Brain/mind: a false divide

Every so often I’m reminded of a conversation I had some time ago with a researcher (who shall remain nameless) who wasn’t too keen on psychiatry. I want to reflect on that discussion to examine the fallacy of the brain-mind divide and how it’s just not possible to partition away emotions as something the medical model shouldn’t be dealing with.

Doctors are quite within their rights to treat brain diseases, this man said. Problems with moving your arms and legs, physical sensation or balance are all perfectly suitable ailments to see a neurologist with. But emotions and the mind are different things entirely. For a doctor to go interfering with those would be quackery.

So I asked him – what did he make of the fact that people with Parkinson’s disease suffer more frequently with depression than the background population? This sadness was understandable psychologically, he said, as a result of being ill. And he seemed quite satisfied with that. The emotions were not brain symptoms but something separate.

But people with Parkinson’s disease, I replied, get depressed more often than people with equally distressing and disabling diseases which don’t involve the brain tissue, like rheumatoid arthritis. Surely the brain being affected by disease must be changing the emotions of the patients? Where on earth are emotions from if not the brain?

Eventually he retreated at this point, conceding pretty reluctantly that brain diseases could affect emotions and therefore these emotions could be treated by doctors. But never, he was firm, should they be conceptualised using the medical model when there is no sign of brain disease. If there’s no organic disease for the neurologists to treat, then no one should go treating emotions – a seemingly convenient divide.

But is that really so simple a segregation? Let’s take an example – epilepsy. People with epilepsy are three times more likely than the background population to have a psychotic episode. So by the rule of treating emotions when there’s a brain disease present, we can go ahead and treat. But hold on – using simple maths, a third of those people would have had a psychotic episode anyway, just like the background population do. And there’s no way of telling which third they are. So what do we do, treat them all or treat none of them as medical symptoms? Or guess?

The same argument can be applied countless times to other scenarios. People who use cannabis are about twice likely to become psychotic than the background population, but that means around a third to a half of people who smoke cannabis who become psychotic would have become psychotic anyway. Who do we treat as genuine organic drug-induced reactions and who do we say are just having ‘non-medical emotions’? Should we draw a line at one spliff a day, one spliff a week, maybe one spliff a year…?

People given steroids for tumours or inflammation can become manic. I’ve seen it many times. But by simple probabilities we know some of them would have become manic anyway, because of the stress of the illness. There’s just no way of telling which are which.

People with multiple sclerosis have a 50-50 chance of being depressed at some point, compared to a variable but lower number for people without the disease. Should we call it disease-related depression if there are only one or two tiny plaques on the brain scan, or not? Where is that divide now?

This all boils down to a simple point. If something is a symptom in the presence of an obvious brain disease, it’s still a symptom if there is no obvious brain disease. It is valid to conceptualise depression, mania, and psychosis in medical terms because there is no convenient dividing line between “brain disease-caused” and “non-brain disease-caused”. In the end, all emotion comes from the brain whether something worrying shows up on a scan or not. Furthermore, the thought of denying people effective medical help for their highly distressing emotions unless they have evidence of a coarse brain disease is actually pretty perverse.

But this is not to say that emotions should be treated like cold, hard neurological signs like loss of sensation or power in your limbs. Every medical discipline has their tools of treatment – surgeons their scalpels, dermatologists their creams, public health doctors their policies, medics their tablets – each catered to their relevant illnesses. We can still use social and psychological treatments to relieve and limit symptoms whilst calling them just that.

Likewise, just because something is a symptom doesn’t mean it has to be treated. Not every cough is a chest infection, not every knee twinge needs a joint replacement. So not every low spell needs a tablet and not every bizarre thought needs a section.

As for the man who I was talking to, I’m not sure he agreed with me. He told me frustratedly that “fine, you can believe in the brain, and I’ll believe in the hand”, and strode off. He never did explain what he meant.

About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

12 Responses to Brain/mind: a false divide

  1. Frankie says:

    Found this really interesting, and links in within another article I have recently read my Mark Salter – Thought you might find it interesting.

