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Biologically-Based Mental Illnesses

As a result of the Mental Health Parity Act, many health insurance companies are now providing the same coverage for biologically-based mental illnesses as they provide for other medical illnesses. A biologically-based conceptualization of mental illness allows advocates to frame parity legislation as antidiscrimination legislation. Using PET scans and MRI’s, researchers have testified before Congress and state legislatures that mental illness is directly linked to brain dysfunction. In light of such evidence, policy makers have been persuaded to admit that certain mental illnesses are brain disorders (Peck & Scheffler, 2002). I see this as a double-edged sword.

On the positive side, it is wonderful that individuals with certain mental illnesses are now getting the insurance coverage they so desperately need. I am a huge proponent of equitable services for all people with mental illnesses. Additionally, I am pleased to see that the tide is beginning to turn in regards to society’s attitudes about psychiatric problems. This is undoubtedly a good start. But it is only a start.

There are a number of problems with the concept of biologically-based mental illnesses as defined by insurance companies:

1.) They are creating a false dichotomy by differentiating between biologically-based and non-biologically based mental illnesses. Empirical evidence challenges the discriminant validity of the “biologically based mental illness” construct. Psychotherapy and medication yield similar changes in brain function when effective. Drug and brain imaging studies show that psychological and biochemical phenomena can be manipulated reciprocally (Seidel, 2005). The truth is, ALL mental illnesses are biologically-based because all mental functioning is biologically-based. Western society clings to the 17th century notion of Cartesian dualism; that is, the idea that mind and body are separate. But let’s take a closer look. The word “mind,” as used today, refers to intellect and consciousness, manifested as combinations of thought, perception, memory, emotion, will, and imagination, including all of the brain’s conscious and unconscious cognitive processes. And where do these cognitive processes originate? In the brain, which is part of our biology! Every thought and feeling we have, every perception and wish and behavior, has a corresponding neurobiological substrate.

2.) The insurance company’s decisions about which mental illnesses to classify as biologically-based seem rather arbitrary. Some insurance companies only classify schizophrenia, bipolar disorder, and OCD as biologically-based, while other insurance companies cover other disorders as well. For example, one major health insurance company defines biologically-based mental illness as “a mental or nervous condition that is caused by a biological disorder of the brain and results in a clinically significant psychological syndrome or pattern that substantially limits the functioning of the person with the illness.” This insurance company classifies the following as biologically-based mental illnesses: Schizophrenia, Schizo-affective Disorder, Major Depressive Disorder, Bipolar Disorder, Paranoia and other Psychotic Disorders, OCD, Panic Disorder, Pervasive Developmental Disorder, Autism, and Alcohol Abuse Disorders. This same insurance company defines non-biologically-based mental illness as conditions that “display symptoms that are primarily mental or nervous in nature. The primary treatment is psychotherapy or psychotropic medication.” I don’t understand this distinction at all. All of the biologically-based mental illnesses they listed are “mental or nervous in nature” and treatment for all of them includes behavior therapy, psychotherapy and / or psychotropic medication. Further, why is alcoholism considered biologically based, whereas are addictions to substances other than alcohol considered “non-biologically based?” And why is anorexia nervosa, which has numerous biological features and complications, a heritability estimate as high as that of schizophrenia and bipolar disorder, and the highest mortality rate of any psychiatric illness, considered a non-biologically based mental illness?

3.) The erroneous classification of certain mental illnesses as non-biologically based serves to increase stigma and discrimination against individuals with these illnesses. There is a subtle implication that so-called non-biologically based mental illnesses are not as serious, not as legitimate, or not as real as so-called biologically-based mental illnesses. Further, there is an even subtler implication that non-biologically-based mental illnesses are somehow the patient’s fault or the patient’s choice. It is as if they are saying: “It’s all in your head.” Well, yes, but so are Alzheimer’s Disease and brain cancer!

