Comments on mental illness, such as schizophrenia as brain disorder, and on mind-body relationship

Mind-Body, Brain-Behavior are two sides of the same coin, and one can chose one perspective over the other, but changes in one correlates with changes in the other. I don’t see real conflicts between medical intervention perspective and psychological-social intervention perspective, unless one blindly promotes one to the exclusion of the other. Whatever one thinks, psychological behavior have underlying correlations in brain activities, and changes in the brain affects overt behaviors. Please see this month’s article in Scientific American by Grabiel and Smith that outlines how all “behavioral habits” have demonstrated neural networks supporting them (of course based on animal studies, which has implications for humans, and it makes perfectly sense).

On Lieberman’s statement the “schizophrenia is a brain disorder”

“The question is what level and intensity of intervention one chooses to follow or wants to investigate through research projects, and what kind or outcome measures one needs to pay attention to justify a specific type of intervention. In this context, mental illnesses, such as schizophrenia, are behavior illnesses (e.g., behaviors that cause personal and or social distress, and are viewed as “maladaptive” by social norms). Both biological and psycho-social interventions could be effective, but not yet found to be universally effective, as such, schizophrenia and similar challenging mental health problems are labeled as “severe and persistent mental illnesses,” needing development of more advances in mental health technology in both fronts. The other issue is that pursuing one level of intervention, biological or psycho-social intervention,( such as changing one’s thinking through therapy intervention, or milieu support by modifying social environment, such as re-engineering) one may still raise ethical issues of compromising “self determination,” “individual choices,” promoting negative effects of over-reliance on “external” intervention, biological or social or otherwise, on the individuals, as each of one of us consciously experience the uniqueness of our living identity and want to figure out ourselves to make the best of our living existence. Personal and social ethical issues must be confronted in pursuing either of the perspectives to the exclusion of others, as both are theoretically valid perspectives to bring about changes in an ideal or controlled experimental situation. But the reality is complex, and we need and use and have made advances in the use of both interventions, biological and psycho-social, and our human civilizations are built on those advances. My final comment relates to politics of mental health or politics of any other economic activity. Mental health service delivery, like any other health service or service oriented industries, is driven by professional identity, our vested interests, and economic motivation, as such , at times objectivity may be lost in advocating one type of service over the other. Open communication and consumer awareness and choices will determine what make sense. In this sense, this kind of reflective thinking and dialogue is helpful.”

“In mental health, the “exact science” has not arrived yet, and perhaps will never be, due to unique individual conscious existence. It is nice to have a belief in “certified defined approach” to give us a sense of certainty of knowledge, but clinical challenge and reality of dealing with individual cases is quite different, as we all may know. As I have said in my original note, mind-body/brain-behavior are two sides of the same coin. The issue is what perspective one chooses to emphasize, and how much one pays attention to one over the other. But also what kind of outcome data, including client satisfaction, (a subjective individual and collective dimension of experience used now in all business and service industry), personal and social distress criteria, and involvement in “productive day routine” (a criterion of social adaptation), are included, taking into account iatrogenic effects of any intervention, medical or psycho-social. Personally, because of my training and professional identity I emphasize psycho-social approaches, but have appreciation of biological interventions in mental o physical illnesses, but I am also keenly aware of limits of both psycho-social and biological interventions. I understand from advocacy and funding or politics of mental health issue, “limits” are not what people want to convey for either of the approaches, and we may be caught up in this.”

