Once a week.
Subscribe to our weekly newsletter.
A psychiatric diagnosis can be more than an unkind ‘label’
A popular and longstanding wave of thought in psychology and psychotherapy is that diagnosis is not relevant for practitioners in those fields.
Among the first people I met was a young man who believed that he might be responsible for harm coming to his family if he didn't engage in time-consuming rituals, including arranging his shoes very particularly for up to half an hour. The logic motivating this man's behaviour was notably rather magical and unrealistic, appealing to notions of spirit possession and evil, which were culturally alien to his family. My supervisor, a sensitive and empathic clinician, who believed that most issues could be addressed by attentive listening and interpretation, tended to have a single diagnostic concern. The central question for him was whether the person was experiencing anxiety or manifesting the early symptoms of a psychosis. The latter ought to receive a more thorough assessment and more support than our clinic could offer.
Because of the magical quality to this person's reasoning, my supervisor decided that this might be an early sign of psychosis. He instructed me to refer the man to a new research clinic near my training site, which specialised in treating and researching the 'at risk' state for psychosis.
Of course, sensible and cautious though this seemed to me, it entailed telling this young man that he could not be seen by us for talking therapy. Instead, he should go to a clinic that specialised in something serious and frightening-sounding. When I broke the news, he was devastated. He left our clinic, and I later learned that he never followed up with the referral.
What I failed to appreciate at the time – and what some remedial reading later painfully revealed to me – was that, rather than being an early manifestation of psychosis, this man's presentation was more likely a case of obsessive compulsive disorder (OCD), a common condition in which people develop obsessive thoughts and feel compelled to engage in actions to prevent feared harms. If I'd had the diagnostic knowledge and confidence to assert this to my supervisor during the initial consultation, the man I met would likely have received help, rather than being referred to an inappropriate clinic that led to him falling through the cracks.
Yet, a popular and longstanding wave of thought in psychology and psychotherapy is that diagnosis is not relevant for practitioners in those fields, and should be left to psychiatrists, if at all. This is not a fringe view, it has been perennially present in clinical psychology since at least the 1960s, when the iconoclastic psychiatrists Thomas Szasz and R D Laing presented a dual challenge to their profession.
Szasz, a Hungarian émigré to the United States, argued that mental illness is a 'myth', rooted in a misuse of language. Neurological diseases are real, Szasz suggested, because they can be confirmed by a postmortem examination of the brain. In contrast, he argued that psychiatric 'illness' has no such neurological basis, and is just a medicalised way of talking about problems in life that could be solved by taking responsibility for yourself and your actions.
Meanwhile, Laing, a Scot who trained at the Tavistock Institute in London, argued in The Divided Self (1960) that psychosis is a psychic response to an increasingly alienated 'false self' obscuring the true emotional core of an individual. He held that so-called 'symptoms' (hearing voices, believing unusual things) were actually attempts at recovery in the face of this alienation.
These ideas resonated and had significant influence over psychiatric thinking throughout the 1960s. They contributed to diagnostic approaches to mental health – the idea that there are illnesses called schizophrenia, bipolar disorder and depression – becoming decidedly unfashionable. Indeed Szasz's and Laing's critiques became so popular that already by the early 1970s, the influential US clinical psychologist Paul Meehl grumbled in his 1973 paper 'Why I Do Not Attend Case Conferences' about an 'antinosological' (ie, antidiagnostic) bias taking hold in his profession.
Recently, the animus against psychiatric diagnosis has become more formal and scientifically argued. The British Psychological Society's Division of Clinical Psychology (DCP) – one of the official bodies representing the profession – published two documents in 2013 and 2015 articulating the difficulties with diagnosis, and promoting instead the value of individualised 'formulations'. While it is clear that the DCP's position on diagnosis is not universally held by practitioners in the UK, British psychologists are around half as likely to report regular use of a diagnostic classificatory system as their colleagues in some other countries (for example, fewer than 35 per cent of psychologists in the UK say that they use diagnosis regularly, compared with more than 70 per cent of psychologists in the US, Germany and South Africa). This likely reflects a UK professional culture steeped in suspicion of diagnostic thinking.
The suspicion is not unwarranted. One of the most interesting recent critiques of diagnosis has come from the Belgian psychoanalyst and clinical psychologist Stijn Vanheule. He invoked the philosophy of language to argue that diagnosis necessarily draws our attention to the shared meanings conjured by diagnostic language, rather than to the individual meanings inherent to people's experiences. Thus, for example, when I say 'schizophrenia', I focus attention on a generalised, clinical definition that exists in a book, rather than on the individual, personal significance of hearing voices or believing unusual things. For psychotherapists, Vanheule argued, the former is irrelevant, the latter vital.
