The myth of normal, p.24
The Myth of Normal, page 24
The journalist and author Robert Whitaker, formerly the director of publications for Harvard Medical School, was a firm believer in the chemical-imbalance theory of mental illness—until he wasn’t. “When I first started writing about psychiatry, I believed that to be true,” he told me. “I mean, why wouldn’t I?” His disillusionment arose from research he uncovered while reporting for the Boston Globe. “I said to people, ‘Can you just tell me where you found that depression is due to serotonin or where you actually found that schizophrenia is due to too much dopamine?’ I asked to read the source materials and, I swear to God, they said, ‘Well, we didn’t really find that. It’s a metaphor.’ The most amazing thing was, when you trace it in their own research, you find they didn’t find it! The divergence from what you’re being told from what is in their own scientific literature—that’s the key—it was just stunning to me.” These conspicuous non-findings are documented in Whitaker’s book Anatomy of an Epidemic and have been corroborated in other literature.[6]
Contrary to what I, too, used to believe, a diagnosis like ADHD or depression or bipolar illness explains nothing. No diagnosis ever does. Diagnoses are abstractions, or summaries: sometimes helpful, always incomplete. They are professional shorthand for describing constellations of symptoms a person may report, or of other people’s observations of someone’s behavior patterns, thoughts, and emotions. For the individual in question, a diagnosis may seem to account for and validate a lifetime of experiences previously too diffuse or nebulous to put one’s finger on. That can be a first and positive step toward healing. I know this from firsthand experience.
The dead end comes when we assume or believe that the diagnosis equals an explanation—an especially futile view when it comes to illnesses of something as inherently abstract as the mind. As the British psychologist Lucy Johnstone said to me, “In physical illness you have, in principle, a way of checking it out. You can say, ‘Let’s look at the blood test or the enzyme levels.’ And you could, in most cases, confirm or disconfirm it. But in psychiatry, it’s simply a circular argument, isn’t it? Why does this person have mood swings? Because they have bipolar disorder. How do you know they have bipolar disorder? Because they have mood swings.” My mind goes to A. A. Milne’s Pooh and Piglet walking in the snow in an unwitting circle, shuddering as they come across yet more “Heffalump” tracks at every turn.
An oft-heard objection to mental health diagnoses, particularly with regard to children, is that they “pathologize” or “stigmatize” ordinary, healthy feelings or behaviors. Aren’t kids supposed to get bored or antsy, angry or sad? My answer would be yes—and it’s not that simple. While overdiagnosis is certainly a risk, I don’t see the spike in, say, ADHD cases over the past decades as being due solely to gullible parents, hapless teachers, overzealous school shrinks, and unscrupulous drug companies. As I discussed in earlier chapters, the world into which kids are being born these days might as well have been designed to promote disruptions of cognitive function and emotional self-regulation. Everything I have seen tells me we are witnessing a sea change in children’s mental well-being.
Why, then, do I persist in my critique of the diagnostic model? Because diagnoses reveal nothing about the underlying events and dynamics that animate the perceptions and experiences in question. They keep our gaze trained on effects and not their myriad causes. There could be multiple reasons why a child may have trouble paying attention or be restless, disengaged, and fidgety: anxiety, stresses at home, boredom with material she finds uninteresting, resistance to the constraints of sitting in a classroom, fear of bullying, an authoritarian teacher, trauma—even birth month, believe it or not. A University of British Columbia study looked at the prescription records of almost one million B.C. schoolchildren over an eleven-year period and found that kids born in December were 39 percent more likely to be diagnosed with ADHD than classmates born the previous January. The reason? December kids entered the same grade nearly a year younger than their January counterparts—they were eleven months behind in brain development. They were being medicated not for a “genetic brain disorder” but for naturally delayed maturation of the brain circuits of attention and self-regulation.[7]
Or consider the DSM-5 diagnosis of oppositional defiant disorder (ODD), often tacked on to ADHD and other “diseases.” “If your child or teenager has a frequent and persistent pattern of anger, irritability, arguing, defiance or vindictiveness toward you and other authority figures, he or she may have oppositional defiant disorder,” advises the Mayo Clinic.[8] The clue is in the word “toward”: oppositionality, by definition, can arise only in the context of a relationship. I can suffer symptoms of a cold in isolation, or break my ankle on my own. I cannot oppose anyone or be angry or irritable with anyone unless that “anyone” is in some relationship with me. “If you don’t believe me,” I sometimes tell audiences of therapists, parents, teachers, or medical professionals, “just lock yourself in your room tonight, make sure you are absolutely alone, and oppose somebody. If you succeed, put it on YouTube—it’ll go viral in no time.”
