Cause is not everything in mental illness
The past week has been great for mental illness. As reported last week in this journal, psychological researchers have uncovered the spread of genetic signs of schizophrenia, potentially shedding some biochemical light on how this dreadful disease develops. At the same time, a major US center for research on mental-health disorders announced a record donation of US$650 million from philanthropist Ted Stanley to promote that work (see Nature 511, 393; 2014).
Good news all around. And more may still follow: the genetic understanding of psychiatric disorders, along with more research on the abnormal ebb and flow of circuits in the brain, promises a revolution. Brain disorders researchers compare the current state of their science to cancer knowledge from a decade or so ago, before molecular approaches could stratify patients and select specific treatments.
The latest study on schizophrenia this March may be a small step forward. Or it could be another false start in a field that has endured more than its fair share. Psychiatric research has not yet provided a single reliable biomarker to aid in diagnosis and treatment.
Self-reported symptoms and their subjective interpretations remain the basis of clinical diagnosis. Pharmaceutical companies have fled. The task of uncovering the biological pathways that drive mental illness, which are necessary before drug targets can be identified, has been declared too difficult and too costly.
Of course, some approach is needed. The birth of psychiatric research was a long and painful birth. Just a generation or two ago, at a time when physicists had split the atom and biologists were understanding the structure of DNA, a common treatment for schizophrenia and other mental disorders was a metal spike placed above the eye socket. It was rotated by and moved around. . With such a history, a gap of a decade or so of cancer research can be taken as a sign of rapid progress.
Whether or not the latest study on the genetics of schizophrenia advances that progress has already contributed to the public debate about mental illness and public understanding of the issues. It has raised and exposed the 'C-word': the reason.
I have obsessive-compulsive disorder (OCD). It used to be a mystery, but in April I published a book about the condition and my own experiences with it. Despite its frequent portrayal as a behavioral quirk, OCD is a vicious and debilitating mental illness, with some similarities to the experiences of schizophrenia.
Simply put, people with OCD may have some of the same deep thoughts, thoughts, and images as someone with schizophrenia, but the person with OCD is fully aware that they generate the thoughts themselves. (The psychosis that defines schizophrenia is characterized by a lack of such insight, and people with the condition usually associate the intrusion with an outside source.)
Now let's talk about my OCD. An oft-repeated question from listeners that I'm still not ready to answer is: "What's causing this?"
I don't know, and to the point I don't care. For almost 20 years I have struggled with the symptoms. Recently, I sought and received treatment for those symptoms – a high daily dose of the antidepressant sertraline hydrochloride and several months' worth of weekly sessions of cognitive behavioral therapy. It seemed to work, and without anyone - the psychiatrist, the psychologist or me - trying to identify the cause.
Maybe others question is just for simple curiosity. I tell a human story and it is natural to know how such stories begin. Maybe there is some selfishness as well because people don't want to follow the path I did.
It may be me who is unusual in not caring about the cause, but when I find out that people have cancer or heart disease or have had a stroke, the cause of their suffering is far down my list of inquiries.
Over the past two or three years, I've met a lot of other people with OCD and other mental disorders. Many of them, like me, do not know this and do not care about who, where, why and when their illness occurred. Only how.
The other questions are not frightening. Instead, I think they reflect an enduring mystery of mental illness. We don't know enough about brains and minds to make up a backstory. (And as I said earlier, existing treatments do not require it.) Myths, misconceptions, and agendas creep into this unknown.
In psychoanalysis, for example, as formulated by Sigmund Freud, reason is everything and, sure enough, psychoanalysts usually find a subconscious cause for a mental disorder that can be easily addressed. Is - oh, psychoanalysis.
The latest schizophrenia study helps bridge that causal gap. Schizophrenia has such problems that it is portrayed in the wider media, but the condition escapes the worst trivialization that plagues other types of mental illness, such as depression and OCD.