These arguments are valuable, and they are correct in important ways. Their conclusions are a significant part of what inspired me to get into clinical psychology in the first place. Reading Laing as a teenager, I thrilled to the challenge he presented: to understand people as they endure the most extreme and bewildering psychic states; to try to find coherence even where it seems to be absent. This impulse is essential. Patience and careful listening can reveal that people are capable of engaging in communication more often than we tend to give them credit for. But my clinical training has shown me that, despite the importance of understanding people in an individualised way, having a knowledge of diagnostic categories is also essential.
To return to the example above, my supervisor and I were ignorant of valuable diagnostic information; we were ignorant of the ways that clinicians can distinguish magical obsessions from the early hints of delusion. We were ignorant of the fact that even quite magical ideas are well within the range of the former without shading into the latter. We were ignorant of how easy it would have been to provide effective help without raising the prospect of a terrifying psychosis down the pipeline. Our ignorance cost someone dearly.
Diagnosis is often vital for ensuring good care. Apart from the importance of ruling out organic causes for apparently straightforward instances of depression and anxiety (which can be symptomatic of a surprising range of endocrine, infectious and neurological diseases), linking psychological distress into a broader framework also helps clinicians make sense of the people they are trying to help. Certain forms of substance misuse could represent attempts at self-medication for highly treatable disorders of mood or attention, for instance. Correct identification of trauma symptoms can avert diagnosis of a psychotic illness. Proper diagnosis of depression in later life can frequently account for changes in memory and attention that might otherwise be mistaken for dementia, as unfortunately often happens. Diagnosis of bipolar mood disorder can prevent people being inappropriately treated for personality disorders.
Psychology's antinosological tendency encourages a belief that diagnostic thinking is somehow inherently unkind; that in thinking about categories you are always only 'labelling' people, and that this is an inhumane thing to do.
Conversely, it also encourages a belief that all you really need in mental healthcare is sympathy, rapport and interpretative heroics. This appeals to some of the questionable impulses of professionals: to our desire to see ourselves as people uniquely able to understand others, and to our ordinary human laziness. Who would want to engage in learning about taxonomy if to do so is both unkind and unnecessary?
Understanding people is a multifaceted enterprise. We all manifest a splendid idiosyncrasy, living out lives that could never be copied or repeated, so it makes sense to consider one another in the light of this uniqueness. But we also bear resemblances to one another. Important though it is to be seen in all your individuality, it is also helpful to know when your problems have precedent.
Psychiatric diagnoses are imperfect, sketchy theories about how people's minds can give them trouble. We know that they are largely less precise and valid than is popularly understood, but this does not render them totally uninformative. We have learned snippets of useful information by considering psychological problems in terms of categories: the effectiveness, or not, of treatments for particular groups of people; the elevated risk of suicide among others. Many symptoms can seem to 'make sense' in the context of a person's life, but we know that humans are sense-making machines, so we need to be vigilant against 'making sense' where it is only illusory. The great intellectual challenge of clinical psychology is to integrate knowledge about reasons and people with knowledge about causes and mechanisms. We should avoid relying solely on diagnostic information, but we shouldn't discard it altogether.
- Diagnostic Inflation: Do You Really Have a Mental Disorder? - Big ... ›
- Psychiatry's Fundamental Flaws - Big Think ›
Scientists are using bioelectronic medicine to treat inflammatory diseases, an approach that capitalizes on the ancient "hardwiring" of the nervous system.
- Bioelectronic medicine is an emerging field that focuses on manipulating the nervous system to treat diseases.
- Clinical studies show that using electronic devices to stimulate the vagus nerve is effective at treating inflammatory diseases like rheumatoid arthritis.
- Although it's not yet approved by the US Food and Drug Administration, vagus nerve stimulation may also prove effective at treating other diseases like cancer, diabetes and depression.