4.) I’m not sure why illnesses of the brain, whether they are classified as “biologically-based” or not, should be considered any different from illnesses of the heart, lungs, liver, or kidneys. Is it because environment and lifestyle, rather than biology, are presumed to be the cause? The development of heart disease, Type II diabetes, skin cancer, and AIDS are all heavily influenced by environment and lifestyle choices, and no one would argue that these diseases are not biologically-based. People with these diseases are not discriminated against in insurance coverage.

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Living Is Easy With Eyes Closed

Unless we are mindful and deliberate in leading lives of conscious action, our fate is determined largely by our inborn temperament; that is, what we find rewarding. The majority of people live lives of unconscious reaction. They are not mindful of their thoughts, feelings, or actions, or the consequences thereof.

For people living with mental illness, this tendency is particularly devastating and self-reinforcing. To the person suffering from alcoholism, it is far more rewarding to pick up a bottle than to endure painful withdrawal symptoms, seek treatment for underlying psychological issues, confront the emotional baggage that led to drinking, part ways with drinking buddies, and essentially create a whole new life. To the person with major depression, it is far more rewarding to curl up in bed all day than to muster the Herculean strength it takes to drag through yet another meaningless day. To the person with borderline personality disorder, it is far more reinforcing to engage in numbing, soothing self-injury than it is to learn and utilize distress tolerance and emotion regulation skills, to come to grips with the abuse history and self-loathing that fuels urges to self-injure. To the person with anorexia nervosa, it is far more rewarding to fast and restrict. The avoidance of discomfort, the physiological euphoria, psychological sense of mastery, and the brief respite from the torturous inner voice make restricting and fasting far more rewarding than consuming a normal quantity of food and keeping it down. To the person with OCD, it is far more reinforcing to engage in compulsions and rituals that create a sense of safety and security than it is to sit with the incredible discomfort that arises from not engaging in these behaviors.

Most people never have to face their greatest fears consistently, repeatedly, and for prolonged periods of time in order to move through hell into the realm of so-called health and normality. This is why recovery from mental illness is so difficult and so heroic. Psychotherapy can help to illuminate patterns in a person’s life and help her come to grips with her own unique neurochemistry, temperament, and life history in a way that is empowering and useful. Psychotherapy can teach coping skills and psychological tools to help people deal with their unpleasant thoughts and feelings. Psychotherapy can provide a supportive, nurturing, unbiased relationship in which personal issues can be explored and understood. Psychotherapy helps to rewire neural pathways, setting into effect new patterns of thinking and feeling and acting.

And as for the rest of us? It is far easier to live lives of unmindful, unconscious reaction than it is to create deliberate, mindful lives of conscious action. It is far easier to absorb the beliefs and ideas of our parents, our teachers, our bosses, our political leaders, our priests and ministers and rabbis, than it is to think and speak for ourselves. It is far easier to assimilate passively the so-called truth we are fed by the media than it is to think critically and creatively. It is far easier to conform to societal norms, to agree with popular opinion, to be complicit and docile, than it is to be the change we wish to see in this world.

Join me in stepping off the beaten path. Join me in blazing a new trail and guiding others to come along. Do you dare?

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Informed Consent

The American Psychological Association’s ethical guidelines require that psychologists obtain informed consent for treatment from all patients and parents of minor patients. But what does it mean for consent to be truly informed?

In standard practice, informed consent generally amounts to a frazzled patient or harried parent signing a consent form after a perfunctory glance. Patients and parents are often in crisis when they first present for treatment, and signing the form is just one more hoop to jump through before getting into therapy. Most therapists’ consent forms cover business procedures and confidentiality issues. This is important information, but does it amount to truly informed consent?

I don’t think so.