Dynamics of the origin of delusional symptoms in schizophrenia:

“Personal based delusional beliefs that are atypical and maladaptive as they cause personal distress and or social distress, as in case of persons with schizophrenia, I believe. originate from incessant preoccupation with inner world of fantasy (above and beyond norm) in response to dealing with “uncertainties” of living experience and exacerbated by possibly “perceived real or imagined traumas” and to “ward off” what one perceives “ego dystonic” thoughts and impulses, which do not match one’s concept of a “perfect self,” (“who does not do any wrong, does not have any “evil thoughts,” and knows everything there is to know, so no need to verify or validate one’s thoughts through interpersonal communication). This gives one a sense of “existential certainty and control” by being the “creator of one’s own world,” At some point, one perceives that it is difficult to expunge these “ego dystonic” thoughts and impulses, which are often related to sexual and aggressive fantasies or impulses, associated with transition to adulthood. Then they attribute the presence of the intrusions of these thoughts and impulses to outside agents and not to oneself, often taking the form of paranoid thoughts coming from outside and being tormented in the process, without acknowledging that the “self” as the originator of such thoughts. This splitting of the mind (a la Bleuler), so to speak occurs, and preference to the “inner world of ruminations and fantasy” become so pronounced that distinction between fantasy and social world may have been lost, so no longer one is able to move consciously from one to another as most people are able to do, because of their continued active involvement in social world. Also, because of repeated visitations to these experiences, by Law of Exercise, the delusional beliefs become entrenched in one’s daily life, as behavioral habits, with possible underlying neural networks supporting them. By trying to expunge intrusion of the “unwanted thoughts and impulses,” they become more pronounced and dominant by the “failure experiences.” In that frame of mind, it is more adaptive and comfortable to say “somebody else is having these thoughts and beliefs, not me.” There could be vulnerability to personal stress tolerance and some level of atypical information processing along with possible “negative” life experiences, a combination of biological vulnerability and social and psychological factors that may promote this kind of “atypical personal adaptation” to coping with everyday life experiences.”

“Working with persons with schizophrenia for 25+ years in individual and group therapy sessions, I have never challenged delusional beliefs expressed, or being judgmental about them, rather pointed out the difficult nature of communicating such beliefs and be understood by others, as they are too personal and atypical. (I believe that we all have some elements of atypical beliefs not shared by others in different forms), but we practice to move on to conversation involving areas of topics that we can communicate with each other using a common frame of conversation rules. By engaging in this type of consensus agreed communication with persons with schizophrenia, we facilitate a greater degree of awareness of the existence of the rational part of mind, which is always present within all of us, including people with schizophrenia, , but may not be accessed or stimulated. This process of “mind stimulation” as we outlined in our book (Mind Stimulation Therapy: Cognitive Intervention for Persons with Schizophrenia, 2013), we hope, will overlay the “irrational thinking,” and promoting more possibility of engaging in adaptive thinking and behavior in these clients, while recognizing the value of additional psychiatric and psycho-social milieu support that the clients might be getting.”

Besides being influenced somewhat by Freud’c conceptualization of “psychotic defense” and Bleuler’s and Arieti’s concepts of schizophrenia, I was greatly influenced by reading Joseph Lyons’ brief article, The Psychology of Angels (1958, Forum), which was given to me by supervisor, Donald Derozier, while I was an Intern at Wnnebago State Hospital some 45 years ago, along with my own personal phenomenological reflections on the issue.”

Another response on the issue of delusion in the Internet Communication Forum:

“At a basic level, we are on the same page, as I basically defined delusions and hallucinations as you describe as “nonconsus” beliefs and “nonconsensus” perceptions, and I labeled them as atypical beliefs and perceptions that are unique to individual and could not be meaningfully communicated to others, and that many other creative and individual minded people have that kind of atypical beliefs, but they are communicable to others using a common frame of communication mode , and are being appreciated for creativity. In many ways, in human societies, cultural and nationalistic beliefs, and religious faiths also reflect “atypical group sanctioned” beliefs that other groups do not understand or accept as part of Reality. Because of human conscious existence, each person as being unique in this Universe, individuals and groups have unique ways of coping with the reality of their living existence, specifically Uncertainty, and develop strategies and thoughts that are unique to themselves, and many such beliefs and experiences cannot be communicated or understood by others or other groups. We also both agree on the issue of “at risk” behaviors that may be influenced by such atypical beliefs and how best to manage them, when they are present in some individuals, and that is where mental health service comes into play.”

