Re: The Mind
I don't believe in such a sharp distinction between mental and physical medicine. Recent research on neuroplasticity as effected by environment is proof alone. The field of neuropsychoendocrinology is not new. The clinical applications are to humans is new. The effects of psychotropic medications are on the balance of neurotransmitters in the CNS. This is physical. Furthermore, there are neurobiological investigations of psychotherapy. The outcomes are in the expected direction.
When it comes to science, it is true that some are softer than others. When we look for more uncontravertible data and understanding, it is probably only mathematics that holds up. Chemistry, physics, biology are still infant sciences comparatively.
So, clinical textbooks do have a short shelf life. I did a recent literature review in the area of clinical neuropsychoendocrinology and there is a vacuum waiting to be filled. In the field of comparative biology, there are many good texts in the non-clinical side of the study.
The most difficult problem I face is not with my patients. The vast majority of my private patients seek treatment with me because they can't find a solution with conventional medicine. The most difficult problem is in getting other physicians to understand what I do - both psychiatrists and other specialists. What I do transcends specialties. If anything, it is basic, old-fashion, medicine applied to the field of mental health.
If you took an internist and asked him/her to start from scratch and determine what a mental illness is, then you may reach where I am. An internist generally assumes an illness has a physiologic basis. After all, we are physicians - i.e. we study physiology and its pathology. Thus, an internist, would then define "the mind", then start measuring the mind to determine what is the pathophysiologic basis for a mental illness. Then at arriving at a pathology, the internist can then definitively determine the appropriate treatment.
If you take a totally health person and asked and answered the question "What physiologic changes do I have to do to create a mental illness in this person?", then you may reach where I am.
The biggest problem in psychiatry - and in the mental health field in general - is that there is NO definition of the mind. It is an entity which is assumed to exist, that we already intrinsically know. But, without a definition, one cannot actually correctly measure it and monitor it for pathology.
As a treat for you, I will give you my definition. And it works spectacularly. Once you understand its implications, you know what mental illness is and how it relates to physical illness, and vice versa.
First: We all should realize that the mind has several functions: To perceive sensory information, to store information, to process information, to determine emotions, to determine thought, to determine behavior, to control our body systems, etc.
Second: We generally think of the mind as analogous to a computer. The mind is somehow a circuit, which uses numerous molecular signals - just as a computer is an electrical circuit which uses electrons as signals. Scientists interested in artificial intelligence are modeling the mind using computers and electrical circuits.
Third: The mind, we can generally agree, is the physical correlate of behavior. It is "the organ" we would point to as mental health specialists, just as a cardiologist would point to the heart.
Thus my definition of the mind:
The mind is the sum of all the signaling systems in the body which determines thought, perception, storage of information, emotions, behavior, and control of the body systems in response to, and in adaptation to the environment. The mind is a fluid circuit, analogous to a computer's electrical circuit, which uses thousands of molecular signals (some of which we call neurotransmitters, hormones, or cytokines), analogous to the electrons used in an electrical circuit.
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The mind developed from the early intercellular communication system which allowed early multicellular organisms to coordinate the activities of its cells in order to survive and adapt to the environment. A human is a highly complex multicellular organism, with a more highly complex mind, necessary for survival and adaptation to the environment.
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Collorary One:
Question: Is there any cell in the body which is not part of the mind?
Answer: No. Every cell participates in intercellular signaling.
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Collorary Two:
By this definition of the mind, inevitably one concludes that:
The mind IS the body.
The body IS the mind.
There is NO separation between mind and body.
The mind IS the body.
[This is my most important spectacular and useful finding.]
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Collorary Three:
Mental Illness is a physical illness.
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This, for example, explains why people with a major mental illness die 25 years younger than people who without (this is true even when removing suicides and accidents as factors). This is true even if they receive physical health care.
In the last few decades, mental illness has shortened a persons life more than any other physical illness.
This explains why people with major mental illnesses are much sicker than those without. They have often numerous physical problems.
This also supports a rule of thumb in consultation-liaison psychiatry - otherwise known as psychosomatic medicine: If a person's medical chart is over 1-inch thick, then that person has a major mental illness.
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Where do psychological issues fit in?
Psychological issues and problems may be considered analogous to software and software problems in computer systems.
They include the stored information (memories, perceptions, social rules, etc.) and stored behavioral programs (e.g. mindfulness skills, mood regulation skills, relationship skills, etc.) we develop to solve problems.
They directly affect the hardware - the mind.
Vice versa: problems in the mind can influence the development of behavioral programs.
For example, low blood sugar can directly lead to the drive of hunger to eat carbohydrates. We then determine what form of carbohydrates we will eat and when - .e.g candy, breads, pasta, fruits, or alcohol.
For example, the loss of sodium from a mineralocorticoid signaling deficiency, may lead to the drive to favor salty foods or adding salt to food.
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When you examine behavior, you have to tease apart the hardware and software issues to help understand the underlying factors.