I believe that the APA’s ethical guidelines should be revised to require full disclosure in informed consent for psychological treatment. Specifically, therapists should be required to disclose 1.) The patient’s diagnoses and explanations of these diagnoses, 2.) What factors caused or contributed to the patient’s illness, as evidenced by the most recent empirical research and the clinician’s informed judgment, 3.) What treatment methods are available for treating the patient’s condition, 4.) Which of these methods are evidence-based, 5.) Which method(s) the therapist will use, 6.) Why the therapist has selected these methods, 7.) The anticipated course of treatment and prognosis, based upon recent empirical research, and 8.) Scientifically informed, practical resources (e.g., books, articles, websites) on the patient’s condition and the type of therapy that will be used. For patients under 18, all of the above should be explained to the parents and to the child, using language appropriate to the child’s age and developmental level. Finally, parents should be provided with guidance as to how they can help their child recover. I’m talking about specific recommendations, not just blanket statements like “be supportive.”

In my consent for therapy forms, which patients (and parents of minor patients) read and sign before meeting with me, I specify the types of treatment I use, all of which are evidence-based. After the evaluation, I provide patients(and parents of adolescent patients) with empirical research on their particular disorder, as well as information on the efficacy of various types of treatment and who recommends these treatments (e.g., APA, Society for Adolescent Medicine, etc.). I explain the type of treatment I recommend for them, why I have selected this type of treatment, how it works, and what to expect on the road to recovery. If there is a type of treatment that is likely to be effective for the patient but that I do not offer (e.g., psychiatric medication, residential treatment), I provide them with referrals to these types of treatments and explain why I think they would be beneficial. At this point, the patient has all of the information she needs to make an informed choice about treatment.

Most patients seeking therapy, and most parents seeking therapy for their children, are not aware that there are different types of psychological treatments with varying degrees of efficacy. I think most people outside of the field assume that therapy is therapy and that therapists are pretty much interchangeable, like dentists or surgeons. Many people assume that as long as you like your therapist and feel comfortable with her, that’s all that matters. While the therapeutic relationship is undoubtedly a critical aspect of treatment, there are other factors to consider in selecting a therapist. Often times, people want to see a psychologist with decades of experience. This is an understandable, albeit unreliable, method of seeking good treatment. The older, more experienced therapists were trained decades ago in theories that have since been discarded, in therapeutic methods with no scientific backing. Sometimes they become set in their ways of practicing, clinging to old theories like religious dogma in spite of evidence to the contrary. Granted, many experienced therapists have kept up with recent developments in the field and have educated themselves. Sadly, many have not.

Informed consent in therapy is complicated by the fact that different professionals have vastly different, and often contradictory, views on the causes of various mental disorders and how best to treat them. To make matters worse, the public has access to a tremendous amount of information on mental health issues through the internet, much of which is either unsubstantiated or patently false. Consequently, many patients arrive in our offices with deeply entrenched false beliefs about their illnesses. As professionals, it is our job to set the record straight.

I have had a number of patients come to me seeking therapy for the first time after being unsuccessfully treated for anxiety or depression by their primary care physician. I use the term “treated” very loosely here – their doctor spoke with them for a few minutes and wrote them a prescription for a low dose of antidepressants or sleeping pills, only to follow up with them a year later. They were not informed about evidence-based psychological treatments. They were not informed about behavioral methods of treating insomnia. And of course, they were not informed that their dose of Prozac is far too low to have any therapeutic benefit. Similarly, I have had patients come to me after years of therapy for depression or self-injury who have done endless amounts of exploration into the supposed causes of their supposed issues, without ever learning the skills they need to recover.

Parents of eating disordered children have come to me for Maudsley family-based therapy after months or years of unsuccessful therapy, after multiple hospitalizations and stints in residential treatment. These families were never informed about the Maudsley Method by any of their child’s previous treatment providers. These parents, desperate to help their children, did their own research on the internet late at night, sifting through the mounds of information to try to find the one thing that would save their child’s bright future. I’ve seen patients, who have been through years of eating disorder treatment with other professionals, who have never once been told that they have a biologically-based, genetically-transmitted mental illness which is neither their fault nor their choice.