“I know that one may object to the use of psychiatric terminologies to advocate individual client centered perspective that does not devalue them or identify them with a demeaning “illness persona,” but in clinical service reality, where we have professional identity as psychologists, social workers, mental health counselors, psychiatrists, etc., we have to operate within the guideline of client-therapist relationships, documenting use of language accepted in mental health service community, both for insurance reimbursement purposes or to follow the agency guidelines that hire us (that support our livelihood), and also for guiding us to provide specific “help” or “therapy” that we are supposed to be trained in and to provide to clients who seek our help to reduce their personal distress or to reduce “social distress related to their at risk behavior,” as well. I don’t see contradiction of your advocacy role for what you consider to be a humane approach to “mental illness” and challenging the existing approaches to clinical practice. But in both fronts, continued advancements of knowledge and development of new technology of service, including modification of “terminologies” to label “people with mental illness” are needed. Yes, none of us know the “truth” yet we may pretend and act as if we know, but then, we may need to operate out of some degree of “certainty” until better terminologies and strategies are discovered, and the process of change will go on both at the client advocacy and client service levels.”

Comment on Benedetti:

“Your quote from Benedetti is quite refreshing!.

Behavior is a function of the brain, and brain mirrors all psycho-social effects, even though we may not currently have the technology to demonstrate all aspects of changes in the brain as a result of psycho-social experiences. The two are constantly interacting and one cannot separate one from the other, but one may choose to emphasize one over the other for purpose of clarity of our conceptual thinking and having some sense of concrete understanding and interventions that we may have been trained or exposed to through our respective professional discipline training. But we need to recognize that they are also dynamic as they change with accumulated knowledge and change of social culture and values. As such, we need to be open to those changes.

I get the sense from the Quote that is what Benedetti is trying to clarify for people who chooses to emphasize psycho-social dynamics of psychoses versus those who are seeking to emphasize biological focus, but one does not negate the other. Ultimately, it will be client and significant other people involved in client’s life as to what level of intervention, and to what degree, or a combination of intervention is useful at a particular time of one’s life that also make sense at a particular time of cultural values and social mores. Therapeutic language and strategies of understanding and intervention are all subject to a dynamic process of change. We are all (including “clients”) are trying to figure what makes the best sense to deal with the current reality of existence, at the moment, recognizing that our understanding and knowledge base will change, and deep down, we all have experience of Uncertainties of our living existence. Psychosis could be one of the manifestation of one’s struggle with existential crisis in dealing with “Uncertainties” of living existence.”

Another comment on schizophrenia:

“…We all live In a world of partial truths, and perception and validity of “reality” can be multi-level, individual and collective. For advocacy sake, it is okay to present a particular point of view as strongly as one can, but it will always remain short of being the only valid accepted framework. Clinicians in the field working with this challenging population, or for that matter in any field, will have to figure out with an open mind what makes sense in the context of current given knowledge and practice, and how best to operate within one’s professional identity and work structure, while having some degree of sense of competency and level of comfort in doing what one is doing!”

“More importantly, how well and articulated we think and express our thoughts and present our views in a logical and elegant manner really get understood by clients and “transferred to clients” with whom we work, so they can integrate or internalize into their thinking and behavior ( a part of our helping profession role), is an outcome issue that I often wonder, which may not not have been paid much attention. That may be a whole another issue of discussion thread”

On Importance of natural support and appropriate use of biological intervention in mental illness

