DEFINING MENTAL ILLNESS

CONTINUUMS, REGULATION, AND DEFENSE

BOOK SYNOPSIS & SAMPLE

BOOK SYNOPSIS

Accurately defining mental illness is crucial for treatment providers and researchers, because it fosters a comprehensive understanding and optimizes therapeutic interventions. In addition, it frees psychopathology from political and financial influences that weaken its scientific integrity.

In combination, continuums, regulation, and defense, robustly define mental illness.

 Continuums: Psychopathology embodied by major diagnostic systems (DSM and ICD) emphasizes discrete conditions, in line with our psychological preference for discreteness. However, nature almost universally gravitates to continuums. Naturally occurring mental illness continuums are identified, based on neuroscience and other relevant data.

Regulation: Despite how biological systems rely on regulation, it is largely neglected when it comes to mental illness. Psychopathology frequently arises from impaired regulation, fostering a shift from milder expressions on continuums to extreme manifestations. A diverse collection of therapeutic techniques, under the umbrella of cognitive regulatory control therapies, is presented that restore effective regulation.

Defense: The surprising role of psychological defense, understood in terms of compensation for stressors, is described for the various mental illness continuums, and techniques are provided to augment healthy defensive functioning.

The model of psychopathology proposed aligns with its natural organization, thereby placing mental illness on a more scientific foundation.

BOOK SAMPLE

CHAPTER 1

Introduction

Defining the true nature of mental illness is essential for interpreting disparate research results, establishing accurate diagnostic profiles, setting robust research agendas, and advancing treatments. Presently, mental health research is characterized by numerous results lacking a unifying framework. One of the key issues underlying this occurrence is the atheoretical (or antitheoretical) orientation of psychiatry and clinical psychology, embodied in major diagnostic systems. We are still very much in the post-psychoanalytic era, with the overthrow of psychoanalysis several decades ago also entailing a rejection of theory. However, it is really a matter of throwing the baby out with what is perceived by some to be the bathwater, due to the crucial role that theory plays in science. Robust science moves ahead with a healthy balance of theoretical and empirical approaches, such as in the so-called ultimate science of physics. Theory is an integral part of physics providing a meaningful framework for interpreting disparate empirical findings, setting key research directions and testable hypotheses, and linking past and present knowledge.

As valuable as empirical results are they simply cannot provide a comprehensive perspective, and in the absence of theory often just accumulate filling academic journals. It might be opinioned that empirical results move knowledge ahead simply by the weight of the findings, but a sobering reality is that about 80% of medical research results are false (see the diagnostic considerations chapter), and this is for top tier results in areas where there are hard endpoints! It only takes a little imagination to realize how weak the empirical results likely are in mental health research with mostly soft endpoints, such as points on a rating scale. Theory can compensate for this sad reality by providing workable models divorced from financial and political influences. The current book defines mental illness by linking empirical findings to advanced theoretical models. In this regard, three major concepts, which combined yield a robust picture of psychopathology, stand out: Continuums, regulation, and defense.

Continuums

Due to our perceptual processes discreteness is preferred, and current diagnostic systems (DSM-5 and ICD-10) for the most part reflect this occurrence. However, natural systems almost uniformly gravitate to a continuous organization, in line with how natural selection operates on the basis of trait variation. Given how natural events tend to be organized, the evidence for discreteness must be very solid consistent with the Continuum Principle, which holds that natural phenomena tend to occur on a continuum, and any instance of hypothesized discreteness requires unassailable proof (see the chapter “Depression”). For each of the proposed categories of mental illness, research evidence is reviewed to determine whether discreteness or continuums apply. Consistent with the vast majority of natural phenomena, mental illness appears to be characterized by a limited number of continuums, there being insufficient evidence supporting most discrete diagnoses, and none that comes even close to that required by the Continuum Principle.

