Trouble in Mind: An Unorthodox Introduction to Psychiatry

1. Organic Mind

chapter one Organic Mind Many people confuse psychology and psychiatry. The two have surprisingly little to do with each other. Psychology refers to the study of the mind, a field of inquiry encompassing a set of theories that inform research and clinical work. Psychiatry refers to a field of medicine. Psychiatrists care for people who have mental illness. Psychiatric research leans on other scienti fic disciplines, such as epidemiology, genetics, and neurobiology. Psychiatrists do, of course, employ principles of behavioral psychology, but no more than many other kinds of physicians. Psychological theories about the nature of perception, knowledge, attention, memory, motivation, attachment, and a variety of other mental phenomena tend to have limited, if any, place in the standard, modern psychiatric approach to mental illness. For a variety of reasons, psychiatry can be and tends to be practiced without reliance on psychological concepts. Rule-based diagnostic practices make it possible to discern a patient’s mental illness via a symptom checklist, and thisinturnpointstoeffectivetreatmentoptions,vettedbyrandomized,doubleblind , placebo-controlled clinical trials. Psychiatrists rarely have the time to delve into a patient’s personal trials, in part because insurance tends to cover 2 Trouble in Mind only brief visits to assess symptoms and renew prescriptions. Medical students who go into psychiatry often have relatively little education in psychology , compared to their education in biochemistry, anatomy, genetics, and physiology. The growing scientific power to probe the genome, and to observe the brain in action, seems to support the promise that neurobiology, not psychology , represents the future foundation of psychiatry. All of these factors render psychology seemingly inessential in the treatment of mental disorder. But this professional neglect of psychology perpetuates a fundamental error. To neglect the study of the mind is to neglect the theoretical foundation of psychiatry’s core mission: the treatment of mental illness. One might object: perhaps the problem for modern psychiatry is not the neglect of psychology, but the relative immaturity of neurobiology. In time, psychiatry will have a thoroughly neurobiological basis. Research has begun to reveal the neurobiology of the major mental illnesses like schizophrenia, bipolar disorder, obsessive-compulsive disorder, and dementia, and also has begun to gain traction in knowing the anatomical components of temperament , the cellular mechanisms of learning and behavior, and the molecular biology of the brain’s response to stress and trauma. Naturally, the biological science behind psychiatry lags behind the development of biological science across the rest of medicine. The brain is difficult to study. It is less accessible to measurement by researchers, compared to other organs. It has no moving parts and emits little measurable substance to collect and analyze. Isn’t it just a matter of time before we overcome these technical obstacles and develop a bioassay for the phenomena of mental life? No more than it was just a matter of time before the early alchemists discovered a philosopher’s stone to transmute lead into gold. Many philosophers have argued eloquently that mind cannot be reduced simply to a mere activity of the brain (Jackson 1986); albeit not everyone shares this belief in the irreducibility of mind (Churchland 1994). A modern account of mind must respect neurobiology, but mind has qualities that cannot be reduced to neurobiology (Nagel 1974). Consider free will: the nearly universal sense that we think and act as independent agents, as opposed to being mere slaves of material or supernatural forces. Free will makes no sense neurobiologically. One may accept that the laws of nature govern the brain, along with everything that arises from it. If so, then the sum total of our physical being, hence our experience, must have been determined by the collected physical interactions of the atoms that comprise us. When a neuro- Organic Mind 3 transmitter activates a neuron that moves a muscle, this follows from a long chain of molecular and cellular events determined by physical and chemical forces. At what point do one’s thoughts, feelings, or intentions acquire the power to impose a new force on the neurotransmitter molecules that will ultimately move our bodies to act? Or is our sense of control over our bodies merely an illusion, and mental life a side effect of physical forces over which we have no real control? Such arguments notwithstanding, even the most ardent believers in the physical basis of all reality think, act, and feel as if they were free to choose their attitudes and actions, including psychiatrists...