The Treacherous Dichotomy: Physical Illness Versus Mental Illness

By Stefan Lerner M.D.

Scientists have shown that “mental” illness is actually the result of physical brain abnormalities, but most people are still using misleading terminology.

The stakes are high, as the way we look at, label, and treat mental illness has resulted in unnecessary suffering, symptomatology, disability, and suicides.

Stefan Lerner, M.D., challenges the status quo in this treatise, arguing that psychiatrists need to be trained like neurologists, focusing on the physical brain and its pathologies. Lay therapists, he says, are perfectly suited to offer psychotherapy.

According to the author, the label “mentally ill” implies that those illnesses are not as “real” as physical illnesses, that an act of will can overcome them. The label is also stigmatizing, which prevents individuals from seeking help.

The bottom line is the very concept of an illness being “mental” is scientifically wrong. They must be reclassified as physical brain illnesses like neurological illnesses. This is the most effective way to reduce stigma and improve diagnosis and treatment.

Join the author as he tackles a weighty topic with serious implications for doctors, psychiatrists, and hundreds of thousands of everyday people.

• Language: English
• Publisher: Archway Publishing
• Release date: Dec 7, 2018
• ISBN: 9781480872103

Stefan Lerner M.D.

Stefan Lerner, M.D. is a senior physician/psychiatrist who has been in practice for more than forty years. He is a diplomate of the American Board of Psychiatry and Neurology and a member in good standing of The American Medical Association. His primary clinical practice is in clinical psychopharmacology and its background basis, neuroscience.

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Copyright © 2018 Stefan Lerner, M.D.

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ISBN: 978-1-4808-7208-0 (sc)

ISBN: 978-1-4808-7209-7 (hc)

ISBN: 978-1-4808-7210-3 (e)

Library of Congress Control Number: 2018965526

Archway Publishing rev. date: 12/07/2018

AUTHOR’S NOTE

The mission of this book is to promote radical change in the so-called field of mental health. In the process, it is highly critical of the psychiatric profession as a whole, while acknowledging that some psychiatrists maintain high standards of care. If your own psychiatrist has been helpful to you, by all means continue treatment with the doctor. If not, an excellent second opinion can be available at a teaching hospital that has a direct association with a school of medicine. The psychiatric attendings in these institutions generally maintain high standards of care. There is usually one such center in most states.

Contents

Preface

Chapter 1     The Stigma of Mental Illness and the Treacherous Dichotomy

Chapter 2     My Patients

Chapter 3     The Treacherous Dichotomy

Chapter 4     Robin Williams

Chapter 5     Phineas Gage

Chapter 6     A Neural Model of Major Depressive Disorder

Chapter 7     The Neuron

Chapter 8     ADHD

Chapter 9     Anxiety Disorders

Chapter 10   Depression

Chapter 11   Depression, Epilepsy, and Pregnancy

Chapter 12   Depression, the Elderly, and the Young

Chapter 13   Bipolar Disorder

Chapter 14   Veterans

Chapter 15   OCD

Chapter 16   Schizophrenia

Chapter 17   Suicide

Chapter 18   Violence

Chapter 19   Sleep

Chapter 20   Expertise

Chapter 21   Comorbidity

Chapter 22   Do You Still Believe?

Chapter 23   Look at All the Mental Veterans

Chapter 24   Expertise and PTSD/TBI

Chapter 25   Final

Chapter 26   Latest Developments

Chapter 27   Final Words

PREFACE

Here are some distinctions between therapy psychiatrists and brain psychiatrists. The therapy psychiatrist’s practice will fit into a particular pattern. He will see each patient for forty-five minutes at least on a weekly basis for several years. He emphasizes psychotherapy as his primary treatment modality. The psychotherapy is often some derivative of psychoanalysis, according to the individual idiosyncrasies of the psychiatrist. It often will follow no predictable goal-oriented format, and there may be no specific criteria for ending the therapy.

