Blame it on the Brain

There is much debate amongst mental health professionals as to whether mental illnesses should be called “brain disorders.” A large part of the disagreement, as I see it, comes from a lack of consensus as to the meaning of the term “brain disorder.”

I conceptualize a brain disorder as a disease or disorder that originates in the brain and influences mood, thinking, learning, and/or behavior. By my definition, all disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are brain disorders, including autism, ADHD, major depression, bipolar disorder, OCD, anorexia nervosa, bulimia nervosa, reactive attachment disorder, Alzheimers, and schizophrenia.

To me, “brain disorder” does NOT mean:
• Environment does not play a role in its development
• Environment does not play a role in recovery
• It is 100% biologically based
• It is 100% genetically inherited
• It can only be treated by physician or with a pill
• Psychological interventions won’t help
• The patient can’t do anything to influence the outcome

None of the above is true for ANY brain disorder, whether we’re talking about one that is commonly accepted as “biologically based” or not. In fact, I don’t know of any physical disease or medical condition in which any of the above is true.

Some people in my field are willing to apply the term “brain disorder” to some illnesses which are widely accepted to have a neurobiological basis (e.g., schizophrenia, autism, Alzheimers) but adamantly resist using this term to describe eating disorders, depression, or anxiety disorders, which they perceive to be something else. The underlying assumptions here, which few people would openly admit, are that some mental disorders are legitimate diseases whereas others are choices or responses to the environment; some mental illnesses are serious and deserve to be treated (and funded by insurance) whereas others are the patient’s or the family’s fault, so treatment is optional.

Clinicians who oppose the use of the term “brain disorder” to describe certain mental illnesses typically fall into one or more of the following categories:
• They don’t have a strong science background
• They lack basic knowledge of biology and genetics
• They suffer from (or have suffered from) the mental disorder in question and are personally offended by the term because they believe it invalidates their personal experience
• They feel that their professional identity, the work they have done for many years, is threatened by acknowledgment of the neurobiological basis of mental illness
• They believe that family dynamics or socio-cultural forces are the root cause of mental disorders, and that changing family dynamics or socio-cultural forces will cure or prevent mental disorders.

My clinical work is grounded in the knowledge that all mental illnesses are brain disorders. I believe my patients benefit from knowing that they have a neurobiologically-based, genetically inherited illness which they did not choose and their family did not cause. In order to get well, they must have a profound appreciation of their unique vulnerabilities and how to make healthful choices in order to keep themselves well. It is important for me, as a psychologist, to understand how the brain works – the mind-body-behavior connection – and it is important for me to educate my patients and their families about these issues as well.

It’s a two-way street – brain function affects thoughts, emotions, and behavior; in turn, psychological and behavioral interventions change brain function. The fact that mental illnesses are brain-based does not necessarily mean that medication is required. Research has shown that, for many brain disorders, certain types of psychotherapy are more effective than medication (e.g., mild or moderate depression, panic disorder, social anxiety disorder, anorexia nervosa). For other brain disorders, a combination of psychotherapy and medication produces better outcomes than either treatment alone (e.g., severe major depression, OCD). Less than half of my current patients are taking any psychotropic medication. Many of my patients recover fully without medication, and those who do need medication can often take fewer medications and/or lower doses once they have had good psychological intervention.

One of my college-aged patients who suffers from severe depression and anxiety recently shared the following insight, which beautifully captures the clinical utility of the “brain disorder” concept:

“With my last therapist, we just talked about what went wrong in my family that made me so screwed up. We spent the whole summer trying to figure out why I’m depressed, and it didn’t make me any better. My relationship with my parents just got worse – I got angrier at them and they felt guilty. Now I know I have a brain disorder and I know how to treat it. I come to therapy, I take my meds, and I’m OK. It works.”