For example, paranoid delusions are not pure psychotic symptoms.
A paranoid delusion includes:
1. A mood - fear - meaning an uncontrolled excess in norepinephrine signaling.
2. An illogic - the development of a false belief - indicating psychosis - probably due to a structural miswiring in the nervous system.
3. Psychological components - the stored belief the someone is having malevolent actions toward oneself; behavioral solutions including staring out the window frequently or scanning the surrounding environment for threats or buying weapons to protect oneself, etc.
Thus, having paranoid delusions indicates the simultaneous presence of a mood disorder with fear as its primary emotion, along with psychosis (which I believe indicates the existence of a structural problem in the nervous system - i.e. miswiring), and behavioral solutions.
The miswiring may be due to the loss of cells or excess of cells in abnormal development of the nervous system. Evidence of this includes the enlarged ventricles in people with schizophrenia, indicating the excess loss of certain brain cells.
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Collorary Four:
To be mentally healthy, one has to be physically healthy.
To be mentally well, one has to be physically well.
And vice versa.
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The problem is:
Physical medicine does not do a good job in treating physical illness.
For example, in the treatment of diabetes type 2, one has to get rid of insulin resistance.
I don't see this happening. Too often, I see diabetes poorly controlled.
One problem is that diabetes is defined arbitrarily as a fasting blood sugar greater than 125.
Thus, a blood sugar between 100-125 is considered acceptable because it is not diabetes.
Yet, one still has insulin resistance (assuming optimal gluconeogenesis), when the blood sugar is between 100-125.
AND, one still has a high risk of getting heart disease and other consequences of diabetes when the blood sugar is between 100-125.
Such a blood sugar implies that insulin production is excessive to control the blood sugar in the face of insulin resistance.
Insulin is an inflammatory signal, triggers fat storage, etc. It contributes to the problems of diabetes - e.g. heart attack, stroke, Alzheimer's disease, depression and other mood disorders, etc.
For optimum mental health, blood sugar has to be much more tightly controlled than is done by primary care and endocrinology.
I, myself, prefer the range between 93-100.
Thus to optimally treat mental illness, you have to do better than what is currently done by physical health doctors. To not do so means your patients die young - 25 years younger than they should have.
Mental illness is a physical illness.
There is NO distinction between mental and physical illness (excepting subsets such as trauma and infection). The mind-body separation is an arbitrary construct.
This is why I prefer, when possible, to take over the endocrine treatment of my patients. The endocrine system IS part of the mind and is involved in all of the mood disorders, most psychotic disorders (particularly those with a mood component), most of ADHD, and other mental illnesses. I don't see endocrinologists doing a good job on their end in treating mental illness. They may not even see how it relates. Yet the earliest and smallest changes to endocrine function leads primarily to behavioral changes.
The early psychiatrists of the 1930s and 1940s recognized that the endocrine system has a strong role on mental function.
In a way, I have come full circle, to the roots of psychiatry. After all, the early psychiatrists were not psychiatrists. They were neurologists (e.g. Freud) and other specialists.
Where psychiatrists got side-tracked is in creating DSM-IV - an abomination which defined the major mental illnesses as having no physiologic basis. Yet drugs change physiology. And why all the ongoing research showing the physical aspects of mental illness. Thus DSM-IV is seriously flawed. It doesn't even have a definition of the mind - its primary flaw.
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In closing:
This definition of the mind works very well for me.
I can now define mental illness by its pathophysiology (i.e. its causes) and treat the pathophysiology rather than engage in trial and error treatments.
For example, why would I give a person a dual action medication for depression, which raises both serotonin and norepinephrine, when the person already has excessive norepinephrine signaling? That wouldn't be my first choice. I would first just target the low serotonin levels and use medications to lower norepinephrine signaling. The usual psychiatrist wouldn't even measure the neurotransmitters, and thus does trial and error - with the primary criteria being avoidance of side effects.
It takes a lot of hard work to get there, however. One has to study psychology, psychiatry (conventional), neurology, endocrinology, immunology, nutrition, general medicine, among other subjects. Having a computer science background also helps. One also has to deconstruct lab tests and determine what they actually mean in relationship to behavior. It is a nearly complete re-examination of, questioning of, and rebuilding of one's understanding of medicine. It makes it a hell of a lot of fun as well when one can see what others can't, and when one can have a much better treatment for mental illness than before.
One last example before I go: I found that men, women, and children all can get hot flashes. But only premenstrual and menopausal women are generally known for it. Why? No one asked the men and children. No one asked what causes hot flashes. It is not an estrogen problem primarily. Estrogen does not always control hot flashes. It may also worsen it in men. Why? Unless you can tie the signaling systems all together (meaning, have an understanding what the mind is), you won't know why.
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And one last note:
Even if others don't understand, the most important thing is that the patient gets healthier.
Cheers. I hope this piques your mind (pun intended).
Now I have to get back to work and writing the book.