A model of mental illness is proposed that defines naturally occurring continuums, based on solid empirical data from neuroscience and other sources such as emotional information processing. These continuums consist of:

• Depression

• Anxiety
• Hypomania-Mania

• Psychosis
• Negative Symptoms

• Dissociation
• Eating Disorders

• Reinforcement-Based Disorders
• Personality Disorders

These continuums align quite extensively with the general content of current diagnostic systems, demonstrating that while the emphasis on numerous discrete conditions is misguided, being influenced by our perceptual tendencies, mental health practitioners and researchers have for the most part identified naturally occurring forms of mental illness. The alternative proposed in this book helps to synthesis the discrete and continuous perspectives. Each of the continuums is based on naturally occurring processes: Depression and anxiety emotional information processing; hypomania-mania is a defensive response to depression and even anxiety; psychosis arises from cognitive and perceptual distortions; negative symptoms are linked to human specific cognition, including executive functions, social cognition, and motivational states; dissociation a stress response; eating disorders stem from evolutionarily derived motivational platforms supporting food consumption and related reproductive strategies; reinforcement based addictive, impulsive, and compulsive behaviors derive from reward systems; and personality disorders are extreme and enduring expressions of defensive responses. Within these major mental health continuums are various sub-dimensions described in the applicable chapter, and also summarized in the chapter “Diagnostic Considerations.” Along with, first, the processes of circumstances activating continuums, and second qualitative variation arising from quantitative variation as an emergent property (see the chapters “Depression” and “Anxiety” for more complete explanations of both processes), these sub-dimensions further assist in synthesizing the continuous and discrete approaches to psychopathology.

Some of the proposed continuums align very closely with current perspectives, while others entail a shift in how mental illness is viewed. As an example of the latter, negative symptoms are currently largely neglected whereas they actually play a robust role in schizophrenia, bipolar disorder, severe depression, and several other conditions. The proposed model elevates negative symptoms to the prominent position warranted. Current diagnostic systems and perspectives are oriented to viewing addictive, impulsive, and compulsive patterns, pluralistically, involving various substances and behaviors including sexual. However, practically and conceptually these terms are difficult to distinguish, and the underlying issue applicable to all is reinforcement. In addition, current methods of identifying, classifying, and researching addictive/impulsive/compulsive behavior are hopelessly inadequate in the rapidly changing computer era. The proposed reinforcement-based model is capable of describing novel instances of dysfunctional behavior of this form immediately. Conditions with clear organic impairments, such as dementia, delirium, and sleep disorders are excluded, on the basis of insufficient psychological import. However, it is common for there to be psychological reactions to these problems, such as depression and anxiety, and these expressions are covered. Consistent with most natural occurrences, each of the organic conditions also appears to be organized in a continuous fashion, such as varying degrees of dementia. Negative symptoms are largely organic, but are included because they have a profound impact on many conditions.

In an imperfect world, no method of conceptualizing mental illness will be perfect. Critiques of continuous models typically pertain to the distinction between the discrete and continuous. Everything in nature is interconnected; we live in an entangled world. Due to this reality everything probably merges at a quantum level. However, at a macro level form emerges from the quantum interconnectedness. For example, planets are distinct instead of being compressed into one large mass. Likewise, mental illness entities emerge that are distinguishable from one another, organized continuously due to the nature of natural selection with trait variation, one of the most powerful forces applicable to biological entities. Related to the interconnectedness of everything, there will inevitably be fuzziness at the borders of these mental illness entities. While such fuzziness may be disturbing from a purely academic perspective, is necessary to accept it. The interconnectedness might best be viewed as dimensions or continuums interfacing (see the chapter “Diagnostic considerations”). For example, anxiety and depression are distinct continuums derived from the underlying emotional information processing, with fear being the root emotion of anxiety and sadness the root emotion of depression. Due to overlap in the emotional information processing circumstances—conditions that entail threat commonly also convey loss and vice versa—anxiety disorders and depression commonly overlap; the continuums interface with one another. Hence, we have naturally occurring continuums that in our interconnected universe must interact with one another.

