biology vs psychology: false dichotomy?

I was speaking with a very intelligent and insightful patient today who mentioned that he'd felt his problems (depression, some obsessional traits, a mild eating disorder) were all 'psychological' until he found a drug that significantly improved them. From that point on he was convinced they were 'biological,' and embarked upon a quest for the Magic Pill that would solve all his neuroses at a single swallow.

I see references to this sort of split all the time, and not just from patients but also from highly educated physicians and scientists. Somehow they consider that our behavior* arises from two distinct sources: one composed of neurons, synapses, and neurotransmitters, and another composed of experiences, drives, and willpower.

If you buy the biological theory of behavior at all, then it makes little sense to imagine a dividing line between 'biological' and 'non-biological' causes of behavior. Experience alters neurochemistry just as surely as medications do.

Here's a nice (but somewhat technical) piece of work discussing some of the cellular-level changes that have been observed to be triggered by real-world experience (Takahashi, Svoboda and Malinow).

Evidence abounds for the utility of 'talk therapy' in psychiatry. In order to separate the 'biological' from the 'psychological,' one would have to believe that there exists an entirely separate underpinning of human behavior that operates on some ethereal plane, unrelated to the biomechanical world of synapses and neurotransmitters.

If you're going to accept that neurobiology underlies behavior, then there is no clear point at all where you can divide the biological from the psychological. If you accept that experience exerts its effects through alteration of our neuronal activity, and you accept that hearing your therapist is an experience, then there is no room for some nebulous 'non-biological' effect. Your therapist's words tickle your ear neurons, which tickle your brain neurons, which make subtle changes - sticking themselves to some of their neighbor cells, unsticking themselves from other neighbors, changing the rate at which they spit neurotransmitters at each other - and voila! You change your behavior.

That the line between biological and psychological is fuzzy to the point of nonexistence is indeed starting to permeate the general consciousness, at least to a degree. This usually arises in discussions of ethics, where the whole edifice of crime-and-punishment rests on an assumption of free will. This assumption is being radically challenged by evidence that our behavior is heavily determined by factors not under our direct control (genetics and medication in particular).

This opens up another can of worms, because we frequently associate 'biological' with 'beyond our control' and 'psychological' with 'within our control.'  Hence my patient (and many like him) and his Magic Pill search.

But I think the educated world at large is not yet ready to join Steven Pinker in declaring us will-less playthings of our genes and environment. Fine for now, but I'm curious to see what we'll make of coming scientific advances that will no doubt push us even closer to the will-free wall.

*I'm using "behavior" intentionally to encompass all of the workings of the human brain that are manifest to others. I'm doing this very deliberately because the question of whether mind is biological at all is a very sticky wicket and not something I can afford to get into in this limited space.

free will and eating disorders

We've a number of eating-disordered patients on the unit at the moment.  Eating disorders have never been a particular interest of mine; yet as I work more closely with eating-disordered patients, I've come to realize their problems raise a number of interesting philosophical questions.

We've all had the experience of being of two minds.  We want something, yet we do not want it. One experiences this on a regular basis, yet it rarely disturbs the view of oneself as a single, integrated ego, a unified mind.  However, the problem is very severe in the eating-disordered.

How to want to be well but also not want to eat?  How to want one's life back, to know that the eating disorder has wrecked it, to understand that one flirts with death, yet be so petrified of food?  Even my patient Ms. G., weighing just 35 kilos and desperate to regain a normal life, was yet utterly unable to prevent herself from binging, vomiting, and binging again.  "Obviously I have free will," she wailed unprompted, "but somehow I can't stop doing it."

Our medical student was surprised at her intelligence, unable to credit her self-destructive behavior because "but she's so smart!"  But 'smart' has nothing at all to do with it; in fact, quite the opposite: anorexics may have higher than average IQs.

(This may be tied to the well-documented association between anorexia and the need for control.  Besides body weight, academic achievement is another area where due diligence generally yields the desired results, and thus appeals to the controlling anorexic personality.  In fact, Dura et al. note that 'perfectionistic striving' actually yields better academic results for anorexics than would be predicted by their IQs alone.)

 

This makes a degree of sense when one considers that a certain level of complexity is required in order to deny one's own basic drives so severely.  At the most straightforward level of functioning, one merely obeys one's basic drives - hunger, thirst, fear, desire - pursuing the most immediate means of gratification.  At a somewhat more sophisticated level, one may delay instant gratification for a bigger payoff later on, forgoing one candy now for two candies later.  Ultimately, one may come to value successively loftier intangibles above the basics: staying up late to finish that big paper; starving for one's art; giving one's life for one's country.

