 108, 465-472.

Julian Ford, Ph.D. - PTSD Becomes (More) Complex in the DSM-5

Julian Ford is one of the experts in the field of complex PTSD (an as yet un-approved diagnosis in the DSM, and not for a lack of effort). Over at his Psychology Today blog, Hijacked by Your Brain, he has posted a two-part examination of the changes to the PTSD diagnosis in the DSM-5.

I like the addition of the dissociative subtype for PTSD. The research suggests that 15-30% of those who have PTSD have persistent dissociation as a key feature. This sub-type is very strongly coorelated with childhood abuse and neglect, which is where the notion of complex PTSD comes from - research has shown that of those who develop PTSD following an adult experience of trauma (war, rape, other violent crime, natural disasters, and so on), there is also a strong correlation to childhood abuse and neglect.

When we are abused, neglected, belittled, and shamed as children, we do not develop the resilience necessary to get through traumatic events without serious complications. This is not a perfect cause and effect, but the link is clear and there are piles of research in support of this thesis.

Dr. Ford, along with Jon Wortmann, is the author of Hijacked by Your Brain: How to Free Yourself When Stress Takes Over (2013), after which the blog is named.

About the Author:

Julian Ford is a Professor of Psychiatry at the University of Connecticut School of Medicine and Director of the University of Connecticut Health Center Child Trauma Clinic and Center for Trauma Response Recovery and Preparedness (www.ctrp.org), the creator of the TARGET© treatment model for adult, adolescent, and child traumatic stress disorders, and CEO of Advanced Trauma Solutions, Inc., the exclusive licensed provider of the TARGET© treatment model.

Ford is also co-author of Treatment of Complex Trauma: A Sequenced, Relationship-Based Approach (2012, with Christine A. Courtois) and co-editor (along with Courtois) of Treating Complex Traumatic Stress Disorders (Adults): An Evidence-Based Guide (2009).

PTSD Becomes (More) Complex in the DSM-5: Part 1

Heading in the right direction, but still not as complex as the brain

Published on June 11, 2013 by Julian Ford, Ph.D. in Hijacked by Your Brain

The diagnosis of posttraumatic stress disorder (PTSD) has undergone much more than a minor tweaking or superficial facelift in the American Psychiatric Association's DSM-5. This guidebook to psychiatric diagnoses, released in May, now defines PTSD as a trauma and stressor-related disorder, not a disorder primarily of anxiety alone. Like our understanding of the brain and behavior, PTSD has become much more complex—and for millions of trauma survivors who have experienced difficulties that go well beyond the symptoms included in PTSD up to now, and the tens of thousands of clinicians who provide treatment to affected trauma survivors, the change is long overdue, but extremely welcome.

Bottom line, PTSD is now described as a disorder of persistent reactivity in all of the domains of self-regulation, and not just troubling memories and chronic anxiety[1]. Distressing memories of past traumatic events and intense stress reactions to reminders that occur in current life continue to serve as the cornerstone of PTSD.

Now, however, these forms of "intrusive re-experiencing" of traumatization are understood as playing out across the full range of ways in which we regulate ourselves: emotions, body functions and health, thinking, motivation, behavior, relationships, and ultimately our sense of self or identity.

Trauma doesn't just terrify or horrify us—it also forces us to make profound biological adaptations in how our brain operates. Basically, the brain is a control system that keeps our body functioning properly. In other words, the brain regulates how our body functions to keep us alive, and when our body is safe and working well, the brain extends its efforts to the "higher" functions that enable us to not only survive but also to become a conscious individual—a self or an identity that makes each of us and our lives unique and not only pleasurable (or tolerably painful) but meaningful.

When the brain detects serious threats to our bodily survival, traumatic stressors such as severe accidents, disasters, violence, abuse, or betrayals, the alarm system in the brain is activated and literally hijacks the rest of the brain's operations in order to put all systems in emergency mode until the threat is escaped or overcome.

This might seem like a simple shift in brain functions that leads to a temporary fight-flight reaction or adrenaline rush that is intense but quickly passes. And in many cases, both with ordinary stressors that are not traumatic threats to our lives as well as with traumatic survival threats, the alarm reaction in the brain does rapidly subside. We’re left somewhat shaken or jangly, but no worse for the wear with a brain that re-sets automatically to its normal modes.

However, as we've described in Hijacked by Your Brain, PTSD is what happens when the brain's alarm system doesn't automatically or rapidly re-set itself. When the brain's alarm continues to signal danger even though safety has been restored, the brain's overall functioning remains in an altered state that is the chronic stress response. Survival trumps self-regulation in this case: staying alert and ready to react in fight-flight mode to the next assault or betrayal takes precedence over sorting out our emotions and thoughts, taking care of our body's health, considering our core values and who we aspire to be.

In service of a commendable goal, survival, the brain's alarm system has hijacked the "higher" operations of the brain itself, keeping us alert and ready for action, and therefore alive. In this state, however, life becomes a constant struggle that involves unbearable tension and ultimately emotional as well as physical exhaustion (hence the depression and physical health problems that so often occur with PTSD).

People living with PTSD, therefore, are not just troubled by terrible memories, worries, and anxieties. More fundamentally they have high functioning brains that have become trapped in survival mode. That's why PTSD is complex, because it's about a fundamental change in how the brain (and body, and mind) are operating. It is not a disease, and not an injury to the brain (although when this has happened as well, such as when the survival threat is a blast explosion or another severe physical injury to the head, the combination of PTSD and traumatic brain injury creates additional major challenges).

How can someone re-set a brain's alarm that's stuck in PTSD (survival mode), so that self-regulation can be restored? That is the $64,000 question, which I'll tackle in Part II of this series on the implications of PTSD becoming defined in a way that is appropriately more complex in the DSM-5.