All physicians are required to acquire a certain number of points documenting they have been attending educational conferences, reading professional journals, etc. The therapy psychiatrist will emphasize the practice of psychotherapy as the main focus of this continuing education and will generally steer away from the study of the brain, neuroscience, and complex, sophisticated pharmacology. They consider themselves philosophers of the psyche, the unconscious, and character molding, ultimately creating a new, improved individual. Although the therapy psychiatrist went to medical school, the objective was never to fully identify as a practicing physician; it was to reach a higher earnings tier for their psychotherapeutic services. Therapy psychiatrists constitute approximately 70–80 percent of all psychiatrists.

The brain psychiatrist generally does not do a long-term psychoanalytical psychotherapy. His standard session, hopefully, is twenty-five to thirty minutes and not a five-to-ten-minute med-check. Many psychiatrists, especially younger ones, are forced into the med-check mode by insurance companies. The med-check is inadequate, not providing the time to survey the patient’s life for significant stressors or provide explanations for what can be complex pharmacological treatments. Treatment session frequency varies widely, from weekly for very acutely ill patients to three or four appointments per year for stable patients. In his continuing education, he will emphasize brain study, supportive therapy approaches, and details of pharmacological treatments. He adheres closely to the medical model in the same manner as physicians in other specialties like internal medicine, surgery, and cardiology.

Since he does not adhere to the time-consuming routine of regular forty-five-minute psychotherapy sessions, he is much more available to see a greater number of patients than the therapy psychiatrist, with much less expense per patient. He does not negate the need for the standard psychotherapy approach, but refers to therapists for that, who are certified to provide scientifically proven specific forms of therapies like CBT (cognitive behavioral therapy) and RP (response prevention therapy for OCD).

Generally, PhDs have expertise in specialized therapies. Social workers (MSWs) are trained to provide a more general form of psychotherapy—the forty-five-minute weekly session that therapy psychiatrists provide—but on a much more economical basis, not adding financial pressure on top of the symptoms and disabilities of the illnesses.

CHAPTER 1

The Stigma of Mental Illness and the Treacherous Dichotomy

The treacherous dichotomy refers to how we categorize human ailments. Out of long habit and for ease of reference, while generally not intending harm consciously, we place them into two discrete groupings: the physical and the mental. We have been referencing diseases in this matter for centuries—since long before the underlying physiological mechanisms came to light. We continue to do so in every aspect of our culture: psychiatry, medicine, the press, literature, media, and educational institutions.

Nearly every informed person would agree that stigmatizing mental illness is undesirable. Over the past half century, there has been some diminishment in the stigma, but the basic tendency remains in force in spite of this half-century effort at destigmatization. The question is if this stigma will ever be eliminated. We need to bring into action the ultimate weapon against this stigma, the elimination of the treacherous dichotomy itself: the very categorization of diseases as physical or mental.

With the enlightenment bestowed upon us by modern neuroscience, we know serious so-called mental illnesses are indeed physical. The mental categorization is totally misleading in addition to conferring the burden of stigmatization. The treacherous dichotomy is like a magnet that attracts and holds metal. If we introduce iron filings onto a paper near a strong magnet, we cannot expect the filings not to be drawn to the magnetic lines of force. Similarly, as long as we categorize certain diseases as mental in our minds, we cannot expect that stereotypical thinking and attitudes toward so-called mental illness will not coalesce in our subconscious minds. Therefore, it is impossible to efficaciously attack the stigma until we abandon the physical-mental dichotomy. In other words, we must no longer call it mental illness. We must eradicate this term when referring to human ailments and diseases.

We can actually categorize the concept of mental illness as a form of a slur, the last in common usage, bandied about in conversation and print as if it was polite terminology. But unlike more neutral words, it immediately attracts to itself like the magnet and iron filings, a constellation of other associated words and attitudes that spring forth in the subconscious and even conscious mind. We all know this is the case as soon as we pay attention to our own subconscious thought processes. This would almost be almost humorous—if it wasn’t injurious to so many millions of people.

This raises the issue of what a stereotype is. Stereotypes are the building blocks of stigma. In the case of the so-called mentally ill, the stereotypes always portray them in a negative light and disrespectful tone, especially when contrasted with people who are designated as having physical illnesses like asthma, diabetes, seizures, or heart disease. It is remarkable the number of insulting, disrespectful adjectives the label mentally ill triggers in the mind: insane, bonkers, loco, madman, fruitcake, weird, crazy, nuts, nut job, demented, wacko, schizo, loony, peculiar, and so on.