Parents of eating disordered children have a right to be informed about the Maudsley Method at the time of diagnosis. The research is clear that Maudsley is the most effective treatment for adolescents with a short duration of illness who are still living at home with their families. For various reasons, Maudsley is not the best choice for every patient or family. Nonetheless, families have the right to know it exists and to decide for themselves whether they wish to pursue it. Patients with depression, anxiety disorders, and personality disorders have the right to be informed about evidence-based treatments such as CBT, DBT, and ACT. Many lives, many years of chronic illness, and many dollars spent on ineffective treatments could be saved if patients and parents were fully informed about evidence-based treatment options from the outset. If a patient has cancer, it is her physician’s duty to inform her of the various life-saving treatment options, some of which may be available in that physician’s office or the local hospital, and some of which are only available in the nearest major city. Why should psychology be any different?

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10 Common Mistakes in Eating Disorder Treatment

Eating disorders are notoriously difficult to treat and have the highest mortality rate of any psychiatric illness. With traditional treatment, average time to recovery is 5-7 years, relapse is the norm, and many patients continue to suffer from chronic physical and mental illness for decades. Fortunately, new research has shed light on how we can help patients recover more quickly, prevent relapse, and live healthy, fulfilling lives. Below are 10 of the most common mistakes I’ve observed in the treatment of eating disorders.

1.) Setting target weight too low.

Physicians and dieticians will often set a patient’s minimum target weight at the low end of the statistically-determined “ideal” range. The minimum target weight thereafter becomes the maximum allowable weight in the patient’s mind, and she will do whatever she can to avoid going above it. There is no such thing as a universal minimum target weight. People vary dramatically in terms of body build, muscle mass, bone structure, body shape, and natural weight. Professionals need to take these factors into consideration when setting target weight ranges. The minimum target weight is often not sufficient to promote brain healing and repair the damage caused by malnutrition. “Out of immediate medical danger” does not translate to optimal physical and mental health. Many patients are left to struggle with ongoing depression, fatigue, anxiety, and preoccupation with food and weight because they haven’t reached their optimal body weight.

For children and adolescents, setting minimum target weight too low is especially dangerous because it fails to take into account the natural growth and physical development that occurs throughout adolescence. The ideal weight for a 13-year-old is not ideal for a 22 year-old. A 13-year-old patient who becomes fixated on her “minimum target weight” and maintains such a weight for a number of years is placing an indefinite moratorium on her physical, psychological, and sexual development. Another problem that is particularly disconcerting is that the minimum target weight set by professionals is often significantly lower than the patient’s pre-eating disorder weight, even if the patient was at a healthy weight before. Think about the subtle message this sends and how the ill patient may interpret it: “You were too big before, so you were right to start dieting.” This just feeds into the eating disorder. We need to send a different message: complete weight restoration is not negotiable.

2.) Discharging patients from inpatient or residential programs prematurely.

By “prematurely,” I mean several things: before the patient has reached her ideal body weight, before she has developed the skills to manage her symptoms, before other comorbid conditions have been diagnosed and treated, before the patient’s family has the knowledge and tools they need to support continuing recovery, or before a solid relapse-prevention plan is in place. According to my standards, then, the majority of patients are discharged prematurely. With treatment as usual, relapse is the norm, and repeated admission to hospitals and residential facilities is expected. It doesn’t have to be this way, and relapse may not be such a major problem if patients were treated fully and successfully the first time around. Of course, this will require healthcare reform and better insurance coverage in order to pay for a much longer duration of treatment, but I digress.

3.) Blaming parents for their child’s eating disorder.

Parents have traditionally been excluded from their children’s eating disorders treatment in large part because professionals have blamed them for causing the eating disorder. This viewpoint is based in psychoanalytic theory, not empirical fact, and to date there has been no reliable scientific evidence that parents cause eating disorders. Blaming parents is harmful to the entire family. It disempowers parents, angers and confuses the patient and her siblings, and interferes with the recovery process. Only a generation ago, parents were blamed for causing their children’s autism and schizophrenia. We now know that these illnesses are biologically-based brain disorders, and the idea of a “refrigerator mother” causing her son’s autism is ludicrous. I look forward to the day when the general public has the same sentiment about parents causing eating disorders.

4.) Failure to involve parents and other family members in the patient’s treatment.

