A ramble on the biopsychosocial model, the future and what is mental illness?

According to the medical model the elements that make up an individual
are of biopsychosocial cause.

Biology includes genetic predisposition and evolutionary preprogramming
of individual psychology as well as the biological impact of the
environment during the individuals' life. The psychosocial is the other
part. Its the impact of experiences and other people's behaviours. Its
the mix of predisposition and change affected by the environment. Its
the social constructs of the time and the individual's ability to fit
within them and/or survive the negative impact of temporal maladaption
(i.e. in another time with social progress they would not be
maladapted). Its life events, stressors and triggers, resilience and stigma.

This mix is the cause of individiality of behaviour, emotional
experience and consciousness. Its positivistic so there is no inclusion
of the idea of a soul or a non-corporeal, eternal part of the individual
as in many religions and cultures.

One day it may be possible to understand the complex interplay of the
biopsychosocial history of any individual, to see the predisposition but
to also see the effect of life and events. Genetics research in mental
health is a minefield compared to the science with physical conditions
because the effect of the psychosocial is considerably greater on the
mind. Psychology is complex and sociology is barely a 'proper' science
but they are essential to the quasi-correct understanding of the an
individual.

Its very, very difficult to do given current state of science in this
area. This is just a thought about the future.

That description or understanding would be an objective map of the
elements of individuality and what it is to be. To be truly scientific
it would make no judgements on what was normal and illness: all is
normal as much as all is illness. That is the only objective truth. It
is the decision of the society at the time through formal structures and
informal public structures as to what was weird, illness, or whatever.

The clarity would exist. The idea of illness is a way of understanding
mental illness but it is not a truth. In the past a similar construct
was called demonlogy instead of psychopathology or psychiatry, though
the 'pathology' was religous in basis. What was subjectively considered
'disorder of the mind' could be clearly marked upon an objective truth.

By the time this sort of understanding of the individual has developed
to become usable I expect and I desperately hope that society would have
advanced in other ways. The understanding of the modern medical model
provides the concept of the privelidge of illness or disability. It is
necessary because in 2010 society is far from advanced though I percieve
that the rate of change is accelerating. I think it is described well by
the social model of disability: the individual is not ill per se but is
disabled by the constructs of society and social prejudice. This way of
understanding is something the public consciousness can understand when
they can not understand the idea of what mental illness actually is as a
construction of society though one that came into being because of the
stigma of behaviours, emotional extremes and unusual experieinces of
consciousness.

In other weird way that's what the mental health system is. It developed
after the Age of Reason took power away from religion and gave it to
science, and mental health took over the role as the new religion
accepted by the scientific paradigm. The exact same experiences that
came to be described as dementia praecox, melancholia and ...mania (I
forget the other Kraeplinian major diagnoses) existed for millenia and
will continue to. Certain behaviours, extremes and unusual experiences
or people have and will always exist. What society chooses to call them
is not an objective truth and there have been many worse interpretations
than the psychiatric understanding of illness.

The pervasive understanding of the social model of disability offers the
best hope for the near future but at its core the mental healthcare
systems - doctors, nurses and other mental health professionals - are
still strongly medical-model based. Some professionals, for example
those with degrees in sociology or psychology, are taught to understand
the social model of disability and social theory however this is not
covered in depth in medical education. Certainly the many doctors I've
spoken to see to understand the social model in principle but without
true understanding of the depth of what it actually means and what it
means to medicalise individuals with socially-constructed illness, and
what it means for mental healthcare.

Fools, risks and what it is to be human

This piece is actually about something or someone however I've self-censored in case the openness created unintended impact.

Its hard taking risks. Forseen and unforseen consquences are usually suffered by those who take risks. Those who don't live in safety and stability. Those that do live, but its a harder path.

But I contemplate if this is the definition of foolishness. To know the consequences of a mistake and to make it again. To make the risk/reward rationalisation and then to act with disregard to it. To weigh one thing above all else in a logical decision-making process, and one which only has value to an idealist: the present feeling of the ignobility of silence. I'm far, far from a noble creature as any reader may have already gathered so why at that time I felt like that was the valuable thing that made me express how I felt rather than internalising it or doing as I'd been ordered to do by her friend is something I have no good answer to.

This is my foolishness though. I'm not one of those fools who never takes a risk because they're afraid of looking like a fool. I'm not one of those fools that doesn't learn from their mistakes. I'm one of those fools who believes that there are some things in life that are about knowing the consequences and understanding the negative - and in this case futile - impact of an action but doing it anyway because of the foolish belief that to do that is more a human being being what they truly are.