This litany remains just below the surface, ready to influence our behaviors, reactions, and attitudes toward the so-called mentally ill, often conveying rejection and coolness to them. This emotional distancing from them has real-life manifestations. They will be seen as less-desirable social companions and candidates for friendship. This sets up an undercurrent of a feedback loop where they, as sensitive individuals, sense the emotional distancing and withdraw more emotionally. The ultimate destination of this vicious feedback loop is painful emotional isolation for the so-called mentally ill individual.

There is also overt discrimination occupationally and in housing. The individual labeled mentally ill has internalized the entire litany of negative labels and attitudes. In addition to the symptoms, suffering, and disabilities stemming from the so-called mental illness itself, he suffers an overlay of shame, guilt, humiliation, and loss of self-esteem induced by the suspicion (or reality) of the people he tries to interact with. Below the surface of social veneer, they really do think of him in disparaging ways.

Illusory Correlation

The headline was In Quest to Explain Shootings, exploring Mental Illness. Included in the article was another heading: Grim Statistics. Some of the Deadliest US Killing Sprees in the Past Three Decades. Certainly what leaps to mind is that serial murders are committed by the so-called mentally ill. The dramatic headings of shootings and mental illness are linked in the bold print of the headline. One could almost shudder at the prospect of being in the vicinity of someone who has a so-called mental illness. Illusory correlation is a process whereby people misattribute rare behaviors at higher rates to minority group members and overestimate the frequency of the negative behavior in the linked group. It can feel like the so-called mentally ill person can be suspected of being seriously dangerous. This does not lead to a relaxed, amiable environment.

Stereotype Threat

Of course, stereotypes are internalized by those who are stereotyped, and this sensitizes the self-stereotyper to the anticipation of being judged by others along the lines of the stereotype. The anticipation of being judged by others according to the content of the stereotype does not lead to a benign sequence of events. The threat of having the stereotype applied to the self has been shown to result in decrements of social and intellectual performance as well as inducing the very behavior predicted by the stereotype. Thus, the stereotype is reinforced in both individuals.

A 1977 study by Snyder, Tanke, and Berscheid found a similar pattern in social interactions between men and women. Male undergraduate students were asked to talk to female undergraduates, whom they believed to be physically attractive or unattractive, on the phone. The conversations were taped, and analysis showed that men who thought they were talking to attractive women communicated in a more positive and friendlier manner than men who believed they were talking to unattractive women. This altered the women’s behavior. Female subjects who, unknowingly to them, were perceived to be physically attractive behaved in a friendly, likeable, and sociable manner in comparison with subjects who were regarded as unattractive.

The Physical Nature of Mental Illness

It is bad enough to be afflicted with a dysfunctioning brain striking at the heart of well-being, inverting experience into a dystopian nightmare, ravishing self-esteem, achievement, and success, but then to compound this suffering by attaching the stigmatizing label, mental illness is gratuitously cruel.

The major so-called mental illnesses strike at the most human organ in the body, that organ which is capable of appreciating what is beautiful and splendid. It also can bring forth the experience of great torment and agony. Modern neuroscientific research makes clear that the data are overwhelming that so-called mental illness must be redeposited on the physical part of the ledger along with the neurological brain illnesses like convulsive disorders, myasthenia gravis, and multiple sclerosis. What will be left under the heading of mental disorders? Nothing should be left. The concept is antiquated, outdated, antiscientific, and stigmatizing. The physical nature of so-called mental disorders is manifested at the genetic, cellular, and metabolic levels. Lesions are not visible to the unaided eye, but aren’t genes physical? Are abnormal neuronal connections physical? Are abnormal chemicals physical?

It is now the time; the gestalt clamors for change. We must radically rearrange our thinking to be consistent with science. We must decide once and for all there is no such entity as mental illness.