Well then, how to be cognitively impaired, like our patient Ms. S., and yet have an eating disorder?  Ms. S. had been impaired since birth, and she behaved for all the world like a sweet and coquettish child, grinning impishly at the team, asking for hugs, requesting praise for her accomplishments.

At first I could not believe someone functioning at this simple level was sophisticated enough to have an eating disorder.  I thought she must have an organic illness, a food sensitivity or irritable bowel.  And yet as we weaned her down to the most elemental and gastroenterically benign food supplements it became clear that the problem was not in her bowel, but in her head.  She played all of the typical eating-disorder games: saving food, dumping food, vomiting food, mixing and freezing and thawing and refusing it, drinking gallons of black coffee and diet soda, and on and on and on.  

Ultimately it became clear that at least one of the reasons for Ms. S.' eating patterns had, unsurprisingly, to do with control - a common theme among eating disordered patients.  In Ms. S'. case, though, it was more to do with control over her family than over her body.  Still living with her mother in her forties, Ms. S. yearned to go out and build her own life.  She found that refusing to eat allowed her to exert a measure of control over her large, loving, yet stifling family, all of whom rallied round her and raised a ruckus of attention over her malnourished status.  Which was, evidently, far preferable for Ms. S. than sitting quietly on the couch watching TV all day and being ignored by those with lives of their own.

I hadn't given Ms. S. nearly enough credit for the complex, multilayered psyche she evidently possessed.  Humans are deep creatures, even the simplest of us.  

Not too much can go wrong with a simple machine like an abacus or a bacterium.  But as you add more bits and parts and cogs and circuits and cells and networks, the number of ways things can go wrong explodes.  Ultimately you end up with personal computers and human beings, both of which are endlessly surprising and infuriating in the sheer number of things that can go wrong with them.  Hence computer wizards, and psychiatrists.

chemical love

One of my more interesting recent patients had a problem straight out of a daytime talk show. This was a young gay man in love with his heterosexual roommate. The two of them had a very close relationship, eating dinner together, going to movies as a couple, and generally engaging in very couple-like domestic activities. They also had a surprisingly open relationship. The gay man had confessed his ardor to the roommate, and the roommate, while he did not return the sexual feelings, was mind-bogglingly relaxed about the whole issue and the two of them remained as close as before.



Matters took a turn for the worse when the roommate acquired a girlfriend. Naturally the gay man could not stand the girlfriend and resorted to drinking alone in his room or going for long drives whenever she was around. Ultimately he became so depressed and consumed by the situation that he was unable to work, could not sleep, lost interest in his hobbies, and finally sought psychiatric help.


At first nobody on the treatment team could understand the situation, and in particular the behavior of the roommate. We speculated that perhaps he was a closeted homosexual who unconsciously returned the feelings, or else that he simply couldn't bring himself to give up the incredibly cheap rent offered by his lovesick roommate (who owned the apartment).


The answer turned out to be a bit more complicated. I sat down with both men for a frank discussion of the situation, and found that, at least to casual observation, their relationship appeared as close and open as had been described to me by the gay patient. Together we dissected the timeline of their relationship. It turned out they had been ordinary good friends until they began to use the drug Ecstasy (MDMA). Over the course of a summer they had used the drug weekly together - rarely with anyone else - in the process cementing a bond that ultimately became more like a love relationship than anything else.


It is likely impossible to convey the emotional power of Ecstasy to anyone who has not tried the drug. Roughly, it works by reversing the direction of the reuptake transporter that vacuums leftover serotonin out of the synaptic cleft. This dumps enormous amounts of serotonin into the synaptic cleft - far more than would ever normally be present there at one time. Just as chocolate cake overstimulates the taste receptors that evolved to detect the more mild and nuanced sweetness of fruit, Ecstasy overstimulates circuits designed to underlie the natural pleasures of romantic attachment and sensory experience.


In a stark demonstration that love really is just chemistry, Ecstasy can make you feel a gush of deep affection for just about anyone sharing the experience with you. It's Cupid's Arrow in chemical form.


In this particular case, these two men overstimulated their 'love circuits' together over and over again for an entire summer. It's no wonder the gay one fell in love with his friend. As for the straight roommate, evidently Ecstasy can't alter sexuality (unsuprising, as anyone who's tried it will tell you Ecstasy has little to do with sexual feelings, and in fact often inhibits them). But it did seem to have triggered many of the other hallmarks of romantic love. The man gazed affectionately at his roommate, expressed all manner of deep and abiding emotion for him, was wracked with guilt for the suffering he'd caused. Everything was there but the sexual attraction.