“An article that I submitted in collaboration with several other psychiatrists on a case report just got accepted for publication in Journal of Geriatric Science and Gerontology (Maintenance of Recovery from Severe Psychotic Depression following Successful ECT in an Elderly Patient with Natural Support by Mohiuddin Ahmed, Ph.D. Harold Bursztajn, MD, Beverly Jalil, Ahmad Newaz Khan, MD, and Reza Rahman, MD). The case involved a family member, who is a close friend of mine, and I have been very involved in his advocacy and consultation service on an informal basis. In fact, the client and his spouse presented his recovery status at a NE Chapter of ISPS meeting some time ago. It is not published online yet, as it is at proofreading level. The summary of the article states. “This is a case report of an elderly man recovering fully from an extreme regressed level of functioning associated with psychotic depression with a successful ECT treatment. He has been maintaining his “recovery status,” without any medication, follow-up ECT, or psychotherapy by his own choice for five plus years. The case illustrates the need for judicious use of psychiatric intervention, and the willingness of psychiatric community to encourage maintenance of one’s recovered functioning with “natural support,” specifically for people who value personal independence, strong motivation to stay well, and have a strong family support and monitoring process.”

Without knowing your case and the premorbid level of functioning, and duration of mental illness prior to ECT, my advice will be not to actively explore “negative feelings and affects,” and status of recovery, except evaluation through indirect observation and report, and provide active stimulation of client’s “intact functioning and adaptive capacity” so as to make them prominent in the person’s life. I have taken the position that in some cases, active probing and exploration of negative feelings and behaviors, however well meaning they could be from the clinician’s perspective, for people presenting long-term psychological issues, may indirectly set up “negative relationship framework” between the therapist and client, and may reinforces client’s continued identification with the “illness persona” interfering with the recovery process. Some of the issues are highlighted in our recently published book : Mind Stimulation Therapy: Cognitive Intervention for Persons with Schizophrenia (by Mohiuddin Ahmed and Charles Boisvert, Routledge, 2013).

I believe that both medication, reflecting development of human science, and psycho-social approaches, reflecting growth of social technology are needed to ameliorate human distress arising from all kinds of biological and psycho-social maladies that we face. We also need continued improvement in the technologies of biological and psycho-social interventions, and active monitoring of evaluation of effectiveness of any intervention, ensuring a sense of balance, specifically for medication intervention for the psycho-behavioral related “difficulties” (illnesses) so that “overdependency” or “side effect” issues are minimal as they may counter the values we cherish as human beings: personal will power, individual choice in decisions, sense of individual freedom and well being, valuation of “natural strength,” etc. Over reliance on medication and drug dependency may not only impact our sense of “quality of life,” but in many situations may promote negative effects on our body and mind functioning, in many other ways. The challenge is how to optimize benefits from medication intervention for psychological conditions, while recognizing its limits, and same may be true for any other “interventions.”

We just published a collaborative article on a case of an elderly person (actually my cousin and a very close friend, as we have been getting together for dinner on a monthly basis for years with another physician friend of mine) who became severely depressed with psychotic features,for the first time in life following his retirement from a successful professional career, and responded positively to electro-convulsive therapy (as he was unresponsive to standard available treatment and hospitalizations). Upon recovery, and feeling well and getting back to his routine of active life, he has refused to be involved in any follow-up medication or ECT for maintenance therapy, as strongly advised by his treating psychiatrists, and also he did not want to be involved in any counseling or psychotherapy process, more out of sense of independence. For the past five years from recovery, he is not not only maintaining a very active retirement life: walking for an hour everyday, going to the library and reading major newspapers, playing tennis tree times a day, including participating in senior competitive program, and started doing a new consultation venture (he is a professional engineer). As we discussed in the report, we did not delve into “causative factors,” as they are highly speculative and “unknown,” but factual presentation of current functioning and changes reported provide some “food for thought” for the psychiatry and psychological community in addressing maintenance of “recovery” following any biological and or psycho-social intervention with “natural support.”.

• Mohiuddin Ahmed, PhD, Harold J. Bursztajn, MD,Beverly Jalil, Ahmad Newaz Khan, MD, and Reza Rahman,MD. Maintenance of recovery from severe psychotic depression following successful electroconvulsive therapy in an elderly patient with “natural support,” Journal of Clinical Geriatrics and Gerontology,July, 2014.

