In previous essays, I’ve discussed a way to look at mental disorders, not as discrete medical entities, but as attempts to describe types or patterns of psychosocial problems. I’ve called these dysfunctions that can be placed on dimensions of dysfunction. Dimensions have no breaks between normal and abnormal, between sane and mentally ill; only more or less.
Now, it is time to address the factors in human experience that either cause dysfunction or protect us from it. For convenience, we can clump these factors into the biological, the psychological and the social. Because these factors interact in complex ways, I like to call it an ecological model. This model contrasts with the typical psychiatric one in which mental disorders are seen as either medical diseases or psychogenic.
The model I’m talking about was first introduced by George Engel in 1977 and was called the biopsychosocial model. Engel wrote that psychiatry was in crisis because “adherence to a model of disease is no longer adequate for the scientific tasks and social responsibilities of either medicine or psychiatry.” He recognized that conceiving mental disorders as bodily aberrations “leaves no room within its framework for social, psychological and behavioral dimensions of the illness.”
Given my background in biological psychology, it was only natural that I gravitated to Engel’s model when I joined the Psychosomatic Medicine Clinic at Thomas Jefferson University Medical School. In 1978, I organized a multidisciplinary symposium on psychosomatic medicine which featured some of the major contributors to the biopsychosocial model and resulted in my book The Psychosomatic Approach to Illness in 1982. This approach has been the foundation for the dimensional model I’m presenting here.
The ecological metaphor is apt for this approach because what we conceive of as mental disorders are adaptations to an individual’s biopsychosocial environment. We are all doing the best we can to thrive – and sometimes just survive – in the complex and particular world in which we live. We each have individual talents, attributes and preferences and learn different ways of coping with life stressors. We then have to live in a social world where must meet demands and rules to achieve our goals and desires. Mental disorders do not strike us down like polio or cancer, but are deficiencies in our adaptive capacities. Below, I’ll outline some of the biological, psychological and social factors that make up this ecology.
We are all born human. None of us is born a lobster (I live in Maine) or a baboon. So all of our attributes are within the range of the human genome. We each come into this world with our own particular assortment of abilities and propensities, emotions and temperaments, and peculiarities. Some of these peculiarities may be related to genetic anomalies, but known ones are rare and there are no clear connections between them and the characteristics that mark different mental disorders. Further, the more we learn about epigenetics, the more we recognize that whether certain genes are expressed or not depends on environmental conditions. What we are left with is that to call a mental disorder genetic is an essentially meaningless statement.
This brings us to the concept of heredity. Heredity is a statistical statement, not a genetic one. It tells us the odds of some attribute being associated with genetic factors, but not the mechanism. For instance, studies show that in identical twins (who share the same genes), if one twin is described as schizophrenic, the other twin has a 48% chance of being described that way by the same criteria. What happens to the other half? Something other than genes are at work here.
The best way to understand data of this sort is in terms of susceptibility. Some unknown thing makes a person genetically vulnerable to the kind of cognitive disruption that is labeled schizophrenia, for instance. More generally, due to our individual biology, we are likely to have different degrees of susceptibility for impairments in functioning across different areas. We can’t say more than that.
More profitably, we can examine brain functioning for clues to a biological substrate for human behavior. The architecture of the human brain follows a consistent plan, but within that plan we each have an individual brain, just as we have unique faces and bodies. The brain we inherit or one that is altered by injury, illness or life’s experiences is the foundation of our behavior. But, like a sculptor’s medium, the marble or the clay, the brain sets limits and direction, but does not directly determine the work of art that results.
A striking fact about the human brain is that we are born with far more neural connections than we actually need. In the course of brain development, experience prunes away unneeded connections. The Nobel laureate Gerald Edelman termed this process “neural Darwinism”. Additionally, groups of neurons that activate together form closer bonds. As Edelman put it, “Neurons that fire together, wire together.” The current concept of brain development is more like an ecosystem then a machine. Each neural network is in constant competition with other brain components throughout our lives. The upshot of this is that a brain’s susceptibility to different forms of dysfunction is an exceedingly complex process. Sorting out specific brain factors may provide important clues, but it will never be determinant for mental disorders.
What we should be clear about is that for us human beings, especially compared to all other animals, brains are shaped by life’s experiences. From the moment we enter the world, we begin to adapt and learn in order to meet the demands of the world around us. As we mature, these demands become more complex and social. We continuously develop our behavioral repertory, based on our abilities and needs. At each stage of life, we must develop new coping mechanisms to meet new challenges.
The patterns of behavior, thinking and feeling that we develop are what we call our personalities. Each personality has its strengths and weaknesses as the person confronts life. Some personality characteristics successfully help us lead satisfying lives, but others may be maladaptive and lead to chronic dysfunction. For instance, some maladaptive personality patterns may leave is unable to form rewarding interpersonal relationships. Other personality attributes leave us vulnerable to anxiety or depression.
Biological susceptibility combined with maladaptive personality resources can make us vulnerable to sudden breakdown. Most people are resilient. They have acquired adequate coping skills to create a firm sense of self and can recover quickly from stressors or conflict. It is likely, though, that each of us can break down if the stress is too great or too prolonged. People who suffer losses may become depressed and people who are threatened by events they cannot control may become anxious. Even otherwise well-functioning people may lose their grip on reality and become psychotic if the threat to self is too intense. On the other hand, some personalities are rigid and subject to catastrophic breakdown, called decompensation. Severe dysfunction of this kind may be labeled schizophrenia, major depression or panic disorder.
Another element of personality is the power of our beliefs. The way we learn to think about ourselves and the world about us influences the way we behave and feel. Maladaptive thinking and false assumptions are a major source of dysfunction. Analysis of the ideas people form about themselves, how they interpret the consequences of their actions and the relationship these thoughts have to distress have been the focus of a remarkable group of psychological thinkers collectively called cognitive behavioral theorists. They have formulated the techniques of cognitive behavior therapy, which teaches the skills necessary to cope effectively.
The power of situational forces to influence our actions, feelings and even our beliefs is vastly underestimated. We have a strong bias toward attributing psychological problems to dispositional factors; that is, personal qualities. When we look for causes of other people’s behavior, we invoke genetic make-up or personality or mental illness. But we are social animals, programmed by evolution to respond to and be shaped by the social forces around us.
The social context is of equal importance to personal attributes, such as mental disorder, in any attempt to understand the level of dysfunction a person exhibits. This context includes the rewards, punishments, social norms and expectations a person is subject to at any given time. These factors can be protective when they boost an individual’s self-esteem and can lead to the belief that the person can overcome difficulties. They can also be destructive and increase dysfunction when they reinforce disability.
My experiences with such social factors has given me additional reason to be extremely skeptical of mental disorder diagnosis. I have often found multiple clinicians making diagnostic pronouncements without the least regard for their patients’ life circumstances. They seem to be so focused on fitting a person’s complaints to the diagnostic criteria for mental disorders and coming up with a label that they pay no attention to the facts of a person’s life even when they know them. They do their patients no service when they don’t step back and take an objective look at the context of their patients’ lives. Clinicians need to learn as much as they can about those circumstances and be modest and circumspect in assigning labels.
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