“You could ask whether something happens to change brain development,” tom Insel said, “but you could also ask if it’s something about the brain that leads to pathology.” He was talking about attention-deficit hyperactivity disorder, showing an animated slide depicting, side-by-side, the the brain development of a normal and an ADHD kid. “We call this ADHD,” he went on, “but it really looks like a disorder of cortical maturation.” ADHD, he acknowledged, encompasses some behaviors, but if you continue to focus on them, “if you don’t start to think abouit it as a cortical maturation problem, you lose.” We have to “stop looking at the behavioral,” he went on, because “the behavioral and the cognitive are the last thing to change. So long as we only stick with what’s observable, he conclluded, “we’re talking about getting into this game in the ninth inning.”
Insel then showed another slide–a moth called the Tropical Skipper. Turns out that the Tropical Skipper can come from ten different caterpillars. In other words, many different genotypes can lead to the one phenotype. There are many neural paths to depression, many genetic paths to schizophrenia, and many different ways in which the same biochemistry, neural and/or genetic can show up in behavior and cognition. Thsi problem–what scientists call heterogeneity–is what haunts phenomenological accounts of suffering. We are blinded by the light of lived experience and fail to see the true reality underneath it.
If Insel grasps the religious nature of this argument, of this idea that appearances are the work of the devil who doesn’t want us to see the4 divine truth, he doesn’t indicate it.
What he makes of it, however, is something that your average knuckle-rapping nun would fully appreciate: that the earlier you catch onto a person’t pathology (the nun would of course call it sin) the more effectively you can intervene. That kid bouncing off the walls in school? The fight between Insel and the nun isn’t over whether or not the problem is in the kid or the school; it’s over what exactly is wrong inside the kid. Is it sinfulness or a lack of cortical thickening?
Either way, it is incumbent to do something now, to prevent perdition later. “Behavioral or pharmacological treatments” is what the modern psychiatrist always says (“behavioral treatments” being some kind of therapy, whcih is acceptable because we know that therapy can have brain effects too), but really they mean drugs. I mean, if you really can’t afford to wait for the ninth inning, there is no behavior to treat.
So don’t think for a second that the drug companies aren’t listening very closely to Insel.
This is why the DSM-5 is going to include Attenuated Psychotic Symptoms Syndrome (or whatever they call it) and Disruptive Mood Dysregulation Disorder (formerly Temper Dysregulation Disorder) and other “subthreshold” diagnoses–because the wave of the future is early detection of pathology, and early intervention. You just can’t start rapping their knuckles too early.
In general agreement with all this, but have two thoughts:
1) “The light of experience” or the phenomenological experience of suffering is not necessarily inferior to
other kinds of truth: it is the level at which we live our lives and, from an existentialist perspective, conduct psychotherapy.
2) Early intervention is is not necessarily stamping out the evil seed; many are grateful to have had early recognition of their life issues. The problem is the commercial exploitation and appropriation of early intervention, and an insurance and legal system that insists on a hard, bright line between illness and wellness.
I agree on both counts. The problem that I was referring to that haunts phenomenological accounts of mental suffering isn’t inherent to phenomenology. It’s the result of trying to marry phenomenology to the medical model, and thus insisting that what you’ve come up with is the same kind of truth that we have come to expect from doctors and other scientists. To go phenomenological is to surrender a kind of certainty, which happens to be the certainty that gives medicine its clout. The DSM is in many ways the result of trying to have it both ways.
Same with the second point, and you said it better than I did: no reason not to be concerned about what today’s behavior or experience means about tomorrow. But here again, to wed that kind of insight to the economic and epistemological structures of medicine is highly problematic.