The Present Situation
The problem with our present understanding of mental illness is our lack of understanding. After 100 years of research, the major mental illnesses remain draped in mystery. Scientists have yet to discover the cause (etiology) of any psychiatric disease, whether it be depression, schizophrenia, obsessive-compulsive disorder or attention deficit disorder. The fundamental nature of mental disease is poorly understood. For example, it isn't known if schizophrenia is one disease or many different diseases with similar symptoms. Depression has the same problem. There are many types and subtypes of depression along with various mixtures of depression with other diseases. So the question, 'what is depression?' is essentially unanswerable.
Since the causes of mental illnesses are unknown, there are no known methods for their prevention. The notion of preventing depression or schizophrenia remains a very distant dream. In the case of depression, our inability to prevent is underscored by the dramatic rise in the incidence of depression this century. The incidence of depression continues to rise every decade.
The possibility of curing a mental illness is also a distant dream, a very long way from reality. In order to cure an illness, there has to be some understanding of the cause. In the case of mental illnesses, the causes are unknown.
There are no blood tests, urine tests, X-ray methods, biopsies or any other physical methods for the objective diagnosis of any mental illness. There are no blood tests or physical measurements which can distinguish a depressed person from a schizophrenic patient or from a healthy person. The complete lack of objective physical methods to diagnose mental illnesses is a reflection of the lack of scientific understanding of these diseases. Instead of objective physical tests, psychiatrists rely on non-specific symptoms (e.g. fatigue, hopelessness, and sadness), non-specific signs (e.g. weight change, sleep problems, slowed movement) and patient self-report for diagnosing a mental illness.
Barriers to Progress
The poor progress in the scientific understanding of mental illness stands in sharp contrast to the remarkable advances in the understanding of the causes and pathophysiology of physical diseases. The lack of insight into mental disease is often attributed to the enormous complexity and inaccessibility of the human brain. On the other hand, over 100 years of unsuccessful research on the etiology and pathophysiology of mental illness could be telling us there is something wrong with our research.
What could be wrong with the research? Of course there are many possibilities. The thesis of this book is that there are two major flaws with mainstream psychiatric research. One major flaw is the division of diseases into mental and physical. The physical illness model is the only medical research model that has yielded results this century. The mental model has been a flop and for good reason. The immunological and pharmacological discoveries to be discussed in this book have revealed that mental illnesses are actually physical diseases.
The common assumption that the brain is the prime place to look for answers to mental disease is the other fundamental flaw. Certainly brain research is important and has provided vital information for the drug treatment of psychiatric diseases. But after 45 years of brain-drug research, we are no closer to understanding the nature or causes of mental illness. The revolutionary immunological discoveries made during the last decade suggest that the immune system is the place to look for answers to psychiatric diseases. And why not, since the immune system is a key interface between the environment and the body, including the brain. It plays a crucial role in every major physical disease, including atherosclerosis, cancer, diabetes, infection, rheumatoid diseases, osteoporosis and many others. Indeed, it would be highly unusual if the immune system didn't have a crucial in psychiatric diseases also.
Physical vs. Mental Disease
For much of this century human diseases have been classified as either physical or mental. Diseases classified as physical are quite familiar to us and include the common cold, influenza, infections of all types, cancer, diabetes and heart disease. They also include a multitude of less familiar pathologies of the heart, arteries, lung, liver, kidney, skin, pancreas, stomach, intestines, bone, joints, blood, nerves, brain, spleen, lymph, immune system, endocrine system and various other sites. Physical diseases are presumed to have physical causes which can range from infection, trauma and biochemical abnormalities to inherited genetic diseases.
