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School of Medicine
Psychiatry Newsletter - Trouble in mind
Hopkins BrainWise Spring 2011
Trouble in mind
Date: March 30, 2011
New book turns an evolutionary eye on psychiatry
“Pundits periodically pitch spitballs at my profession,” psychiatrist Dean MacKinnon prefaces his new book, Trouble in Mind, referring to those who yowl that psychiatric drugs aren’t cures, that psychotherapy is “a scam,” and the like. If such critics “could only spend a month on the wards and see how treatment restores life to suffering patients…perhaps,” he says, “they would shed their ignorance.” But when critics call the present-day theory behind modern psychiatry “a rickety edifice…ungrounded in psychology and neurobiology,” it’s different. MacKinnon believes they have a point.
And so begins the concise text he wrote—200 pages if you skip the appendices—to set psychiatry in a more useful place for helping patients. It’s one that keeps psychiatry in touch with evolutionary biology, and one that sees the mind as a functional construct—a vulnerable one—that the brain cooked up to increase survival. That psychiatry continues to help people isn’t at question. But with a fresh perspective—he calls it an “unorthodox view of mental life and mental illness”—it could do much more.
We asked MacKinnon to discuss his new book. The associate professor of psychiatry and behavioral sciences has been in practice almost two decades.
What prompted you to write this?
A. Our past Psychiatry chair, Paul McHugh, describes what we do as “medicine without a William Harvey.” I’ve taken that as a kind of challenge. Harvey described cardiac circulation well, yet he had no knowledge of how capillaries connect arteries to veins. He experimented, then ultimately put his theory out there without being able to connect all the pieces. Today we lack a Harvey because Psychiatry hesitates to build a theory that considers any mechanisms we can’t yet demonstrate scientifically. But we may have to suspend scientific scruples a little because we and our patients need some explanation for their symptoms, some rational idea why they do or don’t respond to treatment, even if explanations include educated guesses without every detail filled in.
You’ve created a hierarchy of the brain’s workings based on what you know about how it operates as an organ. And as a psychiatrist, you explain how upsets at each level can distinctly contribute to mental illnesses. Is that right?
Something like that. I’ve proposed a model based on the brain function known as mind. And I’ve arranged the model to help understand what a mind needs to do in order to let a person survive. We look at mind first from its most basic functioning: the input of sensory information—like light or touch or having stretched gastric receptors—that, in turn, calls up appetites and arouses the mind. Then appetites and arousal prompt people to act.
And specific things can go awry at that elementary level?
Yes. You can view hallucinations or catatonia, for example, as malfunctions in handling input (perception) or output (motor activity), respectively. Think of delirium as a confused state fueled by abnormal arousal.
You call the next level the integrative mind…
That’s what goes on inside the mind’s black box. It’s more mysterious biologically. It involves associations within the mind that attach meaning to our perceptions. It underlies things like memory, habits, motives.
Disorders exist at that level too? Can you say a person has “integrative problems?”
I describe them to patients all the time: You’ve been depressed quite a while, I’ll say, and in that state, your mind has become trained (gives meaning) to see only the negative, to expect things not to work out in a rewarding way. Then, you no longer get stimulated, say, by pistachio ice cream, a cue that in the past would have been arousing. The effect is that your mind stops trying, extinguishing what you’d otherwise feel as desire.
Then there’s the synthetic mind, which builds on earlier constructs?
The synthetic is more exclusively a human area. It’s the ability to construct a world for ourselves in the mind, given only limited data. We use our biases, our temperament, for example, to tilt us one way or another. Our beliefs become a proxy for having knowledge that we can’t get firsthand. And beliefs let us form relationships with other people that help us survive.
As in the other minds, flaws tie to specific illness. When, for example, there’s a disconnect between our internal state of arousal and our actual perceptions, that can warp our beliefs and our “world” becomes delusional.
How can the model help patients?
It promotes a useful discussion about their illness and what you plan to do about it. Without a theory, you can only say, Well, you have a chemical imbalance and we haven’t yet found which chemicals or how to repair it.
Patients must master their own behavior, take responsibility for it if they’re to get anywhere. So you have to explain what motivates behavior, why they behave the way they do. Sometimes you watch the scales fall from their eyes.
I see a lot of patients with treatment-resistant mood disorders. Their doctors try every drug; they haven’t gotten better. When they come to me, it’s usually not that their “biochemical” depression hasn’t been addressed—they might no longer have the major depression syndrome. But they’ve learned to become helpless. They stop functioning. Then it takes extra effort to get them back to a good place.
Your model justifies integrating biochemical with other therapy.
Yes. If you only see your doctor once a month for 15 minutes to talk about symptoms and medication side effects, when can you learn what else you need to get better?