I know ECT is a very controversial treatment and has a very strong negative association from the past, but when applied judiciously in certain situations, it does work, and upon recovery, one does not have to be dependent on any biological and psychological intervention on an indefinite period, if the person has a strong sense of will power and active social and family support for monitoring any relapse cues as this case illustrates. The quality of life this person is engaging upon recovery will not have been possible if he would remained in indefinite life-long follow-up treatment as per medical advice

.Again this is a case by case consideration, and may not apply to all, but it should be entertained for many whose recovered quality of life may be, otherwise, compromised by indefinite involvement in “follow-up treatment.”

On the Recovery from Mental Illness

“You kind of articulated in a forceful and moving manner the importance of a variety of factors in the recovery process in an intellectually intact person involving varied natural support, ongoing counseling, and short-term (not indefinite) biological intervention primarily to restore vegetative functioning (e.g., normalizing sleep, agitation, appetite, etc) to restore some degree of energy and balance to optimize a persons’s capacity for adaptive thinking and recovery. Once the person is back on feet again, many can function on their own, given the impetus and belief, and need social support just like anybody else in society. Of course, it is a case by case situation. Some may need more involved special services , some may not need any at all, Unfortunately this capacity for inherent recovery and maintaining such recovery with “natural support” is often not recognized in the mental health service community.

Your case reminds me of a family member of mine, who became acutely depressed with psychotic features at around age 65 following retirement. When placed in a geriatric unit of a psychiatric hospital, he was functioning at the level of 3 or so on a hypothetical scale of 1-10, with 10 being the highest level. Following unsuccessful medication treatment, he did receive ECT, and over a period of time regained his “normal functioning.” Now he is functioning at an optimal level, driving, playing tennis, resuming a consultant career, etc. His wife collaborated with me and others in the write-up a case report that was published in Journal of Geriatric Science and Gerontology ( see http://www.e-jcgg.com/article/S2210-8335(14)00057-4/abstract for the article: Maintenance of recovery from severe psychotic depression following successful electroconvulsive therapy in an elderly patient with “natural support,” by Ahmed, Bursztajn, Jalil, Khan, and Rahman, Journal of Clinical Geriatrics and Gerontology,July, 2014.

Yes, people may need a variety of interventions and support systems when experiencing “unusual experiences” whereby their thinking, feeling, and behavior may become confusing to them and to others, causing “distress” to self and others, and presenting what many may believe “at risk” behavior status, but once their “unusual experience” has cleared through a combination of biological, psycho-social, and special natural support, they don’t need to be on indefinite medication or for that matter be involved in indefinite psychological treatment for life, as your case and my cousin’s published case highlight. My cousin was strongly advised to be on indefinite medication treatments for mood stabilization and supposed neurological condition ( which later appeared to be related to drug side effects), which he refused upon recovery, and he never was involved in any psychological therapy, probably reflecting South Asian cultural value. People like him even if they relapse and need to go back to receiving biological and psycho-social intervention, the quality of life he is maintaining for the past 5 years or so, he could not have maintained it or enjoyed this kind of living experience, if you were involved in continued biological treatment. Even involvement in psycho-social treatment could promote a sense of dependency and identification with “illness persona” that could have have impeded his recovery.

After all as human beings, we value our unique sense of independence and our sense of conscious awareness, and they provide the driving force that propel us to figure out in our own way what makes sense for us in the present time of our existence. Somehow, we all have to figure out a balance when “special intervention” is needed and when not. But when the health care industry operates like a business model, and driven by profit goal, it is a challenge for everybody how to keep a healthy balance. It us where consumer empowerment and advocacy becomes paramount.”

Brain, Mind, Soul

“Yes, many people believe that mind is a function of the brain, and the brain mirrors all mental activities; it is a matter of choice as to what perspective one wants to study to highlight an issue. In the same vein environment and social factors affect changes in behavior and the underlying brain functioning, as the evolutionary biologists will argue. Gene expressions can be modified by environmental factors and can be transmitted to future generations without altering gene codes, as some of the recent epigentic studies suggest. Then there is the religious and spiritual concept of Soul, which is larger than mind and continues to exist in some form of Spiritual Reality, either retaining individual entities as practiced in Judea-Christian-Muslim faiths or merging with the Eternal Supreme being, as in Hinduism and Buddhism. Literally, billions of religious people believe in either of this concept of Soul enduring the entropy of the body and mind.