The nervous system’s ancient reflexes<p>You accidentally place your hand on a hot stove. Almost instantaneously, your hand withdraws.</p><p>What triggered your hand to move? The answer is <em>not</em> that you consciously decided the stove was hot and you should move your hand. Rather, it was a reflex: Skin receptors on your hand sent nerve impulses to the spinal cord, which ultimately sent back motor neurons that caused your hand to move away. This all occurred before your "conscious brain" realized what happened.</p><p>Similarly, the nervous system has reflexes that protect individual cells in the body.</p><p>"The nervous system evolved because we need to respond to stimuli in the environment," said Dr. Tracey. "Neural signals don't come from the brain down first. Instead, when something happens in the environment, our peripheral nervous system senses it and sends a signal to the central nervous system, which comprises the brain and spinal cord. And then the nervous system responds to correct the problem."</p><p>So, what if scientists could "hack" into the nervous system, manipulating the electrical activity in the nervous system to control molecular processes and produce desirable outcomes? That's the chief goal of bioelectronic medicine.</p><p>"There are billions of neurons in the body that interact with almost every cell in the body, and at each of those nerve endings, molecular signals control molecular mechanisms that can be defined and mapped, and potentially put under control," Dr. Tracey said in a <a href="https://www.youtube.com/watch?v=AJH9KsMKi5M" target="_blank">TED Talk</a>.</p><p>"Many of these mechanisms are also involved in important diseases, like cancer, Alzheimer's, diabetes, hypertension and shock. It's very plausible that finding neural signals to control those mechanisms will hold promises for devices replacing some of today's medication for those diseases."</p><p>How can scientists hack the nervous system? For years, researchers in the field of bioelectronic medicine have zeroed in on the longest cranial nerve in the body: the vagus nerve.</p>
The vagus nerve<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTYyOTM5OC9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTY0NTIwNzk0NX0.UCy-3UNpomb3DQZMhyOw_SQG4ThwACXW_rMnc9mLAe8/img.jpg?width=1245&coordinates=0%2C0%2C0%2C0&height=700" id="09add" class="rm-shortcode" data-rm-shortcode-id="f38dbfbbfe470ad85a3b023dd5083557" data-rm-shortcode-name="rebelmouse-image" data-width="1245" data-height="700" />
Electrical signals, seen here in a synapse, travel along the vagus nerve to trigger an inflammatory response.
Credit: Adobe Stock via solvod<p>The vagus nerve ("vagus" meaning "wandering" in Latin) comprises two nerve branches that stretch from the brainstem down to the chest and abdomen, where nerve fibers connect to organs. Electrical signals constantly travel up and down the vagus nerve, facilitating communication between the brain and other parts of the body.</p><p>One aspect of this back-and-forth communication is inflammation. When the immune system detects injury or attack, it automatically triggers an inflammatory response, which helps heal injuries and fend off invaders. But when not deployed properly, inflammation can become excessive, exacerbating the original problem and potentially contributing to diseases.</p><p>In 2002, Dr. Tracey and his colleagues discovered that the nervous system plays a key role in monitoring and modifying inflammation. This occurs through a process called the <a href="https://www.nature.com/articles/nature01321" target="_blank" rel="noopener noreferrer">inflammatory reflex</a>. In simple terms, it works like this: When the nervous system detects inflammatory stimuli, it reflexively (and subconsciously) deploys electrical signals through the vagus nerve that trigger anti-inflammatory molecular processes.</p><p>In rodent experiments, Dr. Tracey and his colleagues observed that electrical signals traveling through the vagus nerve control TNF, a protein that, in excess, causes inflammation. These electrical signals travel through the vagus nerve to the spleen. There, electrical signals are converted to chemical signals, triggering a molecular process that ultimately makes TNF, which exacerbates conditions like rheumatoid arthritis.</p><p>The incredible chain reaction of the inflammatory reflex was observed by Dr. Tracey and his colleagues in greater detail through rodent experiments. When inflammatory stimuli are detected, the nervous system sends electrical signals that travel through the vagus nerve to the spleen. There, the electrical signals are converted to chemical signals, which trigger the spleen to create a white blood cell called a T cell, which then creates a neurotransmitter called acetylcholine. The acetylcholine interacts with macrophages, which are a specific type of white blood cell that creates TNF, a protein that, in excess, causes inflammation. At that point, the acetylcholine triggers the macrophages to stop overproducing TNF – or inflammation.</p><p>Experiments showed that when a specific part of the body is inflamed, specific fibers within the vagus nerve start firing. Dr. Tracey and his colleagues were able to map these relationships. More importantly, they were able to stimulate specific parts of the vagus nerve to "shut off" inflammation.</p><p>What's more, clinical trials show that vagus nerve stimulation not only "shuts off" inflammation, but also triggers the production of cells that promote healing.</p><p>"In animal experiments, we understand how this works," Dr. Tracey said. "And now we have clinical trials showing that the human response is what's predicted by the lab experiments. Many scientific thresholds have been crossed in the clinic and the lab. We're literally at the point of regulatory steps and stages, and then marketing and distribution before this idea takes off."<br></p>
The future of bioelectronic medicine<img type="lazy-image" data-runner-src="https://assets.rebelmouse.io/eyJhbGciOiJIUzI1NiIsInR5cCI6IkpXVCJ9.eyJpbWFnZSI6Imh0dHBzOi8vYXNzZXRzLnJibC5tcy8yNTYxMDYxMy9vcmlnaW4uanBnIiwiZXhwaXJlc19hdCI6MTYzNjQwOTExNH0.uBY1TnEs_kv9Dal7zmA_i9L7T0wnIuf9gGtdRXcNNxo/img.jpg?width=980" id="8b5b2" class="rm-shortcode" data-rm-shortcode-id="c005e615e5f23c2817483862354d2cc4" data-rm-shortcode-name="rebelmouse-image" data-width="2000" data-height="1125" />
Vagus nerve stimulation can already treat Crohn's disease and other inflammatory diseases. In the future, it may also be used to treat cancer, diabetes, and depression.