The negativity associated with so-called mental illness, as long as this label persists, serves as deterrence to seeking treatment. It is natural to resist accepting such a label. Even if treatment is finally obtained, compliance with it may be diminished for the same reason. Keeping the category and label of mental illness will greatly increase suffering, interrupt functioning and the prospect of worse disabilities, and enormously increase expense to the health care system. This gratuitous labeling is particularly problematic for the adolescent age group, which is particularly sensitive to stigmatization and humiliation. The cost is delayed entry into treatment or even total resistance to it. Adolescents are particularly susceptible to developmental delays and dysfunctions due to inadequately treated illness, resulting in potentially lifelong suffering and disabilities.

There are difficulties associated with making a major substantive change, but I am going to suggest we start now. We must correct individuals who continue to use the term mental illness. We must advise them that science has proven that the major so-called mental illnesses are not mental at all; they are caused by physical abnormalities of the brain. There is no logic whatsoever to separating them by category: mental versus physical illness, neurological illnesses, and kindred brain diseases, which everyone accepts as physical.

We must eliminate the phrase mental illness and reference the root psyche as a disease identifier. If neurology uses the root neuro, we should too. I declare that psychiatric illness henceforth should be called neuriatric illness. I have transitioned from being a psychiatrist to being a neuriatrist. In the DSM classification of so-called mental disorders, there are many diagnoses that do not classify as major neuriatric disorders. They should be stripped of the mental label and reclassified as cognitive, behavioral, emotional, and personality dysregulations.

CHAPTER 2

My Patients

Over the years, I’ve evaluated and treated thousands of patients. It disturbs me that they are forced to identify themselves as mentally ill. They are the ones who made it into treatment; untold others are unable to accept the label and thereby not do not transition to appropriate diagnosis or treatment. I regard the patients I’ve treated as very fortunate, especially if they have serious so-called mental illnesses, which can cause so much suffering and disability.

I have always participated in continuing education, keeping current in clinical psychopharmacology. The mental health system is a maze of confusing services and varied practitioners. Countless individuals never receive an appropriate diagnosis, differential diagnosis, or sophisticated medical treatment. Clinical psychopharmacology involves an understanding of actual brain mechanisms and which medications may be suitable to ameliorate specific symptoms and dysregulations.

So many of my patients have been gracious, friendly, and personable. What possible benefit can there be to linking them with the stereotypes conjured up by being labeled mentally ill? Suffering and disability do not dichotomize themselves into mental or physical categories. They are erroneously separated from physical illnesses—mental illnesses—and are an equal-opportunity partner when it comes to suffering.

Three Seniors

I first evaluated Mr. Tunis more than a decade ago, when he was sixty-seven. He was the owner of a company he had founded and built. Of particular note was his courtly and gracious manner. He was referred by a psychotherapist for both depression and severe panic attacks persisting in spite of psychotherapy. There was a significant family history in which he described depression on the maternal side. At the time of our first consultation, he was transitioning into retirement and was worried. He said, What’ll I do next? He was concerned about continuing to be an attentive husband who was sensitive to his wife’s needs. He was proud of his family, particularly his grandchildren.

He had experienced a severe panic attack several months prior to our consultation and was constantly in dread of a reoccurrence. On the Hamilton Depression Rating Scale,¹ his seventeen-item subtotal was 20½ (a normal value is 7 or less). This was consistent with major depression of moderate degree. His symptoms included persistent sadness, nagging self-reproach, insomnia in the form of awakening two hours prematurely and being unable to return to sleep, intense worrying, and an unshakable conviction that tormented him that he had a terminal disease. He was started on Effexor, an antidepressant in the SNRI class. A month later, he was much improved; he was no longer in torment and was able to relax about his health. The HAM-D scale score, when readministered, objectively measured his improvement. The score dropped to 7, which was considered a remission of the depressive episode. He also felt secure that additional panic attacks would be prevented.

We continued with Effexor therapy for eleven years. He devised activities to enjoy his retirement and wasn’t at all bothered by his previous symptoms. Then he began experiencing symptoms of light-headedness and dizziness. His cardiologist diagnosed a type of cardiac arrhythmia, and even though it was not proven, he implicated the Effexor, which was then discontinued.

A different antidepressant, Lexapro (Escitalopram), replaced it, but it did not have such a clear-cut benefit. A second antidepressant, mirtazapine, was added (combination therapy), and finally, a third medication, Abilify (Apiprazole), was added for the purpose of augmentation.

