Abstract
New knowledge may be beneficial to our understanding of illness and help us in devising new and more effective treatments. Conversely, the same new knowledge can simultaneously introduce conceptual confusion and an urgent need to re-examine some of our categorical boundaries. Some of medicine's biggest challenges (for example) are due to a successful contribution to the increase in life expectancy which enables us to enjoy the pleasures of life long after retirement. Unfortunately these pleasures are counterbalanced by the increased demands on the National Health Service due to the high incidence of medical problems associated with ageing. The challenges of success are particularly true in psychiatry and forensic psychiatry where recent advances in neuroscience cause us to re-examine many interfaces and basic concepts of illness and many of the related ethical issues.
The recent advances in neuroscience research have finally destroyed the centuries old Cartesian division of the human into two neat compartments of mind and body. We are all comfortable with the view that psychiatric signs and behavioural symptoms are the outward manifestation of underlying structural or biological dysfunction. Conversely, however, we have always found it more difficult to accept that adversity, psychic trauma and environmental stresses can actually act in the reverse direction. Certainly there have been many clues for years, and the concept of psychosomatic illness acknowledges this conceptual link. Modern neuroscience has now taken this link further as many elegant studies have demonstrated structural changes in such subcortical sites as the amygdala and caudate nucleus and related connections in response to life stresses.
But this is not all. Some psychiatric illnesses which are known to be correlated with identifiable brain dysfunction have responded to non-pharmacological treatments. Obsessive compulsive disorder, which for some time has been associated with shrinkage of the caudate nucleus, will respond to either cognitive behavioural therapy or medications of the serotonergic antidepressant type. What is new is the increasing evidence that not only are cognitive behavioural treatments more permanent but improvement is also associated with significant increases in size of the amygdala bodies.
These exciting discoveries have another problematical side. There is currently debate in psychiatry as to who should be responsible for the management and care of people with serious personality disorders, especially the dangerous antisocial types. Some psychiatrists have made newspaper headlines by refusing to admit such people to special hospitals on the grounds that they are untreatable and should be referred to prison if (and when) they commit an offence. The Home Secretary has recently introduced new, controversial legislation enabling courts to give indeterminate sentences to people diagnosed with severe personality disorders. Not surprisingly, this has enraged some of the civil libertarians in the community.
Recent neuroscience research findings strongly suggest that many personality-disordered individuals have abnormalities of their limbic and related neural systems as a result of persistent exposure as children to unsuitable parents who alternatively inflicted neglect with harsh, capricious, inconsistent and affectless punishment.
Once again, difficult ethical questions arise, such as: What is illness? Who should be treated, and who should not be treated? Are people ever responsible for exercising control over their behaviour? Why do we feel sorry for the sufferers of OCD and panic disorder yet angry and intolerant to those whose disorder is expressed as antisocial behaviour? There are other questions concerning responsibility. For example, why do many people expect patients with neurotic symptoms to be more responsible for them than someone who suffers from thyroid disorder?
Sigmund Freud would be delighted. In his later years he stated that one day, when we understood more, the psychoanalysts and the biologists would meet in the middle. Neuroscience and genetics seem to be bringing that day closer as the millennium approaches.
Minds, brains and bodies never become ill on their own. Concepts of mental illnesses or bodily illnesses are illogical and absurd, and along with terms like ‘organic’ and ‘functional’ should be abandoned and rendered obsolete. Only by throwing away these dualistic terms can we progress in providing equal treatment opportunities to all irrespective of whether their symptoms evoke sympathy or disgust.
The current conceptual upheavals created by neuroscience research remind one of Einstein's famous remark that when you move something everything else in the universe shifts.