Parents have a right and a responsibility to be fully informed and actively involved in their child’s treatment. Imagine how confusing and disempowering it is for parents to drop their child off at various appointments without being informed about the treatment and without being given an opportunity to ask questions, voice their concerns, or help with the recovery process. Likewise, adolescents have a right to have their parents fully informed and actively involved in their treatment. No child would have to manage cancer or diabetes independently. Why should it be any different for eating disorders? The research clearly indicates that involving parents in an adolescent’s eating disorder treatment dramatically increases her chance of full recovery.

Some therapists argue that involving parents in an adolescent’s treatment is counterproductive because it interferes with the adolescent’s burgeoning autonomy and encourages the family unit to remain enmeshed. In reality, the opposite is true. The eating disorder itself is disruptive to normal adolescent development and causes the patient to remain dependent on her parents. Family-based treatment approaches, such as the Maudsley Method, are first and foremost respectful of adolescent development. These approaches empower parents to help their children recover so that they may return to normal adolescent life, unencumbered by the illness.

5.) Basing interventions on unsubstantiated theories about the causes of eating disorders.

Our ideas about etiology inform our treatment approach. Consequently, incorrect assumptions about eating disorders tend to result in ineffective treatment. Let’s say, hypothetically, that controlling parents cause eating disorders. Or that media images which glorify thinness are responsible for eating disorders. Or that anorexia nervosa is caused by sexual abuse or is rooted in a desire to avoid growing up. Even if these things were true (and there is no reliable scientific evidence that they are), the first priorities in treatment should still be nutritional rehabilitation, weight restoration, and medical stability. Why? Because the patient’s life and health depend on it. Because research has consistently shown that many of the physical and mental symptoms of eating disorders are caused or exacerbated by malnutrition, restrictive eating, bingeing, and purging, and that these symptoms diminish with normalized eating and weight restoration. Because spending more time at a suboptimal weight, or engaging in food restriction, binge eating, or purging, is causing more physical and emotional damage. Because a weight-recovered, medically stable eating disordered patient who is receiving full nutrition is better equipped to explore and process the issues that may have triggered eating disorder symptoms in the first place.

6.) Viewing the patient’s symptoms as rationally chosen behaviors.

Recent research suggests that eating disorders are genetically-transmitted, biologically based mental illnesses, just like bipolar disorder and schizophrenia. No one would choose the agony and suffering of an eating disorder. I think the general public may get confused about this point because, for healthy people, eating and exercise are voluntary behaviors that are largely under conscious control. For eating disorder patients, restrictive eating, fasting, excessive exercise, bingeing, and purging are compulsive behaviors brought about by a brain condition, perpetuated by malnutrition, and aggravated by emotional stress.

Not only is it incorrect to view eating disorders as choices, but it is dangerous as well. It leads to blaming patients for their illnesses, trying to talk them out of their symptoms, and giving them the responsibility of choosing recovery. Almost invariably, people with anorexia are not able to choose recovery because denial and lack of insight are hallmark symptoms of the illness. People with bulimia are more likely to acknowledge their disorder and enter treatment voluntarily, but they are often unable to interrupt the binge/purge cycle without a major intervention and significant support from others. Insight and motivation are not prerequisites for entering treatment, restoring weight, or stopping unhealthy behaviors. Rather, increased insight and desire to maintain health are natural consequences of full nutrition, improved brain health, abstinence from eating disordered behaviors, and good therapy.

7.) Overemphasizing psychological recovery while underemphasizing physical recovery.

I am not entirely sure why many clinicians work with patients on developing insight and searching for a root cause early in treatment, prior to nutritional restoration and medical stability. We still do not know the causes of many types of cancer, but cancers are treated aggressively as soon as they are diagnosed. A surgeon will operate on a patient to remove a tumor regardless of whether he knows what caused it. It is tragically comical to imagine a doctor and patient searching for the cause of the tumor while it metastasizes.

