The Molecular Hydraulics of Mental Disorder

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Upon obtaining my degree in biochemistry I was convinced that everything in life could be distilled down to simple equations and formulas… e.g. Chateau Latour ’97 = seedless grapes + cellulose +ribose + purple gene protein VvmybA1, +H20 +12% ch3ch20h (alcohol) > great red wine. This simplicity is called reductionism.

By analogy a classic mental illness like schizophrenia = tyrosine>dopa>dopamine and a very sensitive receptor at the post synapse along the meslolimbic pathway > delusions of aliens inserting thoughts into the mind.

Well of course this a hyperbolic analogy, reductio ad absurdum, but hearing some in the field tell patients that your depression is a “chemical imbalance” and adjust the internal chemistry accordingly is not by itself good medical care.

The philosophy, particularly say for bipolar illness, seems at times to be hydraulic: if you are low we can make you high, (Prozac), if high we can bring you down (Haldol), if up and down we can level you out (Lamictal). This is rarely perfect so we can tweak it  (Abilify)…psychotropic mixology.

For schizophrenia there is no doubt that faulty dopamine transmission and communication between limbic system and frontal lobes are substrates. As with all psychiatry none of this is certain despite intriguing MRI and PET studies that reveal something is awry in the frontal lobes where thought and executive function reside.

The newer atypical antipsychotics like Zyprexa or Risperdal do reduce much suffering and with less nasty Parkinsonian side effects, thus rendering the person more amenable to social and vocational rehabilitation. Back in the day there were attempts to reach schizophrenics and understand the meaning of their symptoms through insight psychotherapy.

I was intrigued by a text written by the late psychiatrist Sylvano Arieti titled interpretation of Schizophrenia. Some contemporary psychiatry trainees have no idea it exists. It was an attempt to explore the meaning of the thought process and content beyond reductionism. I am not of the RD Laing school that believes the world is nuts and schizophrenics retreat from it into a safe private reality, but exploring that world provides a lot of data on human nature and universal existential issues.

I learned from talking to so-called residual schizophrenics, which is all of them after the meds have kicked in, that the core of this illness is meaninglessness and feeling of insignificance.

A recent case example is a young man Bill age 34 who suffered from paranoid thinking in the form of ideas of reference. This, as is common, involved personal messages for him from the TV set specifically the news… they were talking about him. The dynamic is simple: I must be an important, interesting and significant person to be on the news.

Feelings of worthlessness are at the schizophrenic core. In their minds the cause of that is others who “reject me” and this starts the paranoid cycle… “I am depressed and useless maybe suicidal; no it’s not me it’s out there (projection) and someone is inserting or withdrawing ideas from my mind. They are even on the TV.”

Bill did well on his meds Zyprexa (though it did cause weight gain) but residual paranoia remained. Certainly I could not attempt to reach him unmedicated. As a therapist I was mindful that I could be incorporated into his delusions as once happened with a woman who accused me of selling her file to the CBC. So I took time to build his trust and make use of his sense of humour to build a therapeutic alliance…..

“Good Morning Bill, how’s the crazy business today?” or “How’s your schizophrenia coming along?”

I employed the techniques of cognitive restructuring derived from psychologist Albert Ellis which boiled down to.. “my thinking is more accurate than yours pertaining to your relationship with reality. Trust me after all we both can’t be right. Either the TV is messaging you or it isn’t, not both.” With  the TV on he would point out subtle references.

“Well Bill frankly I don’t see it.”

“It’s encrypted Doc’.”

“Uh huh sure, That’s possible but not probable. maybe your schizo thinking is getting in the way.”

“Maybe you are helping them Doc.”

“Breach of confidentially Bill, you smoking that green leaf again?”

This kind of exchange went on biweekly for many months and though at times he peeked out of his paranoid cloud it never totally retreated. The risk with this approach is hitting the core too hard and the underlying depression can surface with suicidal risk. However depression can be worked through by addressing low self-esteem but paranoia is intractable and isolating.

Last I heard however is that he acquired a 60″ HDTV.

 

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