  2. elvis jones says:

    Unscrupulous psychiatrists can say all mental disorders (including life it seems) are biologically based. This seems very expert until analysed philosophically. Then it becomes apparent this excludes nothing experienced, because all conscious experience is biologically based (unless religious beliefs are included of a separate soul that exists after death.)
    So a doctor who says your illness/condition is a biological disorder is saying nothing untrue, but hardly the truth as a whole.
    If someone had traumatic stress, it would be very misleading, though factually correct, to say it is a biological disorder.
    What worries me is that because only doctors have specialist knowledge of the brain, treatment becomes paternalistic, because fathers know it all and patients should just receive wisdom like a receptacle. No doubt at some time unscrupulous doctors raise brain arguments when social/psychological formulations are unsympathetic to themselves and their competences. Medicalisation is the means, then, of securing power.
    No, I am not anti-psychiatry and drugs because I dont know enough about them to say responsible things. Experiences my own.

  3. elvis jones says:

    Controlling the mind is more effective than punishing the body. Given that junior doctors have been subjected to endless tickings off by consultants on ward rounds, does that make them free willed or docile? I mean, if their behaviour is made docile by power, what mastery can they have over power, when indeed they are defined by it, made by it?
    I object to clinical power because I dont see its relevance to MY life, because I dont work in a hospital. I need someone who can handle power, not be defined by it (in a harmful way.)

  4. elvis jones says:

    Been thinking about a poem: a prayer before birth, by louis mac niece. Interesting bit about ‘wise lies.’ What are the ‘wise lies’ that causes so much harm? I guess a wise lie is something sophisticated and convincing, but has an inner quality of doing harm. It did occur to me that inexperienced, sheltered or innocent people are vulnerable to choosing the wrong beliefs (or the wrong therapist).
    I think some of the controversies around psychiatry could be solved by illustrating wise lies and contrasting them with “wise truth”. But then like water in the hands…..!

  5. elvis jones says:

    It is not a lack of reason which is today’s problem, says KIERKEGAARD. It is a lack of passion. In the film DIRTY HARRY reason has gone mad. Unable to work in a city dominated by spineless bureaucrats, he goes it alone as a vigilante. He has moral leadership.

  6. elvis jones says:

    I would recommend the novel Alias Grace for those interested at poole. Good reasons why you shouldnt use men to interview women.

  7. elvis jones says:

    Dr Susan Clarke: ‘ im sorry you feel so upset.’ No your’e not. Youre trying to make me out to be crazy. Is that in DBT or am I missing something? Go on, show us your stellar investigative skills and astound us with the results. Or maybe your afraid to……..

  8. elvis jones says:

    You can see how this brain science becomes controversial: will it be used to validate or invalidate subjective descriptions of experience? Will it be used to nudge consultations onto a less favourable footing?

  9. elvis jones says:

    Reading psychology into.biology has had some theories which have been falsified, eg areas of skull volumes corresponding to personality traits (phrenology). The selfish gene by Dawkins gives psychological intentions to molecules of DNA,(well sections of it).
    I sometimes wonder whether some (poor) researchers want to deny existence by finding essences, in the way of sartre (not that I read more than a few pages.) These essences will take the form of biological explanations.
    Biology becomes a way of holding reality at bay, because Reality can be awful and too much. We can all crack given too many bad events.
    Wouldnt it be easy to ‘explain away’ someones behaviour that we find troubling by planting an inauthentic explanation of it in their brain, thus preserving our sense of reality as safe and predictable.
    I think this is what some “psychologists” want to say.

  10. elvis jones says:

    Sartre said we are all responsible for what we choose to believe in, and this choice is a burden (tell me about it!) I think some people who are anti drugs in psychiatry and say it is all about social factors deceive themselves to take away the horrendous fear, terror even, that human existence is so fragile and impermanent and meaningless…..there just HAS to be a social answer.
    On the other side some people use a neurotransmitter imbalance explanation in bad faith e g poverty can make people very stressed for long periods of time, years, so the prescriber can say to themselves ‘its not poverty its biological: im not doing anything wrong !?’ (Like building a wall) and the person taking the drugs says to themselves: its my brain so im not responsible for my feelings of despair. The prescriber and the medicated are both in danger of colluding with each other.
    I expect we all do it and there are advantages as well as disadvantages.

  11. elvis jones says:

    Absence of evidence is not evidence of absence, as phil says on Time team.

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