Illnesses such as schizophrenia, depression, manic-depressive disorder (bipolar disease), anxiety disorders, conduct and character disorders and phobias represent the bulk of the mental illnesses. Mental diseases are presumed to have mental causes, just as physical diseases are assumed to have physical causes. Pathological thoughts and fantasies, emotional conflicts, repressed anger, psychological and emotional trauma, psychological stress and emotional depravation are thought to be the keys to finding the causes, cures and preventive methods for mental disorders. Consequently, for many years severe, chronic illnesses like schizophrenia, major depression, anxiety and manic-depressive disorder were presumed to be caused by various combinations of psychological, emotional and mental stressors but not by any physical causes. Indeed, schizophrenia, one of the most debilitating diseases known to man, was widely accepted, prior to 1950, to be caused by bad mothering, 'malevolent' mothers, or mothers who consistently communicated 'double-bind' messages to their children.
Due to the limited biomedical knowledge before 1950, the bifurcation of diseases into mental and physical was a rational, reasonable concept during the first half of this century. In 1952, with the monumental discovery of the beneficial effects of the antipsychotic drug chlorpromazine on schizophrenia, serious problems developed in continuing to classify diseases as either mental or physical. Before the discovery of chlorpromazine (trade name Thorazine), there were no effective drug therapies for schizophrenia or any other psychiatric disease. Furthermore, psychotherapy didn't work on schizophrenia then and it still doesn't today. Hence, a great dilemma surfaced, namely, that the mental disease schizophrenia was responding very favorably to a physical treatment (i.e. chlorpromazine), whereas patients with schizophrenia rarely if ever benefited from mental therapies (i.e. psychotherapy). This, of course, provoked an obvious question: is schizophrenia really a 'mental' disorder or is it in fact a physical disease? Forty years ago the answer was unclear, but today there is a mountain of evidence demonstrating that schizophrenia is a physical disease.
The discovery of the anti-schizophrenic effects of chlorpromazine in 1952 was a watershed event in the history of psychiatry and mental illness. Chlorpromazine triggered a vast amount of biological and pharmaceutical research on the physical nature of mental illness. This research has resulted in a massive and continually growing body of biomedical evidence demonstrating that serious psychiatric illnesses are basically physical diseases.
Another result of the drug research has been a plethora of effective medications to treat (but not cure) serious diseases like depression, manic-depressive disorder, anxiety, schizophrenia and obsessive-compulsive disorder. Most of the psychoactive medications affect neurotransmitter systems in the brain, which has led to the widely accepted notion that neurotransmitter dysfunctions are the key pathologies underlying mental illnesses. Some of the neurotransmitters affected by these medicines are serotonin, norepinephrine, acetylcholine, dopamine and gamma-amino-butyric acid (GABA).
Nevertheless, here we are in 1997, forty-five years after the discovery of chlorpromazine and the medical world is still burdened with the antiquated system of classifying diseases as either mental or physical. The antiquated system has generated a great deal of conceptual confusion along with a number of fundamental barriers to progress in solving the baffling nature of psychiatric diseases. One consequence of the mental classification of psychiatric disease is illustrated by the fact that after almost 100 years of research on mental illnesses, there is literally no understanding of the cause or basic pathophysiology of any 'mental' disease. Schizophrenia, for example, during the 1920's, 30's and 40's was thought to be caused by bad mothering. We now know that those ideas were incorrect. Today, after much intensive research on one of the most chronic and debilitating diseases known to man, we are left without a clue as to the cause or fundamental pathophysiology of schizophrenia. Moderately successful drug treatments (i.e. chlorpromazine and other drugs) do exist for schizophrenia, but the possibility of finding methods to prevent or cure schizophrenia remains a very distant prospect.
The situation for depression is similar. There are many effective drug treatments for depressive disorders but the cause or causes of depressive disorders are unsolved riddles. There are no known cures or preventive methods for depression and the pathophysiology of depression is poorly understood. The same sad state of affairs exists for obsessive-compulsive disorders, anxiety and manic-depressive disorder.
It is true that neurotransmitter abnormalities are pathologies found with depression and schizophrenia. Some would say the neurotransmitter dysfunctions are the cause of depression and schizophrenia. However the real question of cause remains, that is, what causes the neurotransmitter dysfunctions? So far, none of the drug or neurotransmitter research has discovered what causes the neurotransmitter dysfunctions.
Author: Ronald S. Smith