Hijacked by Your Brain blogs are co-authored with Jon Wortmann. Visit our website at www.hijackedbyyourbrain.com. You can follow us onfacebook or join us on twitter @hijackedbook.

[1] http://www.tandfonline.com/doi/abs/10.1080/15299732.2013.769398#.UaZbsuCb8Rk

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PTSD Becomes (More) Complex in the DSM-5: Part II

Recovering from (Complex) PTSD by Regaining Self-Regulation

Published on June 16, 2013 by Julian Ford, Ph.D. in Hijacked by Your Brain

In the DSM-5 released in May, PTSD just got more complex. It added a new symptom domain of "negative alterations in cognitions or mood," and expanded the hyperarousal domain to include aggressive, reckless, or self-destructive behavior. It also added a sub-type characterized by dissociation (drastic reductions in physical arousal and conscious emotion and thought). These changes reflect advances in science and clinical practice, which echo what trauma survivors have been saying for decades (if not centuries): PTSD is a radical shift from normal self-regulation to being trapped in a constant state of alarm.

To understand, and recover from, PTSD, it's essential to understand what the brain and body do to "self-regulate" under ordinary circumstances—because this is what's lost in PTSD and must be regained in recovery. Self-regulation is a delicate and complicated balancing act in which the brain and body constantly adjust to maintain a balance between mobilizing (being highly activated) and re-grouping (down shifting into less activated states).

Mobilization is essential to experiencing pleasurable excitement, enthusiasm, and achievement. But too much mobilization for too long leads to tension, frustration, recklessness, and even self-harm. Similarly, when the body and brain re-group, this can produce pleasurable and healthy states of relaxation, calm, and mindful acceptance. However, when re-grouping becomes extreme and persistent, the result can be emotional shut-down and exhaustion, depression, despair, or dissociation. Self-regulation is the constant balancing act between mobilization and re-grouping that enables us to be optimally effective and to feel true satisfaction.

Trauma is a threat or injury that requires self-protective stress reactions—essentially fight or flight—which hijack the brain and body in order to achieve the one goal that is a higher priority than being effective and satisfied: survival. Post-traumatic stress disorder derives its name from this key fact: PTSD is a disorder because the the brain and body have become trapped on a roller coaster of dysregulation. PTSD involves rocketing into extreme states of stress reactivity (mobilization in the form of terror, rage, and uncontrollable impulses) and plunging into equally extreme states of being shut-down (exhaustion, emotional numbing, despair, and dissociation). From this vantage point, PTSD clearly is about much more than fear and anxiety, involving the full range of emotions and undermining our body's health, our ability to think clearly, to set and achieve goals, and to fully participate in and benefit from relationships.

A particularly important new symptom of PTSD highlights an important aspect of the loss of self-regulation: "Persistent and exaggerated negative expectations about one’s self, others, or the world (e.g., “I am bad,” “no one can be trusted,” “I’ve lost my soul forever,” “my whole nervous system is permanently ruined,” "the world is completely dangerous")." PTSD thus is inherently complex, and all about the loss of self-regulation that occurs when survival dominates how a person thinks, feels, and behaves in every area of his or her life. PTSD replaces the "me" who was growing, learning, and becoming a unique person before the trauma(s), leaving only a desperate survivor who may have no clear sense of identity and who may even hate or loathe herself or himself.

Although the dilemma of post-traumatic self-dysregulation is indeed complex, as is the array of therapies that have shown promise in treating (complex) PTSD , the key to recovery is not rocket science. Survival threats can cause the brain to be hijacked by its own alarm system, so the key is to re-set that alarm system so it's no longer in survival mode.

Re-setting the brain's alarm requires seven steps, which are at the heart of every effective treatment for (complex) PTSD despite their many differences:

Focus mentally on a single thought that you choose because it is what's most important and positive in your life at this moment—not what's most urgent or problematic, nor what's a lifetime away, but what you value most and what represents the very best part of your life right now.

Recognize the triggers that signal problems or danger: don't ignore them, but don't obsess or ruminate about them, just make a mental note to be alert.

Experience the emotions that are signals from your brain's alarm, but also the sustaining emotions that seem to get lost in the midst of stress reactions but actually are always present if you just look carefully for them; emotions like joy, hope, love, pride, security, enthusiasm, determination.

Evaluate your thoughts not to judge or alter or eliminate them, but to distinguish between the defensive (or offensive) thoughts that are generated by your brain's alarm from the sustaining beliefs that also can get lost in alarm reactions (but actually are always available when you focus on your core values).

Define your goals so that you can tell the difference between defensive (or offensive) goals that are potentially useful warnings from your brain's alarm and the sustaining goals that are based on your core values.

[Choose] Options that enable you to achieve your sustaining goals and to live according to your core values, while being aware of and open to using other options that are more defensive (or offensive) if you are faced with a genuine threat to your, or others', survival.

Make a contribution by doing the one thing that each of us can do to make everyone safer, healthier, and more effective: continue to practice these simple steps in your own individual ways, and in so doing become a role model for responsible self-regulation.

These seven steps spell FREEDOM. They are not a pre-packaged set of techniques for self-improvement. They have to be done by each person in their own individual way. They enable you to use your mind to shift out of survival mode and your body to resume the natural state of self-regulation that is lost whenever anyone becomes trapped in the alarm state that the DSM-5 calls PTSD.

Hijacked by Your Brain blogs are co-authored with Jon Wortmann. Visit our website at www.hijackedbyyourbrain.com. You can follow us onfacebook or join us on twitter @hijackedbook.