An additional critique of continuous models related to the constitution of continuous and discrete entities is that continuums actually represent discrete entities due to limited horizontal capacity, although with vastly better vertical range. This occurrence might even be referred to as meta-discreteness. This is to some extent a valid critique. However, since form does arise from quantum interconnectedness, as with the example of planets discussed earlier, then the task is to distinguish naturally occurring forms, while accepting that at a very fundamental level often beyond our sensory capabilities, everything is linked. Forms of mental illness must be distinguished on the basis of natural processes, such as emotional information processing and neuroscience data, and not political or financial agendas, as with discrete entities favoring the marketing of medications. If the latter is the basis of the definition of mental illness, then the field represents a captured discipline removed from science. The model of mental illness proposed provides what appear to be naturally occurring dimensions, with the understanding that their inevitable interfacing with one another does not compromise their unique form.

Regulation

All biological systems rely on regulatory control over essential processes. Within our own bodies physiological parameters such as electrolyte composition, blood sugar levels, temperature, and blood pressure are tightly controlled. When this regulation falters disease occurs, as with diabetes involving deficient control of blood sugar levels and hypertension sustained high blood pressure. Even the growth of cells is controlled by various signals to keep the system in balance. Cancer arises when cells remove themselves from this regulation and divide without restraint. Regulation in biological systems also transpires at the ecosystem level, such as with temperate riparian systems. For example, salmon mature in rivers and then enter the sea where they live for a few years before returning to the same river system they grew up in. After spawning they die, their bodies providing a crucial source of nitrogen and carbon for their developing offspring, and other animals such as bears that eat the salmon. Partially eaten salmon and the feces of animals that eat them return minerals to the soil enabling the growth of trees and plants, that in turn shade the river cooling the water so that salmon can survive.

The role of regulation in mental health is also profound but vastly underappreciated. To adequately define mental illness, the contribution of psychological regulation is explored and described for each of the mental illness continuums. Evidence supports the position that impaired regulation is instrumental in the shift from mild and adaptive expressions of continuous behavior to extreme and maladaptive levels, with adaptive/maladaptive defined in terms of the functioning of the individual, and in some instances evolutionary fitness implications, such as mania being incompatible with relationships that could lead to reproduction. Perhaps most evident is how the prefrontal cortex (PFC) and higher cortical structures regulate limbic system structures to limit emotional reactions. Anxiety and depression entail deficient PFC-limbic connectivity, and treatments such as cognitive behavioral therapy actually appear to reverse this impairment to restore mental health. On a somewhat more speculative note, the distinction between schizophrenia and bipolar disorder might actually hinge on regulation over a natural defensive response to depression in the case of bipolar disorder, and regulation over psychotic level cognitions. When this regulation fails hypomania progresses to mania, and psychotic cognitions and sensory perceptual experiences intrude into the conscious and awake state. Healthy defensive responses to stress can extend to extreme and enduring expressions, producing personality and dissociative disorders when regulation falters. Eating disorders and reinforcement-based conditions arise when regulation of food consumption and reward continuums is compromised. A key contribution of the proposed model is to elevate regulation to a role of prominence commensurate with that it occupies in mental health and illness.

Psychological Defense

Classical psychoanalytic defense mechanisms automatically come to mind when the term psychological defense is raised. Indeed, defense mechanisms qualify as one of the most robust and enduring of all psychoanalytic concepts, an occurrence anticipated by Freud when he mentioned in a personal communication to his friend Wilhelm Fliess that in identifying them he had touched upon one of the greatest secrets in nature. A key reason why these psychoanalytic defense mechanisms are so robust is that they are actually part of a much larger process, namely compensation and resilience to stressors. To a large extent compensation for stressors characterizes life, and when compensation fails illness and death ensue. For instance, when blood sugar levels rise so does insulin to compensate by storing the excess sugar. When there is a lack of insulin or insulin resistance blood sugar levels rise to toxic levels. Defenses applicable to mental health compensate for stressors in a similar fashion, and when they fail mental illness occurs.

