Jan 11·edited Jan 11

Psychiatry must be a big mess if we ask if mental disorders are true "brain disorders". Do gastroenterologist question whether hepatitis is a disorder of the liver or do urologists challenge the concept of an enlarged prostate? They don’t. Yet, psychiatrists keep wondering if there is something ethereal hiding behind amygdalae and basal ganglia. No wonder other physicians roll their collective eyes listening to us.

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Of course, mental disorders are disorders of the brain. What else could they be?

But I understand how someone might get confused into thinking that these are societal, not biological. Take voyeurism, for instance. It’s not pathological to achieve sexual arousal by looking at naked or undressing people. It turns into a disease when one can’t stop spying on non-consenting people and is arrested and prosecuted for it. ‘The confused’ fails to recognize that voyeurism is not the disease of sexual arousal (the drive) but a mismatch with weak biological inhibition (the brakes) in the face of obvious negative consequences. By analogy, if someone crushes a car with a Corvette engine and Fiat 500 brakes, it would be a car and the driver problem (one or both must be fixed) and not the freeway with rules and speed signs.

Even though society labeled voyeurs mentally ill, voyeurism is not a social disease. Instead, it’s the inability to control the drive. Voyeurism is the disease of brain neurocircuits, not society. The emergence of novel diseases with social and economic advances is not new. For example, there was no common issue with presbyopia during the Stone Age; no learning disabilities and ADHD before universal education; pedophilia was not a problem before it became illegal; and fewer were labeled as exhibitionists after the opening of nudist beaches.

Most of the confusion in psychiatric taxonomy and diagnosis comes from the DSM, which avoids talking about the nature of mental diseases, leaving it to the readers to define. Psychiatric diagnosis would look less mysterious and confusing if one applies a sensible medical model. For that, we must accept the brain as a collection of separate, closely related units, a.k.a. neurocircuits. Ultimately, their dysfunction (it can be deficit, excess, instability, or mismatch) determines thoughts, emotions, and behaviors that we identify as pathological, leading to mental disorders.

In medicine, the evaluation starts with a “review of systems” (cardiovascular, GI, endocrine, nervous, etc.) Grouping symptoms and linking them back to the “units” that generate them is the standard medical practice. In psychiatry, we should start an evaluation with a review of functional neurocircuits. The brain has myriads of them, each serving specific functions, but not all are relevant to psychiatric diagnosis. Mostly, these are the circuits for arousal, mood, automaticity, executive control, reality testing, social relatedness, and information processing. In medicine, the treatments target the organs. In psychiatry, the target is neurocircuits, not descriptive diagnoses, despite the “indications.”

American psychiatrists have been taught to gather bits and pieces from patients’ narratives and turn them into a descriptive label (e.g., major depression, post-traumatic stress disorder, autistic disorder, schizophrenia, etc.). Then, treat the label as a whole. That’s how DSM avoids mentioning the brain and neurocircuits. In contrast to medical classifications, the Manual cuts off the link between symptoms and the organs that generate them. That is its major failure. However, it will be impractical to “repeal and replace” DSM. Instead, we should begin with deconstructing DSM diagnoses. First, separate and then group the jumbled and sometimes contradictory criteria according to contributing neurocircuit.

There is more; unfortunately, blogs' format has limitations. Another time, perhaps.

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