Given that a child develops in the context of relationships, her behavior will be intelligible to us only if we look at the relational environment. Seen this way, these so-called ODD kids turn out to be ones who lack sufficient connection with nurturing adults and have a natural resistance to being controlled by people they do not fully trust or feel close enough to. This aversion, furthermore, is only magnified by all attempts to shame or cajole it into submission. To call this “disordered” says nothing about the child’s inner experience; it reflects only the perspective of the ones who find his recalcitrance inconvenient. It is also completely obtuse about how emotional power dynamics work: there is nothing disordered in resisting authority figures that, for whatever reason, we do not feel confident in and safe with.
If we are today seeing more youngsters in automatic resistance mode, the question we must return to is, How does this culture disrupt healthy adult-child relationships? Why are we diagnosing children with a disorder, instead of “diagnosing”—and treating—their families, communities, schools, and society?
The psychiatrist, author, and leading trauma researcher Bruce Perry[*] has come to disdain diagnoses almost completely. This is no knee-jerk prejudice: his dim view of the norms and practices of his field follows decades spent assessing tens of thousands of troubled children, and extensive contributions to the vast literature on adversity and what we define as “disorders.” “When I got into psychiatry,” Dr. Perry told me, “it became clear really quickly that the diagnoses were not connected to the physiology, that they were just descriptive, and that there were hundreds of physiological routes to somebody having an attention problem, for example. And yet the profession acted as if these descriptive labels were really a thing . . . I knew that if we were doing ‘research,’ if we were using these hollow descriptors which we call ‘diagnoses’ and then study interventions and outcomes, we would just get garbage. And that’s what we’ve done.”
These days Dr. Perry is adamant that “even playing the DSM game is completely wrong.” When invited to contribute to one of the manual’s editions, he refused. “I said, ‘Listen, in twenty-five years they are going to look back and won’t believe that we thought about people that way.’ It’s not a valid way to think about the complexities of human beings.” He practices what he preaches in the clinic he helps run. “We haven’t used diagnoses for fifteen, twenty years,” he said, “and it really has not interfered with our ability to do good clinical work. In fact, we’re able to do better clinical work without using those labels.”
Based on my observations in family practice and my understanding of human development, I have followed the same lines. When I work with any mental health condition, say depression or anxiety or ADHD or addiction, I’m not so interested in the formal diagnosis as such. My “diagnostic” focus goes to the specific challenges the person is facing in their life and the traumas animating those challenges. As for “prescriptions,” I am primarily interested in what will promote the healing of the psychic wounds the ongoing traumatic patterns represent.
Now, here’s a perhaps surprising assertion: I’m not anti-pharmacology. No one who’s felt or witnessed the beneficial effects of psychiatric drugs can deny that neurobiology must, indeed, play a role in the dynamics and potential easing of mental distress, just as it does in all our experiences. Sometimes the healing of which I just spoke can be helped along—not made to happen, certainly, but assisted—by the intelligent use of these medications. That is not just my professional opinion but my personal experience as well.
