Archive for December, 2007

Question: The ethics of brain chemistry

There is evidence that depression is associated with biological changes in the brain, for instance dysregulation of neurochemicals. Do you think that depressed individuals who have committed violent crimes against others (case in point: Andrea Yates, the mother who drowned all five of her children while suffering from depression) should be held morally accountable for their actions?

To blame neurochemicals for our actions is, at once, entirely reasonable and horribly misguided. Our minds, our brains, are all neurochemicals and electricity: saying that someone’s neurotransmitters make him want to kill people is essentially the same as saying that his mind makes him want to kill people. Mentally ill people are, in fact, sick, and studying the dysfunction of the brain can help find ways to treat their very real illnesses, but that doesn’t make them separate and uninvolved from their brains. The in mental illness, the brain doesn’t step in and take control; the brain is always the controller. Mental illness may affect the way that people are help responsible for their actions, but mere pathology of the brain does not.

This may sound cruel, but I believe that in a moral sense people are always responsible for for their actions. Always. Regardless of our insanity, or intoxication, or anger, we always have to live with our pasts, and what we’ve done. It’s not fair to blame our illnesses for our crimes, as if we could so cleanly and easily cut our diseased minds of from the rest of us. I’m not saying that people with mentally illnesses don’t deserve more slack and more forgiveness than sane people who kill others, but if a woman kills her children in a fit of psychosis, shouldn’t she be overcome with grief and remorse? Could we call her human if she isn’t?I believe that mentally ill people have an obligation to seek treatment. I believe that if any of us wake up in the morning with a flicker of my children would be better off if I drowned them, we have an obligation to go to an emergency room and check ourselves in for psych evaluation immediately, before letting things get worse. People don’t control or create their mental illnesses, but it is up to us to decide how we deal with our problems. There are always warning signs when psychosis strikes, and there’s usually some way or some place to put yourself where you can’t hurt yourself. If you are foolish to think that, in the face of mental illness, you can carry the lives of other people with your will alone, you deserve to feel responsible when you break. It’s a different kind of responsibility than rationally going out and shooting someone, but it exists nonetheless.

I feel a lot of compassion for people with mental illnesses. I feel that, by saying this, I’m condemning people who are essentially not in control of themselves to suffering. I want to be very clear that I don’t think mentally ill people ought to be shunned for things the do while not in their right minds, and they certainly shouldn’t be held legally responsible for these things. When I talk about moral responsibility, I mean something highly internal and personal. People prone to delusions ought to, even need to doubt themselves when they start thinking things that other people would find crazy. They need to take responsibility for those thoughts, take responsibility for dealing with them in a way that won’t end with anyone dying.

I guess I’m being a little idealistic here, because I’m assuming that anyone who tries will be able to get the help they need, or at least enough help to prevent them from hurting anyone else. I know that isn’t true. If a trip to the emergency room means thousands of dollars that you don’t have, I can see that it would be hard to check yourself in somewhere. If you can’t get someone to take you to the hospital, or if they give you antipsychotics and kick you out the door, that’s a different story than simply believing you could handle it. If that happens? I can’t blame a person who’s tried the best they could to get help, and been rejected by the world.

a few thoughts on addiction

I believe, and the evidence supports, that people with addictions require treatment to overcome them. Many addictive substances can cause long-term lasting harm, and can have huge financial and relationship-related costs. Addictive substances can physically alter the brain. People may be more prone to addiction due to their genes as well as their personalities. Addiction can be hugely destructive.

That said, addiction is fundamentally a behavior pattern. I believe that behaviors can be maladaptive without being pathological, that is, I believe that people can repeatedly indulge in self-destructive behaviors without having a mental illness. People who regularly go 100mph on the highway don’t have “speed addiction disease”, even though they may be at higher risk of driving-related injuries than people who stay close to the speed limit. People who are physically addicted to coffee don’t consider themselves ill.

I don’t have a problem with people who struggle with alcoholism define it as a disease. If it encourages insurance companies to pay for treatment, in fact, I encourage it. Whatever helps people improve their lives is good, I think. It worries me, though, that in our culture maladaptive behavior patterns are increasingly being defined as diseases.

Against Personality “Disorders”

I don’t believe in personality disorders. I’m not saying that I don’t believe people with a certain character/symptom set appear, or that people can’t identify with these labels, but I don’t believe that they constitute a set of disorders discrete from other mental illnesses. I don’t believe that “personality disorders” are actually problems with a person’s personality. A couple reasons:

1) Many of them seem like mild versions of Axis I disorders.

If you want to define “personality disorder” as something like an Axis I disorder, but without the same severity, I’m not crazy about your choice of terminology, but I suppose that’s fair. However, I notice that Cyclothymia has a place in Axis one, instead of being “cyclothymic personality disorder”. How is that fair? If a person with moderate-but-significant mood swings has a clinical disorder, shouldn’t a person with moderate-but-significant paranoid delusions rate the same respect? Which brings me to my next point:

2) This is pretty much a list of people that are hard for psychiatrists to deal with, isn’t it?

Borderlines are emotionally manipulative. Paranoid people don’t trust in your clear and overwhelming expertise. Histrionics are overemotional women. Avoidant people skip therapy. OCPD people want to control it. Guys with antisocial personality disorder are scary. Depressive personality disorder will probably never make it into the DSM, because it isn’t all that hard to listen to a person talk about how they’ve failed in life. I’ve heard that a diagnosis of Borderline Personality Disorder can become a placeholder for “difficult to deal with” instead of actually implying that the person in question has a certain symptom set. It seems to me like diagnoses exist as much to point out potential problems as to facilitate treatment.

3) Personality isn’t stable over time.

I’d like to think that there’s some special thing inside me that remains constant no matter what happens to me. Something that makes me me. However, I can’t think of a person I knew as an early adolescent who’s retained such specific personality traits. We’ve changed a lot, grown up a little. Schizophrenia can last a lifetime. Mental illnesses persist. Personality tends to change.


About the Author

Lisa Loren is a student at Harvard University's Extension School, where she studies psychology. She lives and works near Boston, MA.

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Contact her at lloren@gmail.com

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