Labelling differences between people as neurodevelopmental

I want to take further what I was saying about ADHD in a recent post. Over recent years, ADHD has been classified as a neurodevelopmental disorder with identification of comorbidity between ADHD and autistic spectrum disorder (ASD). Claims that ADHD is a genetic condition (see previous post) are consistent with the hypothesis of a genetic neurodevelopmental continuum of intellectual disability, ASD, ADHD and other childhood conditions including tic disorders. The concept of neurodiversity (see article in The Atlantic), meaning intrinsic diversity of brain function, implies that neurodevelopment disorders are not necessarily pathological but may merely represent brain differences. 

People are different. The clamour to find a psychiatric diagnosis to explain our difficulties, eccentricities and odd behaviour may not necessarily increase our understanding of the reasons for these problems and differences. Admittedly these may be difficult to understand, at least initially, but that doesn't mean that we shouldn't try. These issues are complex and differences between people are not just due to their brains or genes. I agree with advocates of neurodiversity about human rights and the need for society to adapt to individual differences. That doesn’t necessarily mean, however, that increasing the diagnosis of ADHD and other neurodevelopmental diagnoses is the answer to understanding and managing our differences from others.

Barriers to debunking the serotonin theory of depression.

I concluded my article on 'Towards a more relational psychiatry: A critical reflection' with the sentence:-

Rather than psychiatric practice being based on the notion that primary mental illness will be found to have a physical cause, psychiatry needs to move on to a more relational practice.

I just want to elaborate what I mean by this in relation to the umbrella review that confirmed there is no convincing evidence to support the theory that depression is caused by low serotonin (see previous post). Even though antidepressants may be serotonin re-uptake inhibitors, they do not seem to correct an imbalance or deficiency of serotonin in the brain (see another previous post). 

This may well be surprising to patients and the general public who have been led to believe in the serotonin theory of depression. Simplistic notions of the serotonin theory have actually been untenable for some time (see eg. previous post). Psychopharmacologists gave up the theory ages ago but it persists in clinical practice as a way of persuading patients to take their medication. I'm sure the fundamental faith of psychiatry that primary mental illness will be found to be due to brain disease will continue. Doctors find it difficult to accept that depression hasn't something to do with serotonin because antidepressants can be serotonin re-uptake inhibitors. They are convinced antidepressants work, so this must be due to their effect on serotonin. 

Our modern understanding of illness and disease as bodily pathology has been remarkably successful in elucidating biological processes of disease. Doctors should take a person-centred approach to attain an understanding of the patient as well as the disease. For psychiatry in particular, the danger is that medicine may treat patients more as objects than people by reducing their problems to brain disease.

After decades of intense neuroimaging research, there is still no neurobiological account of any functional psychiatric condition (see eg. previous post). Psychiatry must stop identifying the brain with the person. People’s experience and relationships with others are at the core of depression and cannot be identified with neuronal or biochemical processes, such as serotonin imbalance or deficiency. We may find it attractive to try and simplify the relationship between mind and brain, but it may well be an enigma we cannot solve. We have to accept the integration of mind and brain in the person. Of course brain disease can cause mental disorder, but it may well not make sense to see depression as being in the brain. Depression is mediated by the brain but there may be no brain abnormality as such. This is what psychiatry will continue to find difficult to accept.

Creating panaceas for emotional and other mental health problems

I want to look at some of the wider implications of the BBC Panorama programme exposure of private ADHD clinics. I'm not convinced the NHS is necessarily coping any better than private services with the burgeoning demand for psychiatric diagnosis of emotional and other mental health problems, of which ADHD is just one of the diagnoses for which remedies are being sought. A uncritical biomedical approach to ADHD can be an excuse for licensed fraudulence (see previous post). 

Panorama is not the first media programme to highlight the exploitation of ADHD diagnosis (eg. see previous post). Adult ADHD is a relatively new diagnosis, as ADHD was originally a diagnosis made in children with symptoms of hyperactivity, impulsivity and inattention. Such behaviours may be displayed when children feel frustrated, anxious, bored, abandoned, or in some other way stressed. The increasing diagnosis of ADHD in children, over many years now, has been compounded by diagnosis in adults without a previous childhood diagnosis, considered to have been a major unrecognised condition (see eg. my article). Many psychiatrists see this as an example of the overmedicalisation of mental health problems (see another previous post), which at least partly explains why adult ADHD services have generally been hived off into a special service, mostly with massive waiting lists.

Not all negative emotions and experiences should be labelled as mental disorder. A moral panic about mental health may encourage the packaging of our everyday problems as conditions that can be diagnosed and treated. The reality is not always so simple (see eg. previous post). As this is mental health awareness week, it is perhaps worth highlighting how destigmatisation campaigns seem to have encouraged this oversimplification (see another previous post). Services themselves also ironically have encouraged the expansion of demand, apparently with the misguided notion that a perseverative call for more funding will provide the answer. The cultural process of seeking to create panaceas for emotional and other mental health problems doesn’t always work and may create more problems than it is worth. 

Changing how mental disorders are studied and managed

As Caio Maximino (2023) says in History of Psychiatry, the "over-reductionist neo-Kraepelinian approach" has been criticised for decades. Like me, he also argues that these criticisms tend to disregard and not make as much as they should of advances in enactivism and phenomenological psychiatry (see eg. previous post). Biomedical psychiatry essentially ignored George Engel’s call for a more integrative approach by continuing with its ontological position that mental phenomena are brain phenomena, even if this is now understood in an eclectic biopsychosocial way (not originally what Engel meant - see eg. previous post). But what's needed is a new epistemology that recognises "the complexity of the relation of biology with interpersonal, social and cultural factors (see another previous post). I have tried to summarise all this in my paper 'Towards a more relational psychiatry: A critical reflection' (see yet another previous post).

Value for psychiatry of the explanation/understanding distinction

Joseph Gough (see Gough (2021) and Gough (2023)) seems to me to wrongly undermine the value for psychiatry of the explanation/understanding distinction from Dilthey. True, Jaspers notion of un-understandability as a basis for defining organic disorders does not hold up. And the apparent incomprehensibility of psychosis can be understood (see Wendler & Fuchs (2023)). 

But there is a very real sense in which we may not be able to say what causes functional mental health problems in physical terms. Relationship with antecedents is not linear but more circular (see previous post). This does not mean that it's not important to try and understand the reasons for mental health problems, even that they may provide a kind of explanation (see another previous post). Naturalistic explanations are inadequate because of the need to take a holistic personalistic view of mental health problems. Mind and body are integrated in the organism but this does not really dissolve the mind-body problem, merely acknowledge it can’t be solved.