From astronomy science perspective, everything came from One Point of Singularity, and everything we see and don’t see but infer them to exist are manifestation of the One, and implication is that in the dissolution of the body-mind, it is returned to One, Science also tells us that the Sun is moving around the Galaxy at the rate of approximately 118 or so miles per second to take 240 millions of years to go around. So every second no human beings knows what is in store for us. In some sense, in a symbolic expression, there is convergence of science and religion, that of Existential Uncertainty, which only God or Nature “knows” and return of the Soul in some symbolic way to Supreme Being or Natural Force.

The bottom line is that there is a duality of knowledge: Known and Knowable, the realm of scientific investigation, and the Unknown and Unknowable, the realm of faith based practice. For any consensual discussion, we may need to focus on Known and Knowable, but sometimes they get blended.

It is possible that Schizophrenia and associated psychosis, which is of interest of all of us in the ISPS group, in some form may reflect an underlying struggle in coping with Existential Uncertainty and associated Existential Anxiety triggered by perceived intense stress response, and the origin can be varied: experiential, documented, and or speculative.

But then again, any picture of any human being or a group of human beings will always be complicated to put into a simple reductionist formula, as the Reality is multi-dimensional.

And then there is always the excitement of finding different ways of looking at the same thing, as our knowledge is constantly changing and is fluid, and with it comes a respect for different perspectives that may be be “true” from one level, but not from another.

Comment on Thomas Insel’s Blog on P-hacking.

The problem of replicating efficacy based studies as well as its successful effectiveness study with unique individual cases is not only related to biological variability as he mentions, but also to immense psycho-social-experiential variability that human beings experience.

While group behaviors is somewhat easier to predict on a “gross aggregate level,” individual human behavior, in some ways may be difficult to predict and may be analogous to Heisenberg’s Principle of Uncertainty, whereby the position of the electron cannot be predicted as it changes with the measuring instrument used.

It is also possible that researchers may not pursue or report negative results, and just present data that seem to fit their intended hypothesis corresponding to prior set p value of 1 of 20 possible error finding.. If we believe that human reality experience is manifold and varied, and all of which have some reality basis, one can always design studies and come up with results that show the investigator’s perspective and bias. Just carry on various possible “experiments” to match one’s hypothesis, Not that it is being done regularly, it is just a thought that crossed my mind.

Bottom line is that any generalization from a research study will always be limited as well as its application will also be time limited. Changing social mores and values impact how one deals with “mental health issues” in a given society.

For a mental health clinician, the common theme remains to be the reduction of personal and social distress associated with specific “problems” individuals present. For mental health conditions, efficacy researched studies may provide some directions and food for thought for the practicing clinician working with a client to reduce “distress” but one cannot follow any researched protocol literally. One need to be eclectic, innovative, and creative in addressing any personal issues, drawing from varied knowledge base and practice experience, and evaluates one’s service in the context of some objective index of verifiable improvement.

In biological medicine, where the variability is much narrow, and the individual variability related to psycho-social-cultural as well as genetic variability may be less, one is more likely to get more effective results by following an efficacy based model of evidence. as it is often practiced in medicine. Even there are some unintended side effect issues or ineffective results with some clients, Many medication research shows high placebo effects, as some people positively respond by a power of suggestion of just taking “medication” that may not have any chemical healing properties.

It is very complicated, and I do not fully understand the issues that are highlighted , and I am sure many of us also don’t, as our knowledge, specifically in this area is evolving and it is very fluid.

But nevertheless we all try to make the best what makes sense to us, and thought to comment on this thread of conversation.”