In my mid-forties, I decided to go on the serotonin-enhancing drug Prozac. (Among the brain’s principal neurotransmitters, or chemical messengers, serotonin is believed to be active in such functions as mood regulation and the dampening of aggression.) The skepticism I harbored about this growing trend to medicate millions was eclipsed by my hunger for respite from the daily severities of my state of mind, as summed up grimly in a diary entry from that time: “I have no energy for life. I have spent every weekend for the past two months—every free weekend—in an enervated, passive, demoralized state, depressed and depressing to be with.”
I was soon a different person. Within days, my wife noted with relief the softening of my facial features. I now greeted mornings with vim instead of venom, lost my irritability around my family, smiled and laughed a lot more, and could feel and express tenderness where before I’d been cold and brittle. It was as if someone had bandaged my aching heart so that it no longer hurt or bruised at the slightest touch. I found myself marveling to my sister-in-law: “You mean people can feel like this normally? I had no idea!” My experience was similar to what, some years later, the writer Elizabeth Wurtzel would depict in her 1994 personal account Prozac Nation. “One morning I woke up and really did want to live,” she wrote. “It was as if the miasma of depression had lifted off me, in the same way that the fog in San Francisco rises as the day wears on. Was it the Prozac? No doubt.”
As happens with many new converts, my initial reticence quickly gave way to a period of outsize enthusiasm. In my medical practice I became something of a Prozac booster, succumbing to the error of looking for pathology where there was only everyday unhappiness. “You have a chemical imbalance in your brain—you are lacking serotonin,” I would earnestly explain to patients in whom I detected symptoms of depression, prescription pad at the ready. Little did I know that I was uttering scientific nonfacts. Yes, the medication was helping me, at least in the short term. And yes, I have witnessed other cases where psychiatric drugs were life-enhancing and even lifesaving. But we have to avoid the fallacy of inferring from medication’s (in some cases) observable benefits that the proven origin of mental illness rests in the biochemistry of the brain, let alone that physiological disturbances are genetically caused.
That a medication has a certain positive effect reveals nothing about the genesis of a symptom. If aspirin eases a headache, can the headache be explained by an inherited brain deficiency of acetylsalicylic acid, the pill’s active ingredient? If a shot of bourbon relaxes you, is your tense nervous system suffering from a DNA-dictated whiskey shortage? There are fifty or more neurotransmitters in the brain whose complex interactions we are only now beginning to explore, not to mention the almost infinite possibilities inherent in the lifelong intersection of experience with the biology of body and brain. Once again, the physiology of the brain is a manifestation and a product of life in motion and in context.
Further, as Bruce Perry writes, “The brain is a historical organ. It stores our personal narrative.” Since it does so in the form of its chemistry and its neural networks, it is no wonder that difficult experiences may result in disturbed neurobiology. Even when brain scans show certain abnormalities—as they do, for example, in many traumatized people—these do not prove that the “disorder” has a neurochemical source. A recently published thirty-year study followed people from early life to age twenty-nine. Poor quality of care in infancy was, nearly three decades later, associated with a higher volume of the emotionally key brain structure, the hippocampus, as well as with an elevated risk for “borderline personality” features and suicidality. In other words, the brain’s genetics did not “cause” either the “illness” or the neurophysiological differences: all were the result of life experience.[9]
The British author Johann Hari has explored addictions and depression from both the personal and journalistic points of view. In his bestselling work Lost Connections, he relates his own experience of devastatingly low moods, followed by his initial elation at the depression diagnosis that, at last, “explained” his disturbing mind states. “This will sound odd,” he writes, “but what I experienced at that moment was a happy jolt—like unexpectedly finding a pile of money down the back of your sofa. There is a term for feeling like this! It is a medical condition, like diabetes or irritable bowel syndrome.”