Over the ensuing two years, although not feeling as well as previously on the Effexor, he was managing. During the subsequent summer, his suffering amplified. He said, Severe depression and panic … I cannot lift my spirits … I have feelings of dread … the valley of despair!

I increased his Lexapro from twenty to thirty milligrams. The Hamilton Depression Rating Scale score had increased to 23. I increased the mirtazapine to forty-five milligrams. There was some alleviation of his anxiety and despair, but the extreme morning dread improved.

He said, Not the doom and gloom … I feel better … more myself than in several years. The level of improvement is huge. I have been worse this past month.

I broached the option of hospitalization at an excellent tertiary care center for observation, diagnosis, and treatment, but he felt he couldn’t go because his family was looking forward to the holidays.

Over the New Year’s weekend, he took an overdose of medication and slashed his wrists. He was hospitalized in the local community hospital as an inpatient. He had a course of six electroconvulsive therapy treatments. It’s interesting that the hospital staff did not contact the undersigned during the patient’s hospitalization and discharged him to the care of a nurse practitioner. There was trouble hooking up with her, and he decided to return to the care of the undersigned and his former therapist.

When seen in mid-May, his symptoms were in remission. The hospital doctors had replaced the generic Lexapro with Cymbalta while maintaining the mirtazapine and Abilify. Unfortunately, this period of improvement was transitory.

Pretty bad … Anxiety overtakes me … I toss and turn … I wake up too early.

He was referred back to the community hospital for outpatient electroconvulsive therapy treatments, receiving eight treatments over two months. By early August, he was feeling generally better—more energy, more active—and sleeping soundly.

At the end of August, after the eighth outpatient ECT treatment, he was feeling more withdrawn. He said, The medication interferes with my motivation. He was spending his days in bed, sinking into despair. I see no end to it.

An emergency appointment was made, and his wife accompanied him. She was exasperated that he wasn’t being more active. He’s not himself … He’s staying in his room.

He said, I can’t face life the way I’m doing now.

He agreed to be admitted to the originally recommended tertiary care center, and the undersigned had several communications with the attending psychiatrist there.

He remained there for nearly eight weeks, finally improving after a long course of seventeen right unilateral ECT treatments.

He could not tolerate an older type of antidepressant, a tricyclic, because of orthostatic hypotension. This class of antidepressant occasionally has a special benefit for his subtype of depressive illness, melancholic.

The attending noted the patient’s wife did not wish to participate in discussions at the hospital with the professional staff treating her husband, but his son was more agreeable to it.

He had his first follow-up appointment in my office a week after discharge. The undersigned reviewed the course of treatment and his discharge clinical status with the attending psychiatrist at the tertiary care hospital.

This dignified elderly man never appeared to be mentally ill. The severe, recurrent illness that caused so much suffering and disability at his advanced age certainly packed a vicious wallop of symptomatology, although it wasn’t visible as an aberration to the unschooled eye. His wife had an expectation he should just sort himself out and get over it. This is not a surprise; she has been conditioned by the pervasive mental/physical dichotomy of classifying illnesses wherein mental illness is reflexively viewed as a lesser category of illness that one can control and overcome if one is determined. This unspoken belief that influenced his wife’s view of his illness was an added weight to his suffering.

He could not help—at some subconscious level—agreeing with her. The mental/physical dichotomy exacts an additional burden on those on the mental side of it, including guilt, lowered self-esteem, and a sense of weakness, failure, and disapproval. Indeed, the mental/physical dichotomy is treacherous. It emotionally traumatizes those unfortunate patients classified in the mental categorization of illness.

Two Additional Elderly Patients

Mrs. P and her husband impressed me immediately with their graciousness and warmth.² I truly enjoyed their company as we attended to the business of diagnosis, supportive therapy, and pharmacological management. She was in her thirties when she had her first episode of major depression and subsequently had two additional ones. She required hospitalization on each occasion. Since the last hospitalization, she had been treated with an agent from the older group of antidepressants, Norpramine (desipramine), and a small dosage of a first-generation antipsychotic called Mellaril.