The chemical basis for emotion is nothing new, and at this point carries little shock value. Yet it is still difficult to believe how easily we can manipulate our deepest emotions with a little diddle to the neuropharmacological machinery.


What was the cure for this young man? Fighting fire with fire, I prescribed him Prozac. Prozac works by paralyzing the same reuptake transporter that is reversed by Ecstasy. Instead of being vacuumed back out of the synaptic cleft when their job is done, the serotonin molecules loiter around in the cleft. The simple way to think about this is that more serotonin in the cleft equals more happiness, duh - though in fact the biological effects of SSRIs such as Prozac are somewhat more complicated than that (see Nutt et al for a useful summary).


As one might expect, then, Prozac blocks the effects of Ecstasy. With Prozac in your system paralyzing your reuptake transporters, a nice fat pill of E has no more effect than a sugar tab. That was one little-known side effect I thought might be useful in this particular patient's case.


A more well-documented side effect of SSRIs is inhibition of sexual function, including the ability to orgasm (see Rosen et al. for review). In addition to this, there are some anecdotal reports that SSRIs such as Prozac have adverse effects on romantic love. This is a much mushier and less well-documented realm. I found nothing about it on PubMed, though I did find a bit of schlock in Psychology Today that discusses the phenomenon. If this latter bit did turn out to be true, I would wonder whether the effect were secondary to inhibition of sexual desire or whether it involved a distinct group of neural circuits.





Based on anecdotal reports from people who have used them, it sounds as if SSRIs may in fact dull the capacity for deep emotion. You don't feel sad anymore, you even feel kind of happy, but the happiness is a sort of pleasant zoning out rather than a meaningful joy. Indeed, by some reports the entire spectrum of emotion is flattened out (see, for example, comments posted by readers on this WebMD blog).


Much has been made of the possibility that we are depriving ourselves of essential human experiences by medicating away our emotions (see, for example, this review of Eric Wilson's book Against Happiness). Of course, many others more articulate than I have also argued the opposite side of the story (see this other review of Peter Kramer's Against Depression).


As is often true, I find myself taking a position somewhere in the middle. I don't want my patient to be zoned out forever, but I can't help but think that he's already had more than enough character-building for a while. A little Prozac in this case is probably a good thing.

it's all in your head

Psychiatrists - and doctors generally - see two kinds of symptoms.  There are the 'classic' symptoms that have meaning because they signify something we can treat, and the 'off-road' symptoms that don't seem related to any disease process we understand.

In psychiatry, the former are typified by people who are having frank hallucinations and delusions.  I know how to recognize them  - they look ill, odd, off - and how to treat them - antipsychotics, patience, consideration.

Then there are people who report experiences that are just... not what one normally talks about.  I do brief screenings for psychotic symptoms on all of the patients I see, many of whom may have, e.g.,  mood or anxiety issues, but certainly no evidence of a psychotic disorder.  They may be sad or nervous or emotionally disordered, but their reality testing is absolutely intact.  When asked if they've ever "seen things others don't see," or heard things others don't hear, they typically hesitate.  Then they preface with, "Well, I don't think it's relevant..." or "I'm not crazy, but..." and I know what I'm about to hear.

There was the twenty-two year old girl who said "My sister and I see ghosts.  It's accepted in my family, it's not a problem."  There was the sixty-four-year old Vietnam Vet who heard music when he saw mountains.  It was real music, heard aloud, and specific for each peak. 

Musical hallucinations seem to be an entirely different kettle of fish from the angry, insulting voices that are typically heard by psychotic patients.  (Oliver Sacks has written eloquently about music and the brain.)  

In my short time as a psychiatrist I've already heard many variations on these themes.  They seem a class apart from the psychotic symptoms that are familiar to doctors and treatable.

In fact, this sort of phenomenon is seen throughout medicine.  For doctors, there are two types of complaint: those that signify a known pathological process, and those that don't have a cause we understand.  Most doctors put the second type of complaint in the "all-in-your-head" category.  They may be more or less sympathetic to patients with these complaints (often less, and sympathy tends to correlate inversely with the doctor's workload), but they don't know the cause of the symptoms and there doesn't seem to be an underlying disease they can treat, so they're not really interested.

This gives rise to the common complaint among patients that "the doctor doesn't listen to me."  It's not that he isn't listening, it's that he's categorizing your problems as "meaningful" and "meaningless."  If you tell your doctor your skin is turning yellow, he'll be all ears and will likely order a battery of tests.  If you tell him you have a pain in your left elbow that only happens after you eat,  he'll say "uh-huh" and try to move on quickly.  That kind of pain isn't a symptom of any disease he knows of, so he'll file it under "random aches and pains" and turn his attention to more pressing matters.