Our essence is more than the logical mind and the capability to weigh up our choices. The capability to act with 'soul' or driven by things other than tangible rewards is what defines an individual from a computer. The soul truly expresses itself in the mistakes that are learnt from but subsequently consciously redone.

And this is life, not some computer game. Results are always unpredictable. Right now though that logic doesn't appease my feelings of regret, but I accept that that too is so very human.

I contemplate the definition of foolishness. To know the consequences of a mistake and to make it again. To make the risk/reward rationalisation and then to act with disregard to it. To weigh one thing above all else in a logical decision-making process, and one which only has value to an idealist: the present feeling of the ignobility of silence. I'm far, far from a noble creature as any reader may have already gathered so why at that time I felt like that was the valuable thing that made me express how I felt rather than internalising it or doing as I'd been ordered to do by her friend is something I have no good answer to.

This is my foolishness though. I'm not one of those fools who never takes a risk because they're afraid of looking like a fool. I'm not one of those fools that doesn't learn from their mistakes. I'm one of those fools who believes that there are some things in life that are about knowing the consequences and understanding the negative - and in this case futile - impact of an action but doing it anyway because of the foolish belief that to do that is more a human being being what they truly are.

Our essence is more than the logical mind and the capability to weigh up our choices. The capability to act with 'soul' or driven by things other than tangible rewards is what defines an individual from a computer. The soul truly expresses itself in the mistakes that are learnt from but subsequently consciously redone.

And this is life, not some computer game. Results are always unpredictable. Right now though those words don't appease my feelings of regret about the thing that I'm not talking about, but I accept that that too is so very human.

"That line could be about so many things in life but at the moment I'm taking about the risk I took telling someone that I loved them when there was no hope of a positive outcome. I'm feeling a mixed set of negative emotions. There's a small element of "why do I do it to myself" and my personal answer to that is: because its "me." There's the low feeling where I just want to crawl into bed and there feels like there's no rational or conscious thought to it. Its just a feeling that I don't given into too much. Its the bank holiday weekend and had I not said anything then we'd probably be hanging out right now. I regret what I did right now on an emotional level because I miss this person in my life. But even with foreknowledge I would do the same and lose my
rainbow again."

A useful academic paper on the distinction between a personality disorder and a mental illness. Also very useful for an insight into psychiatric theory.

This paper is one of the most downloaded papers from the British Journal
of Psychiatry and they've made it open access.

Kendel, R. 2002, The distinction between personality disorder and mental
illness, British Journal of Psychiatry.
http://bjp.rcpsych.org/cgi/content/full/180/2/110

There's a lot of information about understanding the underlying concepts
of mental illness but its not an easy paper to read without having a bit
of background knowledge. It makes an attempt to define mental illness
and falls short as every other attempt with 4 definitions explained.
Mental illness clearly isn't a referent term in 2010.

There are some great bits of stigma within psychiatry in there and
examples of how psychiatry misunderstands the human condition.
"Certainly,^ it is commonplace for a diagnosis of personality disorder
to^ be used to justify a decision not to admit someone to a psychiatric^
ward, or even to accept them for treatment — a practice^ that
understandably puzzles and irritates the staff of accident^ and
emergency departments, general practitioners and probation officers, who
find themselves left to cope as best they can^ with extremely difficult,
frustrating people without any psychiatricassistance. The reasons for
this attitude were explored by^ Lewis & Appleby (1988 <#REF18>). Using
ratings of case vignettes^ by 240 experienced psychiatrists, they showed
that suicide attempts and other behaviours by patients previously
diagnosed as having^ personality disorders were commonly regarded as
manipulative^ and under voluntary control rather than the result of
illness,^ and that the patients themselves were generally regarded as^
irritating, attention-seeking, difficult to manage and unlikely^ to
comply with advice or treatment."

There's a useful precise definition of biomedical illness
"Scadding,^ a chest physician, defined a disease as 'the sum of the^
abnormal phenomena displayed by a group of living organisms^ in
association with a specified common characteristic or set^ of
characteristics by which they differ from the norm for the^ species in
such a way as to place them at a biological disadvantage'.^ He never
explained what he meant by biological disadvantage,^ but Kendell (1975
<#REF12>) and Bourse (1975 <#REF5>) both argued that it must at least
encompass reduced fertility and life expectancy."

