Mental illness isn’t like physical illness. Mainly because you can’t see it. Humans have always verified the truth of something with their eyes. ‘You fell off a roof and broke your leg? Oh my God, poor you!’ Our eyes travel back to the plaster cast on their leg, the existence of which triggered the question in the first place. We are full of compassion. We wish them a speedy recovery. We ask them what is the most difficult thing about having one leg in Plaster of Paris. They reply. Their challenge is seen; their frustration, pain and distress are validated. Happy Days.
Now try this. ‘Haven’t seen you around for a while’. The depressed person doesn’t make eye contact, appears a bit shifty. They say something unintelligible, a mumble, making you, the questioner, feel like you are intruding, or getting it wrong. Then when it seems the conversation has stalled, they glance quickly to you, making full but fleeting eye contact. Their expression reminds you of a hungry wolf, their eyes full of pain and need and something you cannot get words to. You feel uneasy, unsure how to respond. You try to keep the small talk going. Then they say, ‘I am not so good, trying the pills the doc gave me, but I don’t know…’ Faced with their doubt, their lack of conviction and a seeming lack of hope in the future, you find yourself turning away. Towards less baffling and bewildering things than depression, stifling social anxiety, or worse, the proper crazy stuff of hallucinations, hearing voices and violent, unexplained madness.
Of course you do. It doesn’t make you a bad person. Mental illness has always troubled us and what to do with ‘mad’ people has always kept us up at night, especially when they are our nearest and dearest. The risks are real – suicide, murder, self-mutilation, acts of mania, addictive behaviours that ruin lives and relationships causing people to lose their homes, or hoard unnecessary crap in them, or wash their hands a million times a day. It can be pretty creepy what the ‘mad’ get up to, let’s face it.
More disquieting still is the fact that the towering technological advances that enable us to make cars with robots and video-call our Mum on the other side of the world hasn’t got around to solving the problem of stopping people from suffering so. In their heads. No, we cannot wipe out mental disorders with the click of a mouse, or have a new, perfectly working brain delivered by drone on Amazon Prime. One day perhaps! Meanwhile, mental illness remains stubbornly invisible and therefore questionable. After all, ‘seeing is believing’. ‘Not coming in again? Sigh. OK then,’ we say, as Boss to such a person. Then we think, ‘Are they really ill? Or just malingering? Or manipulating? Or pulling a fast one?’ We can’t help being suspicious if we can’t use our eyes to verify the truth we are being told. If only mental illness could be rendered with a plaster cast. But it can’t. Not yet.
But I want to use this space to tell you about the many ways in which neuroscientists ARE finding tell-tale signs that underpin the reasons why the mentally ill suffer and behave the way they do. They are discovering how key differences in brain function and form are responsible for the distress and suffering of mental illness, just as a person with a broken leg feels the agony of two bits of bone rubbing against one another instead of being one bone.
For example, recent years have seen discoveries that OCD symptoms can be caused by strep C throat infections. When children with strep throat became compulsive hand-washers, MRI scans showed their caudates had swollen 24%. The caudate is the part of the brain that allows our thoughts to flow. When given immune-suppressants, the childrens’ symptoms eased and those who had the most swelling of the caudate had the worse symptoms, thus showing a causal relationship between caudate size and OCD behaviour. Other researchers have shown that schizophrenic symptoms can be caused by two different microbes, Toxoplasma gondii and cytomegalovirus (CMV). This is not to imply that all schizophrenia is microbe-induced, but it does get across the point that the symptoms of mental illness are caused by pathology in the brain just as illnesses in the body are caused by pathology in the body.
Researchers have discovered that hippocampal volume is smaller in chronically depressed patients and not in those who have recovered. And up to 18% smaller in women who had been abused as children. The mechanism underlying this finding is believed to be because stressful experiences release cortisol, the stress hormone, which in small doses readies us for fight or flight, but repeated and frequent exposure to this hormone causes neurons in the hippocampi to wither and die. And hippocampal volume matters because it is mainly in the hippocampi, where we process and sort our memories from short-term to long-term memories, that neurogenesis takes place. You may not have known that you continue to produce new neurons your whole life long – but you do – and it happens right there in the hippocampi, in those two little seahorse-shaped areas deep down in the limbic system of the brain.
Now imagine being a baby who is neglected or frightened by its caregiver(s) – this is what is meant by ‘cumulative trauma’. Such an infant grows up with its brain being bathed in cortisol and this causes epigenetic changes predisposing him or her to depression and stress-related illness later on. There is a critical period in infant development, notably the first three years of life in our species, when the part of the brain responsible for regulating our emotion gets wired – like a combine harvester mowing paths through cornfields. If we are empathically reared, ie. loved and nurtured well, our neuronal pathways sprout across our right-frontal lobe like densely-branching broccoli enabling us to identify our emotions, label them as feelings and discharge them appropriately. This key part of the right frontal lobe is the wiring enabling us to make and maintain human attachments. I believe it also underpins our sense of self, a belief we have agency in the world and an unconscious conviction that our choices matter.