Of course, patients rarely know the difference between the significant symptoms and the insignificant ones (that's what medical school is for), so they can get understandably upset at getting yes-deared by the doc.

In psychiatry, these sorts of off-road symptoms fall even further by the wayside than do the general medical aches and pains, because they tend not to bother people.  Few people come to psychiatrists complaining of seeing ghosts or hearing music; rather, they accept these things as part of their lives, and the experiences only come to light if they happen to come to a psychiatrist for another reason.

Symptoms can sometimes move from the all-in-your-head category to the now-I'm-listening category when we come up with an explanation or a treatment for them.  A lot of people with the fatigue and joint pains characteristic of chronic Lyme disease got the brush-off from doctors before the cause of the disease (a spirochaete transmitted by tick bites) and the appropriate treatment (antibiotics) were identified.

I doubt we will ever find a 'cure' for the off-road symptoms seen in psychiatry, for the simple reason that most people who have them don't particularly want to be cured.  I would, however, be extremely curious to see whether we might find an explanation.  Are these really psychiatric phenomena, or are they something else?

demon rum

I'm on an outpatient neurology month, mostly a pretty calm scene compared to the inpatient psychiatric wards - until Ms Q arrives on the scene.  Forty-five minutes late for her appointment, she stumbles in on the arm of the fellow, mascara streaking down her cheeks.  "She's intoxicated," the fellow murmurs gently in his refined hint-of-British, hint-of-Indian accent as he steers her to a chair.  

"I hate it, I hate it," she sobs incoherently.  An overpowering odor of alcohol wafts about her.  She has been swigging from a bottle in the car all the way from home, over an hour away.  I shudder at the thought of the unsuspecting commuters who shared her road.

I am assigned to calm her down; my few months' worth of psychiatric education have won me this one.  I murmur soothingly, knowing there is little useful diagnostic information to be obtained from her right now.  She is a blond beach girl, far from home; and it shows in her long yellow hair, bright pink lids and lips, pink toenails in metal-ringed sandals.  "I hate you," she rages.  "I know you're trying to be empathetic, but you don't understand.  Look at you - you're young, you're pretty, you have cute shoes..." She dissolves into a bathtub of drunken tears.  Cute shoes... emblematic of the good life.  I sigh and pat her on the back.  Miss Sunshine, in need of some perspective at the least.

But she is right, of course.  I don't know what it's like to be an alcoholic.  I have worked in recovery programs, and noticed that the addiction specialists with drug histories often seemed more effective than those without.  Regardless of training and other forms of institutionalized expertise, in the addict's own head it is important that his therapist "understand where he's coming from."  All that training is for naught if you can't even get the addict to listen to you.  For people with their own drug histories, that door is already wide open.

One wouldn't expect one's cardiologist to have his own history of heart attacks; nor ask one's internist if he's tried the antibiotic or diuretic he suggests for you.  Yet psychiatry is somehow different, removed from the clearly delineated ethics and protocols that apply in other areas of medicine.  

insight into madness

Mr W, a first-break schizophrenic in his twenties, had looked just terrible on initial presentation.  Flat, near-mute, meeting all efforts to initiate discussion with "No comment," or just a hostile wall of blankness.  Gradually the medications began to work their magic and he became more able to relate to others; but he continued to refuse to discuss his symptoms.  He kept it all inside until he'd been on the inpatient unit for over a month.  Then one day, very carefully, judiciously, circumspectly, he allowed: "Well,  I was hearing people talk and relating it all back to me."

The team psychologist ventured softly, Did you ever hear the TV talking to you?

Mr W burst out in surprised laughter, and it all came tumbling out.  He'd kept it to himself for at least a year.  Said it felt like being underwater, where he would be convinced the people on TV were talking about him; then by dint of effort he would pull himself briefly above the waterline - no that's not true that's crazy -  and then be swallowed once again.

He'd gone traveling through Asia for six months, thinking he could leave behind the stress and deconditioning that, he reasoned, must have been the cause of this - this oddness.  But he found that people on the streets, speaking in languages he did not know, were talking about him.  He was utterly certain of this, though he could not understand their speech.  He had several brief relationships with other travelers, women; but they all ended because, well, "Things got weird." 

He recalled talking with the interviewer when he'd first come in, when he would only say "No comment."  He remembered her eyes looked enormous and he was afraid, certain that if he spoke he would come to some vague and terrible harm.

Delusions - fixed false beliefs, characteristic of psychotic states - call up a whole slew of questions related to knowledge.  We know that we know; but how do we know?  (For an interesting discussion of this question, check out Robert Burton's website and his recent book.)