One of the earliest things we’re taught in our clinical training is how to build a positive, trusting relationship with the patient. If the patient doesn’t trust us and feel comfortable with us, the therapy won’t work. Indeed, psychotherapy research across various disorders and types of treatment has demonstrated that the therapeutic relationship is a very powerful predictor of outcome. However, the therapeutic relationship is more complicated in working with eating disorders because success in therapy requires that the patient do the exact opposite of what her disorder wants: eat more and gain weight. Early in treatment, it often seems as though maintaining a positive therapeutic relationship and helping the patient recover are mutually exclusive. So often, well-meaning eating disorder therapists work hard early on to gain a patient’s trust and build a positive therapeutic relationship in the hopes that the patient will eventually develop the insight and motivation to address her symptoms. While this rapport-building is going on, the patient is becoming sicker, weaker, thinner, more depressed, and more entrenched in her symptoms. Allowing the patient to marinate in malnutrition and continue to engage in her symptoms delays recovery, increases her risk of medical complications, and prevents her from being able to engage in the psychological work of recovery.

The therapeutic relationship is only therapeutic insofar as it facilitates health, growth, and recovery. I have found that my relationships with patients improve naturally, and dramatically, once they are no longer engaging in restricting, bingeing, or purging. I would much rather have an angry, tearful adolescent patient hurl vile words at me as I’m pushing full nutrition and weight restoration than a quiet, sweet adolescent patient who enjoys talking with me as her health declines and her vital signs dwindle.

8.) Overemphasizing physical recovery while underemphasizing psychological recovery.

This is the polar opposite of #7. It happens far less often that #7, but it does happen. Full nutrition, weight restoration, medical stability, and cessation of binge/purge behaviors are absolutely necessary, but not sufficient, for recovery. Restoring physical health is only the beginning of a long, difficult process. The psychological aspect of eating disorders cannot be ignored or minimized. Patients need low-stress environments and lots of support from loved ones. Most patients need psychotherapy to address anxiety, depression, perfectionism, social concerns, body dysmorphia, and other issues that may have contributed to the eating disorder. Therapy can help patients develop the skills they need to manage their emotions, cope with stress, stay healthy, and prevent relapse. Some patients need psychiatric medication to treat comorbid conditions such as ADHD, OCD, or major depression. Fully addressing the patient’s psychological needs, as well as her physical and nutritional needs, gives her the best shot at lasting recovery.

9.) Failure to intervene immediately, and aggressively, at the first sign of weight loss or change in eating or exercise behavior.

The research is very clear on this point: early intervention predicts better prognosis. We should not wait for a teenager to develop full-blown anorexia nervosa or bulimia nervosa before stepping in to help her. We should not wait for her to drop to 15% below her ideal body weight, miss 3 consecutive menstrual periods, or develop a dangerously low heart rate. We should not wait until she has binged or purged twice a week for three months. Let’s step in when she is 1% below her ideal body weight, when she has missed one menstrual period, when she has purged one meal. Better yet, let’s step in as soon as we notice body image concerns, changes in eating or exercise habits, or excessive preoccupation with body weight and shape.

10.) Using physical appearance or statistically-determined BMI charts as definitive measures of physical or mental health.

There is a common misconception that all people with eating disorders are emaciated. This is not necessarily true. Certainly, individuals in the acute phase of anorexia nervosa are often shockingly thin. However, most people with eating disorders don’t “look sick.” Individuals with bulimia are usually of normal weight. People with anorexia who are at or near their ideal body weight, but still actively struggling with eating-disordered thoughts and feelings, generally “look normal.” Further, it is impossible to tell whether a person is underweight simply by looking at them. Because ideal body weights are highly individualized based upon bone structure, muscle mass, body shape, and weight history, a person may fall within the “ideal” BMI range and still be significantly malnourished or dehydrated. The danger in using physical appearance as a gauge of mental or physical health is that people who “look normal” may be overlooked. Their eating disorders may not be as easily detected and may not be taken as seriously. These patients don’t believe they deserve treatment because they’re not thin enough, not sick enough, not worthy enough. As professionals, we must not fall prey to this distorted thinking.