There's a short snip that elucidates on why medicine would want to
medicalise personality disorders
"The evidence that personality disorders are harmful is quite^ strong
and not restricted to clinic populations. Drake &^ Vaillant (1985
<#REF9>), for example, compared 86 middle-aged men^ who met DSM—III
criteria for personality disorder with^ 283 men who did not. Both groups
had originally been members^ of a cohort of mainly working-class,
non-delinquent adolescent^ boys previously studied as a control
population in Boston by^ the Gluecks, so extensive background
information was available^ for all 369. Compared with the 283 men
without personality^ disorders, the 86 personality-disordered men (only
six of whom^ had disorders of antisocial type) had poor mental health
(79%^ /v/. 14%), poor occupational performance and job satisfaction,^
and poor social competence (58% /v/. 10%), and although alcohol^
dependence or misuse was partly responsible for their poor^ occupational
performance, it made little contribution to their^ poor mental health
and social competence."

One of the most interesting passages is on the influence of the
introduction of an effective treatmentin clinicians acceptance of a
social condition or behaviour as a medical illness.
"*The influence of effective therapies*
The second issue is the influence on medical attitudes of the^
acquisition of an apparently effective therapy. For nearly^ 150 years,
claims that alcoholism was a disease, from Thomas^ Trotter in 1804 to
Alcoholics Anonymous in the 1930s and 1940s,^ cut little ice with the
medical profession. It was only in^ the late 1940s and 1950s, when
disulfiram became available,^ that doctors changed their minds. Now, of
course, it is evident^ that disulfiram is not generally an effective
therapy, but^ in its early years enthusiastic reports of cures were
published^ in many different countries, and it was against this
background^ that the World Health Organization decided to include
alcoholism^ itself, as distinct from alcoholic psychoses and acute
alcohol poisoning, in the ICD, and medical organisations throughout^ the
world issued formal statements to the effect that alcoholism^ /was/ a
disease after all. The reasoning involved suggests an^ acceptance of the
socio-political definition described above,^ although this has rarely
commended itself to the medical profession.^ It does seem, none the
less, that possession of an apparently^ effective treatment can produce
a decisive change in medical opinion, and Campbell /et al/ (1979
<#REF6>) showed that an established^ medical role in diagnosis or
treatment has more influence on doctors' concepts of disease than on
those of the public. At^ present, neither personality disorder nor
obesity is accepted^ as a genuine illness by most British doctors; but
as effective^ drugs for treating obesity come into widespread use over
the^ next decade it is likely that obesity will come to be accepted^ as
a genuine metabolic disorder, and the same may happen to personality
disorders. Indeed, it is already happening to the 'borderline' disorders
as evidence accumulates that^ the disruptive and self-destructive
behaviours that characterise^ the disorder are amenable to forms of
psychotherapy (Linehan^ /et al/, 1991 <#REF20>; Bateman & Fonagy, 1999
<#REF3>). There is also some^ evidence that fluoxetine reduces
irritability and aggression^ in people with a variety of personality
disorders (Coccaro & Kavoussi, 1997 <#REF7>).^ If, therefore, the
psychiatrists andpoliticians who maintain that 'antisocial personality^
disorder' has as good a claim to being accepted as a^ mental disorder as
schizophrenia can demonstrate that it responds^ to some form of
treatment that is not simply a disciplined environment, it is likely
that the opposition will melt away,^ and the same will be true for other
types of personality disorder."

A hope from the future from the trends of the past

In the past the Church used to diagnose madness. It chose a few
different criteria. Four of them were: heresy, witchcraft, possession
and canonisation.

Treatments varied and were even more inhumane than some of the
treatments for madness is the 20th century. Those who would now get a
diagnosis of schizophrenia, schizoaffective, schizotypal personality
disorder, dissociative disorders and other psychotics disorders would be
usually persecuted. During the time of the Spanish Inquisition the
results of a diagnosis often meant death unless the experience or the
individual chose to agree with the paradigm of the Church.

Today things have changed a great deal. Persecution has been replaced by
simple discrimination. The outcast were confident to asylums,
medicalised then slowly rejoined society throughout the latter 20th
century. The days of treatments like the lobotomy and leucotomy where
parts of the brain were removed are over, though have resurfaced in
neurosurgery for mental disorder (also know as psychosurgery).
Thankfully these are still experimental treatments however once the
technqiues are perfected society and medicine has the opportunity to
'treat' in new ways from the Inquisition.

In the days of the Inquisition madness was understood not as illness but
as some sort of religious abheration. To the people of the day the
concept that it was an illness was absurd. It was likely punishment from
god or some error of god's way, rather than something with
biopsychosocial aetiology and Kraeplinian ostensivity

Taking a leap into the future, it is my hope that the treatments and
understanding of mental illness will have shifted again such that they
will look on their ancestors' deeds as we look upon the consequences of
diagnosis by the Inquisition. The leaps required away from the medical
dogma are as necessary as the heretic thought required to move away from
the religious model of mental disorder. Progress will happen in in no
other way.

