Where It All Starts

Screen Shot 2021-07-04 at 4.06.03 PMIs it remotely possible that we are double parked around the corner from the TOE (aka: The Unified Theory of Everything) — and just have to make that final turn? My own Hammond’s Road Atlas has been the various iterations of the DSM, the Diagnostic and Statistical Manual, currently in its fifth go-round. This compendium has valiantly, comprehensively (so we hope), and sometimes mistakenly catalogued mental disorders. And evolved over the past 70 years from what, by today’s standard, would be an ‘extended pamphlet’ to the DSM-5’s bulky near 1000 pages. Its editions have ebbed and flowed, reflecting the ‘current wisdom’ on what constitutes a ‘disorder’. The general direction, one hopes, has been an evolution toward a kinder, gentler (and certainly more informed and inclusive) catalogue.

One constant, however, has remained. Diagnosis, the cornerstone of psychological and psychiatric treatment and intervention, has remained slavishly dependent on checklists of clinical symptom clusters — ‘observables’ if you will. Tote up the tick boxes and, if the criteria are met, you have a ‘diagnosis’. With the 2013 advent of the DSM-5, the somewhat cynical, but not wholly undeserved criticism, was that it represented a ‘reshuffling of the deck chairs’. The long-awaited tome that would focus on, or at least include the collecting of genetic, imaging, physiologic, and cognitive data in formulating a diagnosis, had failed to materialize. As one Scientific American article from that year put it: ‘New DSM-5 Ignores Biology of Mental Illness’. The curtain was pulled aside and the same wee wizard revealed — dressed in a nice, new aubergine suit (distinguishing it from its blue predecessor), updated font and numbering in the lapel pin (5 vs. V), but echoing Macbeth’s lament: ‘a tale told by an idiot, full and sound and fury — but signifying nothing’.

Well that’s a bit harsh. But it certainly seems to have contributed to a pretty seismic shift in momentum. Biology, more particularly neurobiology is increasingly the bar to be at when seeking ‘points of origin’ of any number of ‘conditions’ that for decades saw the search end with a tally on the scorecard of diagnostic criteria. Although dedicatedly toiling on in the labs and academic institutions for eons, these ‘rat-runners’ were under-recognized, while their ‘applied’ counterparts garnered centre stage. Just as the mind and the body had remained separate entities (thanks Descartes!), so the researcher and the clinician occupied functionally opposite corners of the ring. The former picking methodically away at esoteric connections between this behaviour and that tiny region of the brain; the latter, confidently trotting out fifty-year old wisdom from the most recent iteration of the Titanic. Happily, fundamentally that is changing.

I have long been interested in psychopathy, that most heinous villain of personality disorders. Somewhat coincidentally in 2013, I was seated in an auditorium at Penetanguishene, a facility, part ‘jail’, part treatment venue where many such individuals are housed. The keynote presenters were Robert Hare and his team, widely acknowledged as the leading experts on psychopathy and the diagnosis of same. His PCL-R is the instrument almost universally utilized in identifying and rating levels of this disorder. In keeping with the scorecard protocol, Hare’s exhaustive research has centred on the 20 elements that define the psychopath. Each scored 0, 1, or 2, in a trained clinician’s opinion, a tally (generally) of 30 or more is pretty much a slam dunk.

The conference participants included corrections officers, police, and mental health practitioners from all walks. When Hare began to introduce his neurological research, I’m pretty sure I saw a large chunk of the attendees start to glaze over. The fMRI results, response times to ‘emotionally-charged’ words, and relative sizes of various brain structures seemed to have scant application to the parolee who failed to show for an appointment or the guy who regularly got busted for assault or fraud. But Hare persevered, introducing a nascent interest of his: Is the psychopath a criminal who chooses to act out against societal norms; or is he a product of his wiring? Should he be incarcerated or treated? He was straying into the moral minefield of culpability, choice, and societal response.

A core ‘deficit’ in the psychopathic tool box — and one of Hare’s 20 — is empathy. Fast forward a half-dozen years. I was listening to a podcast built around a relatively rare condition, in its various forms collectively referred to as synesthesia. In this particular instance, a Mirror-touch manifestation of the ‘disorder’ was being described as experiencing what another might feel, but on multiple sensory levels, at high levels of intensity, and involuntarily — in short, an ‘excess of empathy’. The disorder is being traced to a tiny cortical region, the temperoparietal junction, the TPJ (say that ten times quickly!); and specifically the level of ‘gray matter volume’ present. I began to wonder if one end of the empathy stick saw wildly increased levels of sensitivity to others, perspective taking, interdependence, etc., could the other end of said stick (all those nasty antisocial’s) see the structural opposite. A little digging says, yes. This is not to say psychopathy is bred in the bone, but certainly the wiring — however, it’s shaped and established — plays its part.

So here we are. The marriage of mind and body is slowly being reconciled. Those sacred clusters of symptoms continue to be figural focuses in intervention; but the causes are steadily being revealed — and with them a true paradigm shift in treatment. The art and the science can, will, indeed must play together in the same sand box.

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