Like mine, Hari’s first experience of medications was positive. “It was only years later,” he relates in Lost Connections, “that somebody pointed out to me all the questions the doctor didn’t ask that day. Like: Is there any reason you might feel distressed? What’s been happening in your life? Is there anything hurting you we might want to change?” The answers would have been yeses all around: Hari was carrying both past trauma and present stress that he took to be part of his “normal.” Over time, he came to recognize that the narrow medical model that had helped him manage his symptoms was also leaving him far short of healing. He is not entirely jaded about the biological approach, he told me, but he also noted with sorrow that “it has crowded out the much more common-sense insights that people have about why they become distressed and how to resolve their distress. Really—how do I put it—it’s given us an inaccurate map of our own pain.”
It is known beyond controversy that the greater the degree of childhood adversity, the higher the risk of mental disturbances, including psychosis. One study found that people who had suffered five types of maltreatment in childhood were multiple times more likely to be diagnosed with psychosis than those who had not experienced such traumatic events.[10] A major review in 2018 in the Schizophrenia Bulletin concluded that the severity of childhood traumas was correlated with the intensity of delusions and hallucinations.[11] Richard Bentall, a clinical psychologist, academic, and Fellow of the British Academy, summed up the science a few years ago: “The evidence of a link between childhood misfortune and future psychiatric disorder is about as strong statistically as the link between smoking and lung cancer,” he wrote. “There is also now strong evidence that these kinds of experiences affect brain structure, explaining many of the abnormal neuro-imaging findings that have been reported for psychiatric patients.”[12] This mirrored a Harvard study that concluded, “These brain changes may be best understood as adaptive responses to facilitate survival and reproduction in the face of adversity. Their relationship to psychopathology is complex.”[13]
There is something scientists reviewing research papers will not say, although it is manifestly evident to many clinicians working with mental distress: overt maltreatment is not necessary to exert negative impacts on the neurobiology of the brain or the functioning of the mind. Neurobiology is a continuum, as are “mental illness” and health. Emotional injury during development can have physiological consequences, even without abuse or neglect. As Bruce Perry explains, adverse childhood experiences—of the big-ticket kind that merit the official ACE designation—are of consequence, but “not as determinative as your history in relationships . . . The most powerful predictor of your functioning in the present is your current relational connectedness and then the second most powerful component that we see is your history of connectedness.”
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“Don’t be so sensitive,” people are often told. In other words, “Don’t be so yourself.” Genetic vulnerabilities do not code for illness, but they may confer sensitivity for a person being more impacted by life’s vicissitudes than someone else with a hardier predisposition—a far from trivial effect. Sensitive people feel more, feel deeply, and are more easily overwhelmed by stress, not just subjectively but physiologically. Both monkeys and humans, for example, can inherit genes involved in the production of certain brain chemicals such as serotonin that can make them more susceptible to negative experiences—or, on the other hand, more amenable to the effect of positive ones. (And, of course, sensitivity, too, is a continuum.)
“Genes affect how sensitive one is to environment, and environment affects how relevant one’s genetic differences may be,” the leading geneticist R. C. Lewontin has said. “When an environment changes, all bets are off.”[14] Some people will feel more pain and will therefore have greater need to escape into the adaptations that mental illness, or addiction, represent. They will have more need to tune out, to dissociate, to split into parts, to develop fantasies to account for realities they are unable to endure. But that’s a far cry from saying that they have a heritable neurobiological disease. These are the children that Tom Boyce, a professor of pediatrics and psychiatry at the University of California, San Francisco, describes as orchids, “exquisitely sensitive to their environment, making them especially vulnerable under conditions of adversity but unusually vital, creative, and successful within supportive, nurturing environments.”[15] The same “sensitivity” genes that in a stressed environment can help potentiate mental suffering may, under positive circumstances, help promote stronger mental resilience and therefore happiness.[16] Sensitive people have the potential to be more aware, insightful, inventive, artistic, and empathic, if their sensitivity is not crushed by maltreatment or disdain. The most sensitive of our kind have made some of the most lasting cultural contributions; many of these have also suffered the most intense pains during their lives. Sensitivity can be the quintessential combo package: gift and curse, all in one.