It should not surprise us that high numbers of our prison population were badly abused in that same critical period and they grow up profoundly unable to down-regulate their emotions and find relating to others a fraught business. Their fear and rage spills out of them in violent offences, their lust in rape convictions. I am not suggesting here that horrendous crimes do not deserve punishment – of course they do. But if we believe their crimes are largely the consequence of a poorly-wired brain, wouldn’t we do better to offer prisoners intensive psychotherapy rather than a locked cell 23 hours a day and a TV? After all, surely the aim of prison is to make them less likely to reoffend on re-joining society?
So am I arguing that psychotherapy changes the brain? This is the critical question and it seems increasingly there is evidence to show that it does. For example, when patients have flashbacks, the flow of blood to the prefrontal and frontal lobes decreases. The aim of psychotherapy is to extend the influence of the right prefrontal lobe where regulation of emotion takes place (that key area which wires in the first 24 months of life before we acquire language). Freud’s injunction to let the mind free associate is the ideal way for difficult memories to be retrieved or re-enacted through the relationship with the therapist. Memories must be reactivated to have their neuronal connections altered, so they can be re-transcribed and changed. Neuronal change is possible because our amazing brains stay plastic (able to change) throughout life. Please note neuroplasticity is a feature of brain form and function.
The psychic change I see in my patients through the course of their treatment is happening at a neuronal level; new circuits of neurones wiring and firing together can develop when traumatic memories are re-experienced and vicious self-denigrating thought processes are examined in the safety of the consulting room. Understanding how past pain has been triggered by present-day experiences allows patients to develop new coping methods and these are instantiated in neural networks thanks to the brain’s marvellous neuroplasticity.
I sometimes say to patients, ‘A relationship got you into this mess and a relationship will get you out’. Does it take a long time? Yes. Does it work? Definitely, as long as a patient really wants to change.
Perhaps you are reading this as a potential parent worried about how you might affect the wiring of your own infant’s brain in the critical period. To you I would say: ‘Do you think your parent negatively impacted how you were wired?’
If you have found it hard to make and maintain relationships, if you struggle to name feelings and feel easily overwhelmed by them, then the chances are you will pass that wonky wiring on to your infant, especially if you are the main care-giver. So think about whether it would be sensible to have some therapy before you reproduce not just your genes, but your wiring too.
In Charles Dickens’ A Christmas Carol the Ghost of Christmas Present frightens his main character, Scrooge, with a vision. It is so beautifully written, I hope you won’t mind me reproducing it here:
“‘Forgive me if I am not justified in what I ask,’ said Scrooge, looking intently at the Spirit’s robe,’ but I see something strange, and not belonging to yourself, protruding
from your skirts. Is it a foot or a claw.’
‘It might be a claw, for the flesh there is upon it,’ was the Spirit’s sorrowful reply. ‘Look here.’
From the foldings of its robe, it brought two children; wretched, abject, frightful, hideous, miserable. They knelt down at its feet, and clung upon the outside of its garment.
‘Oh, Man. look here. Look, look, down here.’ exclaimed the Ghost.
They were a boy and a girl. Yellow, meagre, ragged, scowling, wolfish; but prostrate, too, in their humility. Where graceful youth should have filled their features out, and
touched them with its freshest tints, a stale and shrivelled hand, like that of age, had pinched, and twisted them, and pulled them into shreds. Where angels might have sat
enthroned, devils lurked, and glared out menacing. No change, no degradation, no perversion of humanity, in any grade, through all the mysteries of wonderful creation, has monsters half so horrible and dread.
Scrooge started back, appalled. Having them shown to him in this way, he tried to say they were fine children, but the words choked themselves, rather than be parties to a lie
of such enormous magnitude.
‘Spirit. Are they yours?’ Scrooge could say no more.
‘They are Man’s,’ said the Spirit, looking down upon them. ‘And they cling to me, appealing from their fathers. This boy is Ignorance. This girl is Want. Beware them both,
and all of their degree, but most of all beware this boy, for on his brow I see that written which is Doom, unless the writing be erased. Deny it.’ cried the Spirit, stretching out
its hand towards the city. ‘Slander those who tell it ye. Admit it for your factious purposes, and make it worse. And abide the end.’
‘Have they no refuge or resource.’ cried Scrooge.
‘Are there no prisons.’ said the Spirit, turning on him for the last time with his own words. ‘Are there no workhouses?’”
I think the causes of mental ill-health and misery derive from that same two sources Dickens so powerfully describes. The river of Ignorance is turning away in fear from people suffering mental ill-health, while holding stereotypes about them as Scrooge did about the ‘Undeserving Poor’. While the river of Want is where infants receive poor early care and spend the rest of their lives feeling guilty for somehow not feeling OK and managing their lives successfully. Better education about what makes for healthy minds and better mental health services for those who didn’t get what they needed early on would do a lot to change the game: can we banish Ignorance and Want together?