The next years went well. She continued her social life and artistic endeavors. In the fall of her fourth year of uneventful treatment, her husband reported, Things are going real bad.

On Monday, she had been wonderful—and then she abruptly accused him of going to whores. She called 911 repeatedly, demanding that the police come. She admitted she had not been taking her medicine. She said, I don’t need it.

He contacted the undersigned and was advised that she needed immediate evaluation in the emergency room. She was admitted and had a course of ECT.³

A month later, when seen after her discharge, she was her usual pleasant self. Her clinical course was uneventful for an additional five years. Then, prior to Christmas, she started staying in bed and watching religious programs. She admitted, I’m getting very emotional in church.

She accepted hospitalization and received five or six ECTs. When seen after discharge, she gave her signature declaration of well-being. I feel wonderful … I’m not tired … I have much more energy.

It should not be acceptable that Mrs. B. is pigeonholed in the category of being mentally ill. It is perfectly obvious she is an intelligent, creative person who is pleasant, social, and good-hearted, and she has a pleasing sense of humor. Her episodic symptoms were manifestations of a severe dysregulation of specific brain mechanisms, some understood, many not yet known. This dignified woman does not deserve being stigmatized by the humiliating label mental.

***

Mr. X made a deep impression on me. He was not my private patient. He had been assigned to my care when I was employed on a hospital psychiatric unit. It had nothing to do with what he told me—he could not talk—but I learned of his accomplishments from his adult children. He was a veteran of World War II. After the war, he had a family and a successful career as an engineer. Then, in his senior years, he developed a severe vein thrombosis in his leg. He stopped talking, communicating, or caring for himself.

When I first met him, he was seated in a chair and not moving. He did not acknowledge my presence. His eyes were glazed, staring ahead. He was transferred to a psychiatrically supervised medical unit, and I lost contact with him. I always wondered what this previously active, successful veteran of World War II made of his sudden state of complete helplessness and vulnerability. It was such a wrenching twist in the course of his life in its final phase, and he had no chance to prepare for or adjust to it. The random punishment meted out to some unfortunate individuals is ghastly.⁴ Perhaps we breathe a sigh of relief that it isn’t us, but perhaps it could be? Perhaps we could be labeled mentally ill at some unforeseen future time.

A Married Mother of a Young Son is Tortured

Sarah, when first seen, was married and the mother of a young son. It was clear that she was very intelligent and desperate to gain relief from her symptoms. She had been under treatment with another psychiatrist for four years, but the chart notes were available. She had related her symptoms to him: It feel like my skin is crawling … intense panic and fear to the point, I feel crazy at times.

Her mother had said, Sarah, this is not you; something is happening to you.

During our interview, Sarah said, It’s extraordinarily painful … I feel intense pressure. I want it to stop.

She originally went to the psychiatrist after she called her ob-gyn, describing her symptoms and saying, I’m in serious trouble.

The psychiatrist prescribed Pamelor (Nortriptyline). After starting it, she called a day later complaining of anxiety and more disorientation.

She was seen in follow-up sessions two weeks later, after taking Pamelor 30 mg nightly. She felt back to her old self. She was a forward-thinking, optimistic person.

The psychiatrist described her as calm, in good control … not distressed or worried.

She called two weeks later and requested that the medication be increased. Strange things in my head that come and go … like a twinge, a spark, as well as feeling very hot and flushed.

Pamelor was increased to 40 mg and an additional 10 mg as needed. When seen two weeks later, she was on the 50 mg but still occasionally feeling shaky, trembly inside, or extremely hot. For the most part, she felt well, hopeful, and energetic. She was having fun. Over the next six months, not encountering the previous severe symptoms, she requested the Nortriptyline be tapered and discontinued. But then there was a recrudescence.

I’m on a roller coaster against my will. I can feel my body hardening. It’s like screaming people are running through my body. This thing keeps rearing its ugly head. I don’t even know who I am. She began sobbing. I can’t accomplish anything.

She was started on 50 mg of Zoloft (sertraline). After two and a half months, she said, I’ve been much better generally. I can cope. There isn’t this underlying feeling.

The patient appeared much more relaxed and was able to smile pleasantly. She requested an increase in the Zoloft to 75 mg so she could be totally