Was Jesus mad?

Now this is a piece that's likely to offend people because of the stigma
of madness but I hope readers are openminded.

There is a high likelihood that were Jesus to be born today he or she
would have a very unusual experience of consciousness and would get a
diagnosis related to psychosis, unshared perceptions or auditory
hallucinations.

40 years ago hearing voices meant immediate hospitalisation. Today
hearing the voice of god is assumed to no longer experienced anywhere in
humankind anymore, and anything akin to it is severe mental illness
according to the medical and psychiatric model. Believing yourself to be
the direct descendant of god is also a psychiatric illness worthy of the
honour of being called madness.

Happy Easter.

Victory for science, freedom of speech and in a way for the legal system

http://www.guardian.co.uk/uk/2010/apr/01/simon-singh-wins-libel-court

http://jackofkent.blogspot.com/2010/04/that-easterbrook-quote-on-scientific.html
(for the legal impact from the blog of one of Simon's key supporters)

After a 2 year fight Simon Singh finally won his appeal against the
British Chiropractic Association for libel.

The case has brought to light Britain's absurb libel laws and also
ruined the reputation of the BCA. Had they not brought it up the
evidence, or lack thereof based on the paradigm of evidence-based
medicine, about their treatments being very rarely better than the
placebo effect (if ever).

It seems that any treatment that doesn't hold up against a high quality
RCT, for example CBT for psychosis, could be described as a bogus
treatment now. So NICE's schizophrenia guidelines last year in fact
promoted a bogus treatment with its recommendations on CBT as the
primary psychological therapy. It recommended against certain treatments
that are equally bogus. Sadly it came to this conclusion using what is
considered the gold standard technique for evidence scoring and
evidence-based commissioning.

Why do suicidal thoughts happen?

In the last few months I've had one person open up about suicidal thoughts and one person who won't tell me if they're experiencing suicidal thoughts. The first seemed to be toying with the idea as much as they didn't want to do anything about it. The second person has been
harder to get them to open up again. I've met someone else who's been suicidal for a long time like me. And another person who accidentally mentioned she'd felt suicidal in the past.

Between the four of them and me there's a range of experiences of suicidal thoughts. One person described theirs as though separate from themselves, as though they had no control over them. They seemed almost surprised at the question as to why they felt suicidal. Another seemed
to be trapped in an internal reality where ideals and philosophical thought seemed to be creating some sort of existentialist crisis and it seemed like there was little joy they took from their lives.

I've had suicidal thoughts on a regular basis. "I wish I was dead" and other phrases I can think and then move on from now I've had them appear so many times. These can be irrespective of mood, moment and events. At other times they can come through looking at life and seeing it lacking or seeing my life as a failure. I'm sure its a feeling many people experience.

Usually I can deal with those thoughts and feelings by either looking at the positive or accepting the truth of my life: it gets better, and we just keep surviving. At other times it was a way to deal with a life crisis like getting into what I thought was an irrecoverable financial situation or after the end of a relationship. Both those experiences were about the castle in the sky that is status (in all its forms), respect and self-respect (and others) collapsing or being percieved to
collapse. And now I've learnt that these things are simply constructs, fluid and intangible - they're very far from real and to be clung to like life should be. Those are also experiences other people have had though perhaps they reacted better than I.

Then there was the parasuicidal behaviour that was the war against the entity - the noncorporeal force or whatever that I feel in my life and in my heads. My sense of "I" discovered it wasn't in control of me, i.e. my sense of self came to be aware that it was not alone nor in control of my mind and body. I'm sure many a reader has a thought popping into their head at this moment like "schizophrenia" or "psycho" or "psychosis". Maybe those who read this who have understanding of this experience can sympathise and perhaps even empathise. This was a force I couldn't control so I fought with the only thing I thought I could control: my life. There were many recent attempts and prolific self-harm as a bizarre way to fight back and take
control. I'm out of that phase now and me and my entity are in a period of peace.

The point of this is there are many reasons why people kill themselves. There are also many experiences of suicidal thoughts. Another person I've met has told me they experience their suicidal thoughts as coming from the voice inside their head. It seems the opposite of my experience in the sense that I attempted to regain control or die trying as my will, whereas it seemed their path was for their "I" to fight against the command to kill themself. Perhaps it was the same experience however one person experienced themselves as one of the selves while my experience was the experience of the other self (this makes no sense without having experienced what I'm talking about or having a good understanding of madness).

There are lots of reasons why suicidal thoughts happen and why people kill themselves.