If we are to understand the true role of defense, it is necessary to break free from the notion of psychological defense consisting only of classical psychoanalytic defense mechanisms. In line with this conceptual shift, classical defense mechanisms are likely only components of two much broader psychological defense templates, positive cognitive distortions and dissociation, concepts developed in the chapters “Psychosis” and “Dissociation.” These defense mechanisms templates operate largely at the level of emotions, defending against excessive negative emotions, such as fear and sadness. The evolution of human intelligence appears to have amplified emotional states, making us the most emotional of all creatures, with amplified fear and sadness contributing respectively to anxiety disorders and depression. To attenuate and compensate for excessive negative emotions, psychological defense mechanisms evolved. At the level of mental illness defensive processes have also evolved, and in particular hypomania for depression and even anxiety, at least that derived from social sources.

Extreme expressions of psychological defenses play a major role in bipolar disorder, psychosis, dysfunctional dissociation (including Post-Traumatic Stress Disorder), eating disorders, and personality disorders, as covered in the given chapter. Readers definitely should not take from this that the various forms of mental illness represent defenses, as most have no defensive value, such as anxiety disorders and depression. Some, such as psychosis, mania, and extreme dissociation can provide a defensive capacity under limited circumstances, and several have pronounced defensive value in a mild form, as with hypomania, dissociation, and the processes underlying personality disorders. Nor should readers assume a set role for defensive processes applicable to all of the naturally occurring mental illness continuums. Researchers prefer ideal symmetry, but nature can be much more “messy,” and models accurately describing it often reflect this, as with the Standard Model of particle physics, that while quite “messy” is very accurate.

Conceptualizing and applying psychological defense in terms of compensation for stressors, reveals the natural and robust role that defense processes play in mental health and illness. Restricting psychological defense to classical psychoanalytic defense mechanisms obscures their significance, particularly since these defenses apply to many emotional states, and hence are not specific to given disorders, other than perhaps as trends in highly limited scenarios. A potential critique of expanding defense to compensation for stressors is that it can become so general and diffuse as to lose meaning and relevance. In this regard a high threshold of relevance as a compensatory process has to be applied. This high threshold entails not citing psychological defense when other more parsimonious explanations apply. For example, you come home from work and express anger towards your spouse for an unnecessary purchase when money is tight. Is this a defense against stress? The answer is no because the occurrence can much more parsimoniously be explained by emotional information processing, whereby you perceive a violation. In contrast hypomania, at least understood in terms of its modal time frame and ensuing expression, compensates very well in the moment for depressive inhibition, and lacks other more parsimonious explanations. When the compensatory role is clearly identified, and alternative more parsimonious explanations are lacking or weak, the adaptive value is clear and meaningful, as it is restricted to a particular circumstance. The applicable role of psychological defense is explored in each chapter, focusing on compensation for stress when other more parsimonious explanations are lacking.

Continuums, Regulation, and Defense

By defining mental illness based on continuums, regulation, and defense, a vastly different picture of psychopathology emerges, and one that aligns very well with neuroscience and other relevant data. This occurrence will allow mental illness categorization to move ahead, and not be structured on the basis of preferences and political agendas. Diagnostic profiles will need to shift in the direction of far fewer conditions emphasizing the naturally occurring continuums identified here. However, the notion of categories can to some extent be maintained based upon primary continuums, sub-dimensions within these, qualitative variation arising from quantitative variation, and also eliciting mechanisms.

To enhance practical applications, in line with the saying by the social psychologist Kurt Lewin that there is nothing so practical as a good theory, novel psychotherapeutic techniques are presented. Several of these techniques, falling under the umbrella of cognitive regulatory control therapies, are designed to restore compromised regulation occurring with anxiety, depression, mania, and psychosis. In addition, the chapters on dissociation, eating disorders, reinforcement based disorders, and personality disorders provide novel approaches to managing these conditions. By embracing theory, in combination with empirical results, a unique conceptual framework with practical treatment applications is thus generated. An unfortunate consequence of the current-day rejection of theory in mental health research is that there is little impetus or capacity for paradigm shifts, so crucial for the advancement of science. The current book facilitates this crucial paradigm shift, and will hopefully open up much needed dialogue while providing an informed direction for the necessary changes.

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