Trouble in Mind: An Unorthodox Introduction to Psychiatry

5. Psychiatric Mind

chapter five Psychiatric Mind We have come to the end of our trek through the mind and mental dysfunction , from norepinephrine to neurons to neuroses. We now can map troublesome mental symptoms, propensities, experiences, and behaviors to specific adaptive functions. If this were a standard textbook of psychiatry the chapters would have been patterned after the official manual of psychiatric diagnosis, the DSM, which chops psychiatry into a manageable number of classes of disorder (mood disorders, psychotic disorders, personality disorders, and so on), comprised of rule-based diagnoses. Instead, this book has deconstructed these diagnostic entities and distributed their components throughout the entirety of mental life. Has it made psychiatry more complicated? Indeed it has, but only in the sense that a modern textbook of general medicine complicates the simple and elegant but artificial categorization of disorders developed before the modern medical era. For example, William Cullen’s nosological grouping into pyrexic (fever), neurotic (neurological), cachexic (systemic but neither febrile nor neurological), and local (confined to one organ or body part) syndromes had a pragmatic logic, but with respect to the 174 Trouble in Mind modern classification of diagnosis by function and cause, it often lumped where it should have split, and split where it should have lumped (Cullen 1800). With the sacrifice of simplicity, one gains a logical framework to understand the relationships between brain dysfunctions, behaviors, innate vulnerabilities , and the meaning the patient attaches to his or her experiences. In this chapter, the various manifestations of mental dysfunction are sorted roughly into groups defined by the nature of the illness. Borrowing (and paraphrasing a bit) from Paul R. McHugh and Phillip R. Slavney (McHugh and Slavney 1998), there are essentially four distinct methodological approaches to mental illness: to see it as a disease, as a dimensional aspect of a person (trait vulnerability), as maladaptive behavior, or as a disrupted life story (adverse experience). Each of these employs a different logic to gauge the identity , significance, and severity of illness. One employs these distinctive modes of clinical reasoning in the typical patient who presents with a complex clinical problem: a disease that incites maladaptive behavior, as obsessive aversion to the touching of different foods on a plate may constrain the food choices of a person with anorexia; or a temperamental vulnerability that exposes one frequently to adverse experience, as histrionic overdependency may strain relationships and bring on the abandonment the person most dreads. 5.1. Psychiatry Rebuilt Each of the mental dysfunctions described in the book falls more or less into one of four types of problem. In this section, we will reorganize them according to the type of dysfunction they represent, and show how the identi fication of these manifestations of illness leads to a useful formulation of a patient’s clinical problem. For simplicity, the mental dysfunctions are assigned to only type of problem, based on clinical relevance, though in some cases (for example, dysregulation of appetite), they could be discussed and employed to understand the patient’s problem in several ways (for example, as a deficit in the biological regulation of food consumption, or as a trait of excessive hunger, or as a maladaptive behavior). Disease States Many diverse phenomena are attributable primarily to expressions of abnormal brain activity. Psychiatric Mind 175 agitation, delirium, dysregulation of sleep, appetite, or libido; hallucinations, illusions, agnosia, disorganization, catatonia, apraxia, dyskinesias, extravolition, obsessions/ compulsions, avulsion/intrusion, amnesia, disinhibition, anhedonia, apathy, dejection , excitement, irascibility, paroxysms, paranoia, delusions, asociality, dysfluency/ hyperfluency, derailment, and telemission If a person has several of these dysfunctions, or a severe and persistent form of any of them, then he or she almost certainly has a disease: a biological abnormality in brain activity. A patient who has pathological symptoms is likely to have other problems as well. Each of these pathological symptoms can and does contribute to other kinds of problems, and each may arise as a complication from other kinds of problems. If one does not know the pathological cause of a symptom, how does one know it is pathological? One can infer this when the same symptom can occur from a known biological malfunction. For example, steroid and stimulant medications each can induce states of excitement alternating with irritability , agitation, and paranoia (Hall et al. 1979; Snyder 1973). This does not tell us the cause of these symptoms when they occur without drugs, but...