Credit: Adobe Stock via Maridav<p>Vagus nerve stimulation is currently awaiting approval by the US Food and Drug Administration, but so far, it's proven safe and effective in clinical trials on humans. Dr. Tracey said vagus nerve stimulation could become a common treatment for a wide range of diseases, including cancer, Alzheimer's, diabetes, hypertension, shock, depression and diabetes.</p><p>"To the extent that inflammation is the problem in the disease, then stopping inflammation or suppressing the inflammation with vagus nerve stimulation or bioelectronic approaches will be beneficial and therapeutic," he said.</p><p>Receiving vagus nerve stimulation would require having an electronic device, about the size of lima bean, surgically implanted in your neck during a 30-minute procedure. A couple of weeks later, you'd visit, say, your rheumatologist, who would activate the device and determine the right dosage. The stimulation would take a few minutes each day, and it'd likely be unnoticeable.</p><p>But the most revolutionary aspect of bioelectronic medicine, according to Dr. Tracey, is that approaches like vagus nerve stimulation wouldn't come with harmful and potentially deadly side effects, as many pharmaceutical drugs currently do.</p><p>"A device on a nerve is not going to have systemic side effects on the body like taking a steroid does," Dr. Tracey said. "It's a powerful concept that, frankly, scientists are quite accepting of—it's actually quite amazing. But the idea of adopting this into practice is going to take another 10 or 20 years, because it's hard for physicians, who've spent their lives writing prescriptions for pills or injections, that a computer chip can replace the drug."</p><p>But patients could also play a role in advancing bioelectronic medicine.</p><p>"There's a huge demand in this patient cohort for something better than they're taking now," Dr. Tracey said. "Patients don't want to take a drug with a black-box warning, costs $100,000 a year and works half the time."</p><p>Michael Dowling, president and CEO of Northwell Health, elaborated:</p><p>"Why would patients pursue a drug regimen when they could opt for a few electronic pulses? Is it possible that treatments like this, pulses through electronic devices, could replace some drugs in the coming years as preferred treatments? Tracey believes it is, and that is perhaps why the pharmaceutical industry closely follows his work."</p><p>Over the long term, bioelectronic approaches are unlikely to completely replace pharmaceutical drugs, but they could replace many, or at least be used as supplemental treatments.</p><p>Dr. Tracey is optimistic about the future of the field.</p><p>"It's going to spawn a huge new industry that will rival the pharmaceutical industry in the next 50 years," he said. "This is no longer just a startup industry. [...] It's going to be very interesting to see the explosive growth that's going to occur."</p>
Researchers figure out the average temperatures of the last ice age on Earth.
- A new study analyzes fossil data to find the average temperatures during the last Ice Age.
- This period of time, about 20,000 years ago, had the average temperature of about 46 degrees Fahrenheit (7.8 C).
- The study has implications for understanding climate change.
Surface air temperatures during the last ice age.
Credit: Jessica Tierney, University of Arizona
"The Expanse" is the best vision I've ever seen of a space-faring future that may be just a few generations away.
- Want three reasons why that headline is justified? Characters and acting, universe building, and science.
- For those who don't know, "The Expanse" is a series that's run on SyFy and Amazon Prime set about 200 years in the future in a mostly settled solar system with three waring factions: Earth, Mars, and Belters.
- No other show I know of manages to use real science so adeptly in the service of its story and its grand universe building.
Credit: "The Expanse" / Syfy<p>Now, I get it if you don't agree with me. I love "Star Trek" and I thought "Battlestar Galactica" (the new one) was amazing and I do adore "The Mandalorian". They are all fun and important and worth watching and thinking about. And maybe you love them more than anything else. But when you sum up the acting, the universe building, and the use of real science where it matters, I think nothing can beat "The Expanse". And with a <a href="https://www.rottentomatoes.com/tv/the_expanse" target="_blank">Rotten Tomato</a> average rating of 93%, I'm clearly not the only one who feels this way.</p><p>Best.</p><p>Show.</p><p>Ever. </p>
Contrary to what some might think, the brain is a very plastic organ.
As with many other physicians, recommending physical activity to patients was just a doctor chore for me – until a few years ago. That was because I myself was not very active.