Mr W was madly curious, he wanted to know everything - and what's a neurotransmitter? and are there other ones besides dopamine? and what part of the brain? and how does it all work?  

All good questions, and ones for which the answers are far from clear.  He was fascinated, scared, but also relieved to know this had a name, that others had suffered from it, that he was not alone in this bizarreness.

It is an incredible treat to speak with schizophrenic patients who have such clear insight into their disease.  Many of the patients we see are old and broken from long years in and out of hospitals and many trials of different drugs, both prescribed and recreational.  Even at the best of times, when they are not frankly paranoid or delusional or hallucinating, they typically cannot or will not describe their experience in any kind of meaningful way.   I was fascinated by Mr W, I could have sat and talked with him for hours about his experiences.  I had a similar feeling when I read Elyn Saks' excellent book, The Center Cannot Hold.  It offers a rare and precious chance to hear an eloquent and clear-minded individual recall the alternate reality of psychosis.

boundary transgressions

I found out for myself, again, the hard way, why 'professional boundaries' are so important.  Cardinal sin - I hugged a patient.  Should have thought twice, then twice again.  He was a thin wreck of a heroin junkie with wise sad gentle eyes behind scholarly horn-rims, sunken cheeks fuzzed with gray stubble, yellow horse-teeth in an occasional bitter laugh.

Strange how some patients leave me utterly cold, without a fig's worth of worry for whether they end up in the gutter or not.  Others take odd hold of me.  I remembered this man from a previous admission, after he'd driven his car into a tree - for the third time.  What was going on behind those sad gentle eyes that could make anyone wish to die so violently?  He spoke from between clenched yellow teeth, a mountain man trapped in a prison made of poppy stems.  Somehow he struck me.  

He was oddly, unexpectedly open in the interview.  He described unbidden his fear, loneliness, abandonment - until his eyes began to well and I quickly reassured him that he needn't speak of anything that would upset him so.  He drew back, but later returned to trying to explain. Finally he offered, "You ever just need a hug?"  He was staring frankly, a challenge perhaps?

Of course, I think that's pretty normal.

He described standing in the same room with his mother and brother and how desperately he'd wanted a hug, but had been completely unable to ask.  

Why not?

The expected cant about manliness, etc.  My heart rushed out to him.

You want a hug?

"Yeah, I do want a hug."  Testing me?  Wanting to see if I would be as good as my word?  Or, instead, if I would have the strength to resist?  I wasn't sure which option was the failing one.

I'll give you a hug.  No turning back now.  But you have to ask for it.  A psychiatrist's trick, or a weak attempt to give myself - or him - an out?  Regardless, he met my eyes.

"Could I have a hug?"

I hugged him, in my office, with the door closed, this man I'd just met; a long hard hug, rubbing his back as I would that of a sister or dear friend who was sobbing on my shoulder.  He smelled of cigarettes and pine bark.

Afterward I asked something inane, like How was that? or Was that helpful?

The former, I think.  He said he felt unsettled, almost nauseated.  I asked if he needed to throw up; he said no.  He said he hadn't had a hug in ten years.  Then he amended it: "Well, a hug from one of your buddies, that's something different.  But a nurturing hug..." He trailed off.  Then, "I haven't touched a woman in ten years."

Uh-oh.  Sirens, alarm bells.  How could I think such an act could stand independently of gender?  Fooling myself utterly.  But not innocently either - would I have done that for a patient I hadn't felt so drawn to?  Honestly, probably not.  Or, just - not.  Then how far could I fool myself to pretend I thought he would take it as such?

Let's get back to the interview.  I sought escape in a return to officialdom - pathetic and weak, as I'd abandoned that bulwark voluntarily already, showing it to be nothing but a sheet of tissue.  But he cooperated, bless him, returning also to the thin fiction of protocol.  

And later, of course, he avoided me entirely while others laughed and waved; as if we'd shared an intimacy far beyond what we had in deed.  That was when I realized the magnitude of my error.

Later I crafted fictions to forgive myself.  I wanted him to see that he could ask a small favor and have it granted.  I wanted to show him the possibilities that remained for human touch.  He needed it.  But all those were rationalizations.  True in ways perhaps, but at bottom I wanted to do it, wanted to pull close this scrawny middle-aged heroin junkie, this wasted scrap of human potential and make him feel warmed, supported, loved.  Why him and not others, I don't know.  Probably just because he had once been handsome, and because he spoke with such measured dignity and cocked his head so attentively to one's words.  Difficult to explain, of course.  Of course.